Although not as well studied in diabetes, some research suggests anxiety disorders are more common in adults with type 2 diabetes than the general population (66 - 68)  and anxiety symptoms are linked with worse glycemic control (67).

Demographic comparisons parallel depression, in that women, African-Americans, and those with less education are more likely to report anxiety symptoms (28).

Formal anxiety disorders include panic disorder, which involves repeated episodes of intense fear that strikes often and without warning. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, abdominal distress, feelings of unreality, and fear of dying.

Obsessive-compulsive disorder is characterized by repeated,  unwanted thoughts or compulsive behaviors that seem impossible to stop or control. Phobias include two major types of phobias: social phobia and specific phobia.

Social phobia involves the experience of an overwhelming and disabling fear of scrutiny, embarrassment, or humiliation in social situations, which leads to avoidance of many potentially pleasurable and meaningful activities. Specific phobias can produce extreme, disabling and irrational fear of something that poses little or no actual danger, the fear effectively leads to avoidance of these objects or situations and can cause people to limit their lives unnecessarily.

Finally, generalized anxiety disorder (GAD)  involves exaggerated,  worrisome thoughts and tension about everyday routine life events and activities, lasting at least 6 months. Individuals with GAD always anticipate the worst, even though there is little reason to expect it and the fear is accompanied by physical symptoms, such as fatigue, trembling, muscle tension, headache, or nausea.

Two clinically proven forms of psychotherapy used to treat anxiety disorders are behavioral therapy and cognitive-behavioral therapy. Cognitive-behavioral therapy teaches patients to understand and change negative thinking patterns, so the individual can react differently to the situations that cause them anxiety. In diabetes, behavioral interventions have reduced anxiety and improved glycemic control (69,70). Psychopharmacological agents can be effective in the treatment of anxiety disorders and treatment with SSRIs is becoming increasingly popular. Okada et al. (71) found reduced anxiety levels with fludiazepam, a benzodiazepine,  in a study involving a small patient group,  and glycemic control was improved in another study that focused on anxiety symptoms (72). There is relatively little information on benzodiazepine use in type 2 diabetes,  although one study found that antidepressant treatment reduced blood glucose levels in a sample of obese type 2 diabetics (28,73). Anxiety symptoms may be confused with the symptoms of low blood sugars among patients treated with sulfonylureas and insulin. Self-monitoring of blood glucose concentrations can help the anxious patient discriminate between hypoglycemia and anxiety (74). When emotional and behavioral symptoms (e.g., persistent fears, worries, obsessions, compulsions) are predominant, as opposed to physical symptoms (e.g., palpitations and sweating), the diagnosis of anxiety disorder is more readily made (29).

Garry W. Welch, Alan M. Jacobson, and Katie Weinger
Behavioral and Mental Health Research, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.

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