4.13.2.0 Anx­i­ety Disor­ders

Rec­om­men­da­tions

4.18 Con­sid­er screen­ing for anx­i­ety in peo­ple ex­hibit­ing anx­i­ety or wor­ries re­gard­ing di­a­betes com­pli­ca­tions, in­sulin in­jec­tions or in­fu­sion, tak­ing med­i­ca­tions, and/‍or hy­po­glycemia that in­ter­fere with self-‍man­age­ment be­hav­iors and those who ex­press fear, dread, or ir­ra­tional thoughts and/‍or show anx­i­ety symp­toms such as avoid­ance be­hav­iors, ex­ces­sive repet­i­tive be­hav­iors, or so­cial with­draw­al. Refer for treat­ment if anx­i­ety is pre­sent. B

4.19 Peo­ple with hy­po­glycemia un­aware­ness, which can co-‍occur with fear of hy­po­glycemia, should be treat­ed using blood glu­cose aware­ness train­ing (or other ev­i­dence-‍based in­ter­ven­tion) to help rees­tab­lish aware­ness of hy­po­glycemia and re­duce fear of hy­po­glycemia. A

Anx­i­ety symp­toms and di­ag­nos­able disor­ders (e.g., gen­er­alized anx­i­ety dis­or­der, body dys­mor­phic dis­or­der, ob­ses­sive-‍com­pul­sive dis­or­der, specific pho­bias, and post­trau­mat­ic stress dis­or­der) are com­mon in peo­ple with di­a­betes (85).

The Be­hav­ioral Risk Fac­tor Surveillance Sys­tem (BRFSS) es­ti­mat­ed the life-‍time preva­lence of gen­er­alized anx­i­ety dis­or­der to be 19.5% in peo­ple with ei­ther type 1 or type 2 di­a­betes (86). Com­mon di­a­betes-‍specific con­cerns in-‍clude fears re­lat­ed to hy­po­glycemia (87,88), not meet­ing blood glu­cose tar­gets (85), and in­sulin in­jec­tions or in­fu­sion (89). Onset of com­pli­ca­tions pre­sents an­oth­er crit­i­cal point when anx­i­ety can occur (90). Peo­ple with di­a­betes who ex­hib­it ex­ces­sive di­a­betes self-‍man­age­ment be­hav­iors well be­yond what is pre­scribed or need­ed to achieve glycemic tar­gets may be ex­pe­ri­enc­ing symp­toms of ob­ses­sive-‍com­pul­sive dis­or­der (91).

Gen­er­al anx­i­ety is a pre­dic­tor of injection-re­lat­ed anx­i­ety and as­so­ci­at­ed with fear of hy­po­glycemia (88,92). Fear of hy­po­glycemia and hy­po­glycemia un­aware­ness often co-‍occur, and in­ter­ven­tions aimed at treat­ing one often benefit both (93). Fear of hy­po­glycemia may ex­plain avoid­ance of be­hav­iors as­so­ci­at­ed with low­er­ing glu­cose such as in­creas­ing in­sulin doses or fre­quen­cy of mon­i­tor­ing. If fear of hy­po­glycemia is iden­tified and a per­son does not have symp­toms of hy­po­glycemia, a struc­tured pro­gram of blood glu­cose aware­ness train­ing de­liv­ered in rou­tine clin­i­cal prac­tice can im­prove A1C, re­duce the rate of se­vere hy­po­glycemia, and re­store hy­po­glycemia aware­ness (94,95).