The correct answer is C.
Comorbid anxiety disorders and diabetes mellitus is known to occur more than would be predicted by chance alone. In a meta-analysis of 12 studies including data from nearly 13,000 individuals with diabetes, diabetes was associated with an increased probability of anxiety disorders (odds ratio [OR] = 1.20) as well as anxiety symptoms (OR = 1.48).1
Patients with diabetes who have a history of psychiatric disorders are at increased risk for depression and anxiety symptoms, and these high-risk patients should be monitored more vigilantly for symptoms of anxiety. The American Diabetes Association recommends that all patients be screened and assessed for symptoms of diabetes distress and anxiety (in addition to depression, disordered eating, and cognitive capacities) using standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.2 They also recommend including caregivers and family members in this assessment (with the explicit consent of the patient) and referring to a mental health specialist if indicated.
Hypoglycemic episodes and anxiety
Anxiety and diabetes are indirectly related via mutual factors. Pain, disability, depression, obesity, and inflammatory markers are independently associated with diabetes as well as anxiety, and the presence of one or more of these factors may underlie some of the comorbidity seen between the two conditions.
Physical symptoms of anxiety, particularly during panic attacks, such as increased heart rate, sweating, trembling, nausea or abdominal distress, feeling dizzy, numbness or tingling sensations can mimic symptoms during hypoglycemic states. Patients with diabetes may develop a phobia for needles or they may show an excessive fear for hypoglycemic episodes, and these anxiety reactions can result in poor glucose monitoring, non-adherence with insulin administration as well as deliberately maintaining hyperglycemic states to mitigate the fear of hypoglycemia. These anxiety and phobic symptoms may be particularly prominent in children with type 1 diabetes mellitus.
The following statement is FALSE: GAD-7 is not an appropriate instrument for screening of anxiety disorders in individuals with diabetes mellitus.
The 7-item self-report anxiety scale GAD-7 is a valid and efficient tool to assess for anxiety and was noted to have a sensitivity of 89% and specificity of 82% for diagnosis of GAD.3 It can be used to assess response to treatment, and it is a good indicator of symptom severity. GAD-2, which consists of the first 2 items of GAD-7, is also utilized as a screening instrument. It uses a cut-off of 3 and has a sensitivity of 80% and specificity of 81%.4
For more on this topic, see Treating Patients With Comorbid Anxiety and Diabetes Mellitus, on which this quiz is based.
1. Smith KJ, Beland M, Clyde M, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74:89-99.
2. American Diabetes Association. Standards of medical care in diabetes: 2019 abridged for primary care providers. Clin Diabetes. 2019;37:11-34.
3. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.
4. Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic meta-analysis. Gen Hosp Psychiatry. 2016;39:24-31.