Diabetes and Fear of Hypoglycemia

Hypoglycemia (low blood sugar) and fear of becoming hypoglycemic are two major concerns for patients who have diabetes mellitus. Actual hypoglycemia can be dangerous for patients because of the potential for accidents or death. Recurrent bouts of hypoglycemia, and the physical and psychological discomfort felt by the individual often leads to treatment nonadherence, higher levels of blood sugar, and subsequent complications (e.g., blindness, kidney failure, neuropathy, and amputations) from chronic hyperglycemia (high blood sugar).

Hypoglycemia occurs when blood glucose levels drop too low to maintain normal body and brain functions. The hypoglycemia can be classified as either mild (symptoms include shaking, sweating, and slowed thinking; patient can self-treat; symptoms disappear with self-treatment) or severe (severely low blood glucose in the brain causing lethargy, mental stupor or unconsciousness; person unable to self-treat because of low brain blood glucose). Actual measurements of what constitutes hypoglycemia for an individual are variable. However, a recent study of patients with Type 2 diabetes found that 3.2% of blood sugar readings were less than 70 mg/dl (normal ranges from 80 to 120 mg/dl). Patients who are utilizing intensive treatment methods (e.g., multiple daily injections of insulin or an insulin pump) are at greater risk for hypoglycemia.

Who is at Risk for Developing Fear of Hypoglycemia?

• Newly diagnosed patients who haven't yet learned to recognize symptoms or self–treat methods.
• Patients who have had a scary past episode of hypoglycemia.
• Diabetics who have generalized anxiety in other aspects of their life.
• Patients who live alone.
• Patients whose job or career could be negatively affected by hypoglycemia (e.g., truck drivers, pilots)

How to Recognize Symptoms of Hypoglycemia There are two ways to detect hypoglycemia: 1) self-testing of blood glucose with a meter and 2) detecting physical symptoms of hypoglycemia. Hypoglycemia can have a quick onset when individuals are not testing their blood glucose. Therefore, early recognition of physical symptoms of low blood sugar is very important in preventing a worsening course of events. Early signs of mental and motor dysfunction caused by neuroglycopenia (low blood glucose in the brain) include: difficulty concentrating, slowed thinking, lightheadedness or dizziness, and lack of coordination. There are a number of other symptoms not listed here. Additionally, mood changes such as irritation, anger, stubbornness, or euphoria in someone with hypoglycemia can interfere with others (e.g., family members, coworkers) attempting to assist the hypoglycemic diabetic.

Can Patients Learn to Recognize Hypoglycemic Symptoms? In a word, yes. The individual with diabetes can learn to recognize their own warning signs that they are headed toward a low blood sugar. However, there are three psychological barriers to accurate symptom perceptions:

• Inattentiveness which can occur when distracted or paying attention to other interests.
• Inaccurate symptom beliefs or "false alarms" such as hunger, fatigue, or anxiety which are just as likely to occur with normal or high blood sugars as they are with low blood sugars.
• Misattribution of symptoms. For example, an individual who is exercising may misattribute his or her sweating as being caused by the exercise rather than to hypoglycemia.

Patients can be taught blood glucose awareness training (BGAT) which improves their ability to detect and avoid both hypo- and hyperglycemic episodes. Briefly, BGAT involves an objective assessment of the patient's ability to detect hypo- or hyperglycemia and which symptoms most reliably co-occur with low blood glucose levels. The objective assessment involves the use of a daily diary where the patient:

• Observes themselves of any symptoms and records them on the diary.
• Records recent insulin or other blood glucose lowering medications, food, drink, or physical activity that the patient believes could be causing changes in blood glucose.
• Estimates or guesses what their current blood glucose level is and records it on the diary.
• Measures their actual blood glucose level with their meter and records it on the diary.

The diary gives a measure of how sensitive and specific a symptom is to fluctuations in their blood glucose. The best symptoms for the patient to become aware of for early detection of mild hypoglycemia, for example, are those that occur mostly when blood glucose is low and rarely when it is not. Patients can also be taught to become aware of neuroglycopenic (low brain blood sugar) symptoms as an early warning sign of hypoglycemia. That is, patients may note they are thinking or moving more slowly and that they have to exert more effort to do simple tasks such as reading, following a conversation, or typing. Patients may ask themselves the following questions to check for neuroglycopenia. Compared to my usual ability:

• Am I performing this task more slowly?
• Is it taking more effort to perform this task?
• Does this task seem more difficult than usual?
• Am I making more mistakes?
• In general, how impaired do I feel?

References:

Gonder-Frederick, LA, Cox DJ, & Clarke WL. (2002). Helping patients understand, recognize, and avoid hypoglycemia. In Barbara J. Anderson and Richard R. Rubin (2nd Ed). Practical Psychology of Diabetes Clinicians: Effective techniques for key behavioral issues. Am Diabetes Assoc.

Strauss GJ (1996). Psychological factors in intensive management of insulin-dependent diabetes mellitus. Nursing Clinics of North Am., 31, 737-745.

Gerald Strauss, Ph.D.
Clinical Health Psychologist