Fear of diabetes complications

Received: 1 December 2004 Symptoms of anxiety and depression are common in people with diabetes. While there may be, in part, a biological explanation for these symptoms, nonbiological factors such as concerns regarding employment, insulin injections and future complications are likely to be of considerable importance. In recent years, much attention has centred around the assessment and measurement of ‘Fear of Hypoglycaemia’ in people with type 1 diabetes. In this issue of DMRR, the development of a new scale to assess ‘Fear of Complications’ in type 1 diabetes is described. The scale has been derived using sophisticated statistical methodology and has been shown to be reliable and valid. Scales such as these are essential to allow health care professionals to determine accurately the prevalence and magnitude of psychological problems in people with diabetes and to aid in the scientific evaluation of putative management strategies. It has long been recognised that anxiety and depression are more prevalent in people with diabetes than in the general population. The symptoms of anxiety and depression may, in part, be caused by biological changes associated with diabetes, for example, fluctuations in blood glucose concentrations out of the normal physiological range, hypertension and the occurrence (and treatment) of microand macro-vascular complications of diabetes. However, much of the psychological burden of diabetes probably relates to non-biological factors, for example, concerns regarding insulin injections, dietary restrictions, risk of future complications and employment prospects. Since the 1980s, Dan Cox and colleagues at the University of Virginia, USA have performed a variety of seminal investigations exploring the psychological impact of hypoglycaemia on people with type 1 diabetes. They developed a ‘Fear of Hypoglycaemia’ scale, which sought to quantify the anxieties that people with type 1 diabetes have regarding hypoglycaemia and the extent to which individuals take steps to avoid experiencing such episodes [1]. Unsurprisingly, there is a close risk between fear of hypoglycaemia and perceived risk of future severe hypoglycaemia [2]. In many instances, this is appropriate in that ‘fear’ ratings are often high in people who have impaired awareness of hypoglycaemia and/or have experienced multiple episodes in the past. However, in other people, fear of hypoglycaemia may be high, while absolute risk is low – such individuals often display high levels of trait anxiety or have had a traumatic previous experience of hypoglycaemia. It is often extremely difficult to persuade such individuals to maintain strict glycaemic control. Conversely, there are people with very low fear of hypoglycaemia, despite a propensity to recurrent episodes. Such individuals may fail to take appropriate precautionary measures, thereby putting themselves at risk and, indeed, the wider population if hypoglycaemia occurs, for example, when that individual is driving. The importance of the studies by Cox and others is that, by having a properly validated scale of ‘Fear of Hypoglycaemia’, it is possible to measure this construct in a scientific fashion. This increases our understanding of the problem and, in theory, should allow health care professionals to work with patients to reduce the psychological burden associated with hypoglycaemia. In that regard, the publication in