We all know what it feels like to be anxious. Whether it was when you were waiting for your driving test or the difficulties you had trying to sleep whilst worrying about a particularly challenging meeting or clinic ahead, these emotions are well known to us all.
Anxiety is a common reaction that people experience in response to a challenging situation, difficult people or things they view as threatening. Experiencing anxiety can be useful as it can warn us about dangerous situations so that appropriate action can be taken. Anxiety can help with vigilance, learning and general performance. In the short term, anxiety is useful; however, in excess and for prolonged periods it starts to work against us.
Most people experience anxiety to some extent and different people will have different experiences. Some people have general anxiety that is manageable but never seems to go away, whilst others experience intense, acute anxiety attacks. Others experience anxiety in challenging social situations, or need routine and cleanliness in order to relax.
Anxiety disorders are most common emotional disorder and symptoms include:
- Devastating feelings of panic and terror.
- Overpowering obsessive thoughts or intrusive memories.
- Frequent nightmares and poor sleep.
- Physical symptoms, such as feeling nauseous, heart pounding or muscle tension (Anxiety UK, 2015).
Anxiety disorders differ from normal feelings of nervousness. Untreated anxiety disorders can push people into avoiding situations that trigger or worsen their symptoms. People with anxiety disorders are also likely to suffer from depression, and they also may potentially abuse alcohol or drugs in an effort to gain relief from their negative symptoms. Job performance, school work and personal relationships may become problematic.
Anxiety disorders and diabetes
People with diabetes have a significantly higher risk of anxiety than the general population. This can limit their ability to self-manage their condition and reduce medication concordance, which in turn can lead to poorer diabetes management and a higher likelihood of the complications associated with diabetes. (Trigwell et al, 2008).
For diabetes nurses, having a good understanding of the types of presentation of anxiety can support us within our everyday diabetes consultations. It is important to have a good knowledge of the services that are available to people with diabetes and anxieties (American Psychiatric Association, 2005). Managing diabetes and anxiety concurrently will have a positive impact on your consultation and will enable the individual to self-manage their condition.
As a diabetes practitioner, it is always difficult to truly assess what is going on in someone’s head. Although anxiety is normal, there are times when we cannot accurately predict how much of an impact the diagnosis of diabetes has on someone’s anxiety levels. Without this knowledge, it is hard to help them progress with the self-management of their condition(s).
Providing a list of definitions of various psychological and psychiatric conditions may be interesting, but within a busy diabetes clinic it can be difficult to see the relevance for us; however, if we look closer, we may be able to distinguish the links between the two and how diabetes and anxiety can become negatively entwined. It is important we understand the importance of anxiety as a condition, as evidence would suggest people diagnosed with diabetes are approximately 20% more likely to experience anxiety than those without diabetes. (Li et el, 2008).
Impact on social issues
Being diagnosed with diabetes can bring about anxiety in a number of ways. For example, people with diabetes may be anxious about how their condition will be perceived by others, including friends, family and work colleagues (Fliege et al, 2005).
Often having type 2 diabetes creates anxiety around the individual’s weight, lifestyle and dietary choices, especially in social events (Grossman et al, 2004). We frequently hear how people are challenged by others about their lifestyle, driving them to hide the condition and, in some cases, denying their diabetes altogether. Furthermore, as healthcare professionals, we certainly walk a tightrope between educating people about their lifestyle but then not creating a state of anxiety, which is no longer is productive.
Fear of hypoglycaemia
Some individuals develop anxiety over the fear of experiencing a hypoglycaemic event, especially while driving or when looking after their children or family members (Wild et al, 2007). We cannot underestimate the impact hypoglycaemia has on individuals. Although there is an importance in understanding hypoglycaemia and ensuring that these are discussed thoroughly in consultations, we need to be mindful of the levels of anxieties this can cause. (Hicks et al, 2011).
In a person with anxiety, we have to be able to distinguish between hypoglycaemia and panic disorders. Since unusual behaviour, palpitation or shaking are all symptoms of both conditions, it is important we have a good understanding of both conditions to be able to identify what the symptoms relate to and that the appropriate treatment is given.
Excessive worrying
Excessive worrying about diabetes can be the trigger for generalised anxiety disorder, social phobias or obsessive compulsive behaviour towards monitoring, treating or managing diabetes.
We should have discussion with people with diabetes about the frequency of monitoring. This may be a difficult conversation if the individual lives in an area that restricts blood glucose test strips. Although there is a consensus document relating to blood glucose monitoring available (Hill et al, 2014), restricting test strips in an anxious person can be problematic. Supporting the individual by referring them for psychological interventions can overcome this issue.
Treatment phobia
When starting on injectable therapies, it is not uncommon for people to show some level of anxiety at the thought of regularly injecting themselves. However, occasionally someone will present with a very real needle phobia that can prove problematic.
Many people with a phobia do not require specific treatment for that phobia and avoiding the object of their fear is enough to control the problem. Unfortunately, however, this is not true of diabetes treatments that involve injections so we have to support these individuals with appropriate management of this very disabling anxiety. It can take a healthcare professional a great deal of time and motivation to support someone with real treatment phobia. Often, with appropriate training and knowledge, talking therapies, such as cognitive behavioural therapy, can be very helpful. It is very important to gain the support of psychological therapies to help with these problems as the longer people are left without professional support, the more intense the negative feelings can become. Prompt referral to psychological therapies is the best option for people with severe treatment phobia.
Diabetes denial
It is not uncommon for people to develop “diabetes denial” following their diagnosis. Denying the severity of diabetes can lead to the avoidance of self-care and the positive lifestyle changes required. Newly diagnosed people may deny that they have a chronic condition that can result in serious complications. As healthcare professionals, we have to ensure that we do not fuel this denial; we should remind our patients that there is no such thing as “mild diabetes” or “just a bit of sugar”. Denial can be a problem in any aspect of diabetes, so it is important to be alert to this in consultations.
Long-term complications
People with type 2 diabetes have a two-fold increased risk of stroke within the first five years of diagnosis, compared with the general population and, in relation to hospital admission, there is a 75.7% increased risk of angina, a 55.1% increased risk of myocardial infarction, a 73.2% increased risk of heart failure and a 34.1% increased risk of stroke among people with both types of diabetes (Diabetes UK, 2014).
People diagnosed with diabetes should be educated about the long-term implications of their condition. Although it is vital for us diabetes nurses to have good in-depth knowledge, it needs to be recognised that without relevant support from other services, such as psychological support, anxieties about diabetes complications may continue or worsen and this will significantly impact on diabetes control.
Treatment for diabetes-related anxiety
The main aim of treatment is to help reduce or remove the symptoms so they no longer have an impact on day-to-day life of the person with diabetes and their diabetes management. In the time-limited diabetes consultation, an assessment has to be made about the impact of anxiety on the person’s well-being and it is important to ensure that all the information about diabetes and its management is communicated well and understood (Nash, 2013). The treatment options provided by the healthcare professional will depend on many factors, such as the level of anxiety, the severity and the type of anxiety.
Treatments for anxiety management will fall into the following categories:
- Talking therapies that allow the individual to verbalise about their feelings and anxieties. This support helps break the cycle of avoidance and helps the person to manage stressful situations with the use of relaxation techniques.
- Cognitive behavioural therapy (CBT) is very effective in helping the individual to understand the link between negative thoughts and mood, and how altering behaviours can help with the management of anxiety and allow the person to feel more in control.
- Mindfulness is a variation of CBT, focusing on changing the relationship between the individual and their thoughts. Using meditation can help people be “mindful” of their thoughts and break out of a pattern of negative thinking.
- Medication, such as antidepressants, can be used as a short-term help, rather than a cure; however, they generally are most useful when used in combination with other treatments.
The mental health service can support the diabetes practitioner to manage the anxiety condition with a holistic care plan, which ensures there is appropriate management of both conditions. If you are lucky enough to have psychological support attached to your service, it is vital you make a referral at the earliest opportunity. As stated previously, it is difficult for the person with diabetes to truly engage in diabetes self-management when anxiety is overwhelming. Therefore, the quicker someone can have the support needed, the sooner they will be able to address their diabetes needs.
If there are no services within your local mental health trust, NHS Choices or NHS 111 will be able to direct you to the most appropriate service in your area.
A recent report from Diabetes UK (2015) suggests there continues to be a significant gap in the provision of psychological support and care for people with diabetes. Although there is a gap in provisions in psychological support, we should continue to be positive about the services we do have and make sure we utilise those services effectively. Psychological support does have a positive impact on diabetes management, especially when it is incorporated into the diabetes service (Ismail, 2009; Britneff and Winkley, 2013; Nash, 2014).
The goal for the next few years should be to continue to improve the resources available, to continue to bring these teams together and utilise the knowledge and expertise from these services to more organisations throughout the country (Trigwell et al 2008; Diabetes UK, 2010).
Self-help
While the psychological support services available on the NHS can help manage anxiety in the person with diabetes, the reality is that there are often long waiting lists. While waiting to see a psychologist, the person can be signposted to a number of self-help resources designed specifically for people with diabetes. Some of these resources are listed in Box 1. It is also helpful to suggest that regular exercise can be a good way of alleviating anxiety.
Conclusion
Anxiety is a common emotion that people experience in response to situations that are viewed as threatening. Having anxiety can be useful as it can warn us about dangerous situations so that we can take appropriate action.
There are some good treatments available for a diagnosis of anxiety in a person with diabetes. These treatments will only be beneficial if they are utilised correctly and there is true collaboration between all healthcare professionals to support the individual with diabetes with both their diabetes and their anxieties. It is hoped that the importance of psychological support in diabetes and other long-term conditions is recognised as a priority for commissioners in the future (NHS Diabetes, 2009).
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