Anxiety about complications of diabetes?

Many patients become very anxious when physicians tell them about the potential complications of diabetes. Their reactions cover a broad range of behavioral patterns. Some become permanently afraid. They either try to severely restrain themselves in order to achieve a normal blood glucose level or give up all efforts of self-discipline altogether. Others fight their fear either by playing down the danger or by ignoring it completely. In essence, they all seek to eliminate any impact of the disease on their life. Many patients find their own way to cope with the potential consequences of diabetes by a combination of confronting the challenge and avoiding it when they deem necessary.

Medical complications further complicate patients' social and individual life: the impairment of vision deteriorates their general orientation; diabetic-foot-syndrome restricts patients' ability to move; renal disease requires more therapeutic effort particularly when dialysis becomes necessary. In many cases anxiety increases when complications of diabetes occur and patients get depressed. Therefore, it is essential for mental health to avoid complications as much as possible and to deal with them when they occur.

How people respond to the onset of complications depends on several factors: age, individual circumstances, or previous practices of coping with psychological stress influence patients' reactions. What adolescents simply ignore may be extremely shocking to young adults; an older patient with type 2-diabetes may perceive a small and not particularly upsetting change in health conditions merely as another inconvenience that adds to several others resulting from different diseases.

Anxiety is part of life

Anxiety is a normal emotional reaction to perils that cannot be avoided. It generates uncertainty about their nature and is a proper response to danger. It is therefore quite natural to be anxious about the complications of diabetes. We know that modern diabetes therapy can minimize the risk of further complications but nobody can guarantee successful prevention. People experience anxiety about chronic diseases differently. Most diabetes patients state that anxiety is always present in the back of their mind. Special circumstances and situations, e.g. when an ophthalmologist performs a routine eye examination, can move it to the front and it will automatically recede to the background afterwards. Naturally, people discuss this healthy type of anxiety with friends, in a self-help group, or with members of a diabetes-team.

However, when anxiety endures and becomes so overwhelming that it starts to dominate and restrict a patient's life, he or she should seek psychological or psychotherapeutic support. Such treatment is neccessary for example when patients continuously think about complications, when they frequently seek their physician's confirmation about their health, when they test their blood glucose level very often due to anxiety, when they overly restrict their diet, or when they feel compelled to pedantically weigh each food item. These behavioral patterns may indicate a compulsive disorder closely related to anxiety that renders living a normal life virtually impossible. In all these cases psychotherapists familiar with diabetes provide crucial support. The Arbeitsgemeinschaft Psychologie und Verhaltensmedizin provides a list of psychologists in Germany who have completed special training in psychological problems associated with diabetes.

Parents of kids with diabetes

Parents experience anxiety about diabetes complications and are concerned, too. They hope their child will grow to good health, be educated, find employment, and be able to enjoy the prospect of a long, happy, and successful life without complications. This anxiety is an appropriate emotional reaction to vague threat, too. Often parents experience anxiety more intensely then their child because children unintentionally take risks that expose their parents to permanent apprehension. As with adults suffering from diabetes such fear is natural and serves the useful purpose of orientation as long as diabetes does not dominate the entire life of the child and its family and as long as it does not interfere with the child's natural development.

However, if parents prevent their child from making its own experiences because of their anxiety they interrupt his natural development towards independence. At the appropriate stage of its development a child with diabetes has to learn to manage his own therapy as much as possible. Diabetes teams offer professional support to parents with permanent and intense anxiety about complications. Other parents, active in self-help-groups such as in the Deutsche Diabetiker Bund, may provide support, too. Also, there are opportunities to interact with other parents of diabetic kids on the internet (www.projekt-d.de; www.diabetes-kids.de). When these opportunities prove insufficient and anxiety remains it can be treated by psychotherapy. The Psychotherapieführer of the German Association of Psychology and Behavioral Medicine has a list of psychologists in Germany familiar with the specific problems of diabetic children, adolescents, and their families.

Adolescents are often not frightened and take risks. This general observation applies to many adolescents with diabetes, too. Understandably, parents are extremely concerned about their children's risk taking behavior. Their anxiety interferes with their permission of typical teenager activities such as nightly visits to a disco or alcohol-drinking. Explicit agreements between the adolescent and his/her parents may help control risks by specifying conditions. In addition, these agreements may reduce parents' anxiety. Teenagers with anxiety about complications should seek help primarily from their diabetes team. When anxiety persists and especially if it is combined with depression, adolescents should not hesitate to seek professional psychotherapeutic help (the German Association for Diabetes and Behavioral Medicine provides useful addresses and helps with arranging appointments).

Help yourself

Try to find out by talking to other people with diabetes if your anxiety is similar to that of others or if it is significantly more severe. If you are more negatively affected by your anxiety than you would like, you may find a way to minimize it here:

1. "Life is always dangerous" is a common dictum. It means, that we are not able to eliminate all threats. As we all have to die sometime, despite of all precautions, we cannot avoid all diseases. When we are too cautious, precaution becomes an obsession that restricts the pursuit of a normal and happy life. In this case, prevention of complications turns into a psychological problem. Following common sense and pursuing an active life including risk taking are the best protection against an overwhelming and paralyzing anxiety.
2. Anxiety increases because one overestimates the danger and underestimates one's own skills in coping with it. Patients with diabetes need professional and detailed training that addresses these fears and teaches key techniques to help cope with anxiety. Participants of such training lessons learn that an appropriate therapy and self-management can minimize the risks of complications but cannot completely eliminate them. Since everybody faces some risks, one needs to learn how to accept the inevitable ones. Most diabetes patients will usually find their own individual way of coping.
3. Emotions do not disappear by suppression (e.g. permanent distraction and activity or avoidance of threatening information). Living with anxiety means checking the danger and preventing it in an appropriate way. Studying every detail of a threat only increases anxiety. You should learn how to endure residual anxiety, how to make it a normal part of your life, and how to discuss it with others. To experience no fear of complications is not an indication of mental health.
4. Coping with the anxiety is more difficult, if complications already exist and if you fear their deterioration because you are permanently confronted with the cause of your anxiety. However, the psychological coping mechanisms for coping with anxiety do not differ fundamentally from those used before the occurance of complications. It is necessary to seek information, to find opportunities for self-treatment and prevention. The dialogue with your diabetes team and other patients is the key to an effective treatment. It is important "not to get wound-up" but to look for opportunities that remain in spite of a deteriorating health. In cases of very serious complications a steady relationship to others who can encourage with help and understanding is most important.
5. If you notice that you are making no progress despite all your efforts at self-treatment, you should not hesitate to contact a psychologist familiar with diabetes. It is possible that depression is impeding your ability to self-treat and it is necessary to gain therapeutic support for the depression, too.

Author: Dr. Axel Hirsch
Translation: Dr. Christian Tuschhoff, Susan Woods

Last update: 2004-03-17