Anxiety + Diabetes

WRITTEN BY: Kristi Caporoso, MSW, LSW

State(s) of Fear

Anxiety has become one of the most commonly diagnosed mental illnesses in the United States. It seems everywhere you turn, someone is talking about it. Whether it’s their child or themselves that are afflicted, everyone and their mother seems to suffer from some level of anxiety. There has been a particular uptick in the level of anxiety reported in children and adolescents. While mental health professionals are trying to put their finger on what exactly is contributing to this – technology, political climate, homework – you don’t have to dig deep to find a reason for increased levels of anxiety in those living with Type 1 diabetes. To begin unpacking this issue, first let’s take a look at what the “A” word actually means.

What is anxiety, exactly?

A certain level of anxiety is healthy – necessary, even. It is what prevents us from engaging in dangerous behaviors, and what keeps us motivated to accomplish the things we need to do. The dictionary definition of anxiety reads as follows: “distress or uneasiness of mind caused by fear of danger or misfortune.”1 When this distress gets too high, or is disproportionate to the situation provoking it, the person tends to suffer from anxiety instead of benefitting from it.

Some of the more common forms of anxiety disorders are:

Generalized Anxiety Disorder (GAD)

A prolonged state of worry or tendency to worry about any and everything. GAD can have physical manifestations, such as GI problems and difficulty sleeping.  Someone living with GAD will have a tendency to view everything through a lens of anxiety, and be bombarded with “what-ifs?”

Panic Disorder

Panic disorder can occur after a person experiences one or multiple panic attacks, and is living in constant fear of the next one occurring. Everyone experiences panic attacks in different ways, but the most common symptoms are shortness of breath, feelings of impending doom, de-personalization (that feeling when you are floating outside your body), and heart palpitations, to name a few.

Social Anxiety Disorder

Basically what it sounds like, social anxiety disorder is when people experience extreme discomfort and anxiety around other people. This anxiety is rooted in the fear of what others think of you, or of embarrassing yourself or looking foolish.

Diabetes & Anxiety

T1D and anxiety are made to exacerbate one another. The fears and thought patterns that fuel anxiety are inherent to managing diabetes. On the flip side, struggling with anxiety can wreak havoc on your blood sugars. The more time I’ve spent working with and trying to pick apart anxiety disorders, the more I’ve realized how counterintuitive diabetes management is to anxiety levels.

What ifs

Running through the back of every anxious mind is a pestering whisper of what if? “What if I die?” “What if I embarrass myself?” “What if I fail?” These persistent questions can be crippling. However, when managing diabetes, it is often necessary to ponder what if. For example, I am about to pre-bolus for my dinner on my way home, but what if I get stuck in traffic? I am preparing for a run by adjusting my dosage and snacking, but what if it rains?

At the forefront of diabetes management is planning. Unfortunately, planning often invites what ifs, and what ifs can easily manifest into anxiety. When you are living with anxiety, it is often difficult to differentiate between rational or helpful what ifs and irrational, detrimental ones. Considering the rain or traffic while planning your insulin dosage can be productive, while repetitively pondering the possibility of going low and passing out during your exercise routine is not.

Living in the present

Similarly, planning for diabetes care can interfere with being present in the current moment. In recent years there has been growing evidence of the efficacy of mindfulness-based stress reduction (MBSR) and meditation for treatment of anxiety2. Much of our worry is rooted in what may or may not happen in the future. But it is hard to focus on the present moment and often difficult to be spontaneous when you’ve got insulin on board (IOB), sensors with downward-pointing arrows, and a fixed amount of juice in your handbag. Even the actual practice of meditation can be interrupted by alerting insulin pumps and CGMs. As mentioned above, diabetes management involves a lot of planning. And a lot of planning means a lot of future-oriented thinking.

Checking

Much like planning, with diabetes checking is essential. Checking you blood sugar, checking your IOB, checking your low supplies. But for someone with anxiety, checking can spiral into an obsessive ritual. People suffering from obsessive-compulsive disorder (OCD) have certain rituals they perform to quiet obsessive thoughts that repeatedly run through their mind. Because checking is so essential for diabetes management, it’s easy for someone susceptible to anxiety to fall into a pattern of over-checking. Picture this: you feel anxious about going low, check your sensor data and see no downward arrows. You feel a temporary wave of relief. But moments later, those thoughts recur. They get louder and louder in your head, until you have to check your sensor again – still no downward arrows. You see how this can fall into a negative thought-behavior cycle.

Where do we go from here?

Fortunately, much like type one, anxiety is manageable. But it takes work. If you feel like anxiety is interfering with you or your child’s everyday life, consider seeing a therapist. There are many therapists who have experience working with people with chronic illness. And if they don’t, BT1 has a helpful guide to teach them about type 13.

Where to start: finding a therapist

Your primary care doctor or pediatrician may have some referrals. Or, if you feel comfortable, ask around. It’s more than likely that many people in your life see a therapist and you have no idea. Or, if you have private insurance, you can try calling the “Member Services” number on the back of the insurance card and asking for referrals to local in-network behavioral health providers. There are also many ways to locate a therapist online:

If you have Medicaid (or Medical, or your state’s equivalent), your state’s Division of Mental Health and Addiction Services should have resources for local community mental health centers that accept this insurance. Your therapist or primary care doctor will also be able to suggest if you should consult a psychiatrist. A psychiatrist can prescribe medications for behavioral health concerns.

While diabetes and anxiety may make a great pair, you don’t have to constantly live at their mercy. As you learn to accept and manage your anxiety, you’ll learn how to live well with it. It won’t be easy, and there’s a lot of trial and error. Of course, having type one means you’re used to that! And always remember, you’re not alone in this.

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Diabetes Burnout

WRITTEN BY: Mark Heyman, PhD, CDE

Have you ever felt like you are just “done” with diabetes?

Are you sick and tired of doing everything you’re supposed to do, but feel like your blood sugar is still out of control? Do you feel like you don’t care anymore about managing diabetes and want to just give up? If any of these things sound familiar, you may be experiencing diabetes burnout.

Diabetes burnout is a state in which someone with diabetes grows tired of managing their condition, and then simply ignores it for a period of time, or worse, forever. Unfortunately, diabetes burnout is common, and most people with Type 1 diabetes (T1D) have experienced it at some point in their lives. After all, if you have T1D, you have to be “on” 24/7, and as much as we would like one, there are no breaks. People who experience diabetes burnout aren’t necessarily depressed and are certainly not lazy. In fact, almost everyone with diabetes, even those experiencing burnout, want to live long healthy lives. But sometimes diabetes can feel overwhelming and folks can get burned out from all the hard work.

What does diabetes burnout actually look like? While it may look different in people, there are some common signs and symptoms. These include:

  • Strong negative feelings (e.g., overwhelmed, anger, frustration) about diabetes
  • Feeling controlled by diabetes
  • Isolation, or feeling alone with diabetes
  • Avoidance of some, or all diabetes management activities and being unmotivated to change this behavior

If you have T1D and are feeling burned out, please know that there is hope! Diabetes is hard work, and until we have a cure, it will continue to be hard. However, there are some thing you can try that can help you overcome, and even prevent, feelings of burn out.

Manage your expectations

People with T1D tend to be really hard on themselves. They expect a lot from themselves, and when they don’t meet their own expectations, it can be frustrating. Anyone who lives with T1D knows that it is almost impossible to do everything “right” all the time. And even if you do everything “right”, your blood sugar can have a mind of its own and do some crazy things. If you expect perfection, and perfection is not possible, it’s normal to want to give up. Instead, try cutting yourself some slack. It’s ok to strive for perfection, but it’s important to cut yourself some slack sometimes and be ok with slipping up. And remember that sometimes, having wacky blood sugars is part of having diabetes.

Take small steps

Diabetes takes a lot of hard work and sometimes everything can seem overwhelming. When things get overwhelming, you may not even know where to start. Instead of tackling a big task all at once, try breaking it down into small steps that you know you can accomplish. For example, telling yourself you want to reduce your A1C from 8% to 7% may sound like a Herculean task. However, if that is your goal, identify the specific things you can do today to get there. For example, you can check your blood sugar at least 4 times a day and count carbohydrates at every meal and take insulin to cover. Taking small steps can make achieving big goals seem a lot more obtainable.

Get support

Feeling like you’re alone in your life with diabetes is a big risk factor for diabetes burnout. With diabetes, isolation is one the biggest risk factors for becoming burned out. If you feel that nobody understands what you are experiencing or that you are the only person with diabetes that feels this way, life with diabetes can be a lonely place. While feeling supported does not make T1D go away, it can make it easier to live with. Getting support, encouragement and empathy from others can be a critical part of staying motivated to manage your diabetes. Sometimes the people in your life may not know what kind of support you need. Be clear with these people what would be most helpful and what you want them not to do. Remember that other people with T1D can also be a great source of support. These are the folks who know exactly how you’re feeling, because, at some point, they have probably felt the same way. If you don’t know anybody else with T1D, there are resources that can help. Many communities have meet-ups for people with T1D and there is an active diabetes online community on social media.*

If you feel burned out with T1D, you are not alone. Just remember that many people have overcome their burnout and are able to live long, happy and healthy lives with T1D. If you are experiencing diabetes burn out and you feel like you can’t deal with it on your own, it’s important to get help from a mental health professional who understands diabetes. Talk to your endocrinologist to see if s/he can recommend one in your area.

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Depression and Its Relationship to Type 1

Are depression and diabetes related?

The simple answer: yes.

Research shows that if you have diabetes, your risk of developing depression more than doubles. In fact, some studies show, that it could be as high as four times more likely.

And while this information may seem like just one more thing to worry about, it’s important to address and discuss, because doing so has the potential of improving your quality of life. And who doesn’t want that?

Someone once said, “Diabetes is a full-time job that you didn’t apply for, you can’t quit and there’s no vacation or pay.” (We’re nodding.) Agreed — no one lined up for the diabetes merry-go-round or the diabetes loop-dee-loop, because diabetes isn’t fun. Actually, it’s a royal pain. And you never get a break.

You know the drill: count carbs,  administer insulin, (factor in activity, stress and consider what’s happened before),  monitor blood sugars, rest, eat or compensate.

And no matter how vigilant you are and how meticulously carbs are counted and insulin accordingly dosed, you’ll get the rogue BGL, the unexpected zinger that just makes you feel like chucking that juice box or screaming or crying or crawling into a ball and giving up because sometimes you can’t be perfect — no, you aren’t perfect and this diabetes thing is hard, really hard and just when you think you got it right and you’re really hitting your stride … you’re tested, you’re thrown and have to try again then again and again. It’s no wonder the chronic condition can cause anxiety, feelings of frustration and even hopelessness.

Diabetes isn’t just a physical challenge with serious implications; it’s also emotionally demanding and can be extremely difficult to navigate mentally. That’s why the most effective treatments for Type 1 include medical care as well as psychological care.

Everyone at some stage of their life will experience “feeling down.” It’s important to note though, that depression is more than feeling “bummed out.” It’s a persistent feeling (lasting more than two weeks) of sadness or loss of interest, among other symptoms. It can be debilitating, life-altering and throw you down the rabbit hole of self-doubt. It also can be subtle. Perhaps you hadn’t really noticed, and it’s a loved one who’s mentioned the changes, has noted that things aren’t “okay”. Whichever way, don’t worry; take heed! You’ve made it here and you aren’t the first.

If you’re experiencing symptoms in at least three of the following categories, you may be depressed:

Things you may do …

  • Stop doing things you used to enjoy
  • Have trouble getting things done
  • Are unable to focus
  • Remain in your home for long periods of time
  • Pull away from loved ones
  • Use alcohol or sedatives excessively

Things you may think …

  • “I’m worthless”
  • “I’m not good enough”
  • “I deserve to feel like this”
  • “I will never be happy”
  • “This is my fault”
  • “Life is not worth living”

Things you may feel …

  • Guilt
  • Irritability
  • Anger
  • Frustration
  • Unhappiness
  • Indecisiveness
  • Disappointment
  • Sadness

Things you may experience physically:

  • Lethargy
  • Feeling sick and run down
  • Having headaches and body pains
  • Having an upset stomach
  • Irritabile bowels
  • Insomnia or excessive sleeping
  • Extreme weight changes and appetite changes

Note: This is just a short list of symptoms you may be experiencing if you’re depressed. Consult a mental health professional for proper assessment and treatment.

Did you say, yes to all of them? Say, yes to none? Either way: keep reading.

Your mental health affects how you deal with your physical health, so if you become depressed, you’re less likely to manage your diabetes well, which can lead to complications and poor health in general. Essentially, both aspects of care are paramount and affect your well-being in tandem, so don’t neglect either today or tomorrow!

Dr. Diana Naranjo, Assistant Professor of Psychiatry & Behavioral Studies and Dr. Korey Hood, Professor of Pediatrics at Stanford University, work exclusively with diabetes patients and believe that in terms of having optimal mental health with diabetes, depression prevention is key. If you know you are at a higher risk of developing depression or an anxiety disorder, being proactive can also improve your quality of life in the long run.

Planning ahead is all a part of self-care and can include reaching out to the support sources of friends, family, community groups and your credentialed diabetes educator or therapist.

If you have diabetes, it’s normal to experience a wide range of emotions as well as suffer physical setbacks. Especially right after diagnosis, many people report grieving for their health from before and the life they had previously. This is also true for parents or caregivers of those diagnosed with Type 1 diabetes.

The bottom line is that your mental health matters — early in the game and later on — so talking to a health professional can help. Treating your depression or anxiety may require more than talk therapy though. Some people are genetically predisposed to developing mental illness while life circumstances and stress can bring the onset of symptoms. Treatment could include short-term or long-term medication in conjunction with other forms of therapy.

Be sure to ask your therapist if he or she has had experience with clients who have Type 1. If not — and this is most likely the case — you can provide your mental health caregiver with additional information to help her or him understand what Type 1 is and the difficulties you face daily.

“Remember, you’re interviewing and hiring your therapist,” says Dr. Korey Hood. “And the discussion of mental health should not be separate from the discussion about your diabetes.”

In addition to working with a mental healthcare provider, try implementing the following in terms of self-care to help maintain a healthy mental state:

  • Join a community, reach out to other T1D groups and share your story
  • Ask questions of others, learn more about diabetes and depression
  • Perform moderate physical activity (consult your doctor about what would be a healthy level of exercise)
  • Eat healthy foods
  • Maintain a healthy weight
  • Limit your alcohol use

If you think you or someone you know might be contemplating suicide, reach out for additional help here:

Suicide Prevention Lifeline Or call 1 (800) 273-8255 (United States)

Just as much as blood glucose levels are important information in managing your diabetes successfully, so are feelings. Remember that you aren’t alone and there are people out there who understand and have been there. Reach out. Be proactive. And talk about it. There is a wide range of mental health treatments available, so consult a expert today to learn how you can improve your quality of life.

Verified by Dr. Mark Heyman, Director of the Center for Diabetes and Mental Health (CDMH) in Solana Beach, CA. Mark received his PhD in Clinical Psychology from The George Washington University and completed his clinical training at UCSD School of Medicine.

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