Fears and phobias in people with diabetes

CLINICAL CHALLENGES IN DIABETES

Fears and phobias in people with diabetes

Lucinda Green1*

Michael Feher2

Jose Catalan3

1Psychological Medicine Unit,South Kensington and ChelseaMental Health Centre,1 Nightingale Place,London SW10 9NG, UK2Beta Cell Diabetes Centre,Chelsea and Westminster Hospital,369 Fulham Road,London SW10 9NH, UK3Imperial College School of Medicine,Charing Cross and WestminsterCampus, Psychological MedicineUnit, South Kensington and ChelseaMental Health Centre,1 Nightingale Place,London SW10 9NG, UK

*Correspondence to: Dr L. Green,Psychological Medicine Unit, SouthKensington and Chelsea MentalHealth Centre, 1 Nightingale Place,London SW10 9NG, UK.E-mail:[email protected]

Published online: 3 July 2000

Summary

Phobic disorders are more common in people with diabetes than in thegeneral population. The management of phobic disorders in patients withdiabetes, particularly when associated with a fear of hypoglycaemia, isespecially challenging and requires close collaboration between psychologicalmedicine and diabetes teams. Dif®culty in distinguishing symptoms of anxietyfrom those of hypoglycaemia, and the real dangers associated with hypo-glycaemia, complicate the delivery of psychological interventions that areused routinely in the treatment of phobias. Avoidance of hypoglycaemia canlead to deterioration in diabetes control. This case report describes a manwith Type 1 diabetes who developed agoraphobia with panic disorder,associated with fear of hypoglycaemia and deterioration in glycaemic control.The management of patients with diabetes and phobic disorders, withparticular reference to those associated with fear of hypoglycaemia, isdiscussed. Copyright # 2000 John Wiley & Sons, Ltd.

Keywords diabetes; phobic disorders; fear; hypoglycaemia; therapy

Background

People with diabetes may develop a variety of phobic disorders associatedwith treatment with insulin, such as fear of needles and injections and fear ofhypoglycaemia. In treating such patients in a joint diabetes±psychologicalmedicine clinic [1,2] we have found that phobias associated with fear ofhypoglycaemia are particularly challenging, both in terms of the managementof the patient's diabetes and of the phobia. A case example is presented of aman whose fear of hypoglycaemia led to agoraphobia, and the managementof phobic disorders in people with diabetes is discussed.

Case report

A 35-year-old man, with a 15-year history of Type 1 diabetes which hadalways been well controlled (HbA1c<7%, compared to a local non-diabeticrange of 4.3±6.11), was referred to the diabetes clinic after experiencingfrequent episodes of hypoglycaemia. These started 3 months previouslywhen, in an attempt to lose weight, he reduced his total food intake andstopped having snacks between meals. Initially he experienced four episodesof hypoglycaemia during the same day, one while he was driving. By the timethe patient was reviewed in the diabetes clinic, he realised that many of theepisodes of shaking and palpitations had occurred with near normal, and notlow, blood glucose levels. His insulin dose was reduced, and he was assessedby the liaison psychiatrist attached to the diabetes team, who subsequentlybecame involved in his management.

During his psychiatric assessment the patient recalled that the hypo-glycaemic episode which occurred while he was driving in busy traf®c hadbeen very distressing. He described having narrowly avoided a serious road

DIABETES/METABOLISM RESEARCH AND REVIEWSDiabetes Metab Res Rev 2000; 16: 287±293.DOI: 10.1002 /1520-7560(2000)9999 : 9999<: : AID-DMRR123>3.0.CO;2-T

Copyright # 2000 John Wiley & Sons, Ltd.

traf®c accident by pulling over to the side of the road andstopping the car. He initially avoided driving for a fewdays following this episode. However, he needed to driveto work and so had resumed driving but only withsomeone else in the car or at times when he was sure theroads would be quiet, taking routes he knew not to bebusy. If he found himself driving in traf®c he would stopand wait for the roads to clear. While driving he hadfrequently experienced episodes of palpitations, breath-lessness, nausea, a feeling that he was `shaking inside' andthat his mind was `going blank'. This was associated withthoughts such as: `My sugar's going low. If I don't pullover I'm going to cause a major accident'.

Initially his worries related only to driving. Howeverthe symptoms soon became more generalised. Heincreasingly became preoccupied with the idea that hemight have a hypoglycaemic episode in a place wherenobody knew him. He began to feel unsafe walking anydistance from home or from his workplace. He bought amobile phone and made various people aware that hemay need to contact them in the event of developinghypoglycaemia. He avoided travelling on public transportand going to crowded places from which he could noteasily escape. One on occasion he had to rush out of asupermarket. On most days he had episodes which heassumed to be hypoglycaemia. However, testing revealedthat his blood glucose was in the normal range, and hewas usually not hypoglycaemic.

As a consequence of avoiding hypoglycaemia hisglycaemic control deteriorated and his HbA1c rose to8.5%. He became increasingly preoccupied by thepossibility of suffering complications of diabetes. Atnight he lay awake ruminating anxiously about theprospect of either dying as a result of nocturnal hypo-glycaemia or developing diabetic complications. He hadpreviously coped with diabetes extremely well and it hadnot interfered with his life. He now felt increasingly outof control and frustrated by his symptoms and thelimitations they imposed on his daily functioning.

The patient had no previous psychiatric history and noother signi®cant medical problems. There were noproblems at home or work that could have contributedto his presentation. However, his avoidance of drivingand walking far from home was beginning to cause somedif®culties in these areas of his life, although both his wifeand his employer were supportive.

A diagnosis was made of agoraphobia with panicdisorder. The cognitive behavioural model of phobia wasdiscussed. A formulation using his symptoms, as shown inFigure 1, was shared with him. It is usual to explain topatients that although anxiety symptoms are unpleasantthey are not dangerous. By contrast, this may not be thecase with exposure to severe hypoglycaemia with the riskof producing irreversible neurological change. Distin-guishing between anxiety symptoms and hypoglycaemiawas initially an important focus of treatment. The patientcompleted a diary of episodes in which episodes of eitherpanic or hypoglycaemia were documented, an example ofwhich is shown in Figure 2.

It was dif®cult to make a de®nite distinction betweenpanic attacks and hypoglycaemia, but certain featureswere identi®ed. These included the fact that the onset ofsymptoms was more sudden and the tremor was moresevere during hypoglycaemic episodes. If he had testedhis blood glucose or eaten shortly before the onset ofsymptoms, the patient was more con®dent that theepisode was in fact panic-related.

A graded hierarchy was constructed in relation todriving, with situations ranked according to the degree ofanxiety expected. These ranged from driving with some-one else in the car on empty roads, to driving alone inrush-hour traf®c. A separate hierarchy was constructedfor walking from home and entering crowded places. Thepatient agreed gradually to attempt each stage of thehierarchy, beginning with the easiest, and initially testinghis blood glucose each time. He rated the degree ofanxiety he anticipated experiencing and that actuallyexperienced, in addition to recording associated thoughts.He was also instructed in the use of relaxation anddistraction techniques which he found helpful. He learntto challenge catastrophic thoughts as they occurred.Practical measures such as carrying a card identifyinghimself as having diabetes and always carrying snacks orglucose were also helpful.

The patient was able to cope increasingly with fearedsituations. Recording blood glucose alongside physicalsymptoms and thoughts in a variety of situations providedevidence that his blood glucose was not low on themajority of occasions and that many of the episodes hehad perceived to be hypoglycaemia were in fact panicattacks. This has reduced his general levels of anxietyand behaviour to avoid a low blood glucose. His HbA1c

has returned to 7.4%. He has remained relativelyfree from episodes both of hypoglycaemia and panicand no longer avoids situations because of a fear ofhypoglycaemia.

Discussion

Hypoglycaemia is usually an unpleasant experience andnot only affects cognitive function and generatescharacteristic symptoms, but is also associated withchanges in mood including a feeling of tense-tiredness,anger, irritability and pessimism about life events [3,4].Fear of hypoglycaemia is common and worries patientsas much as the development of serious complications[5], and can alter behaviour and attitudes to self-management, so that hypoglycaemia is considered thegreatest limitation to achieving strict glycaemic control.

The present case illustrates how fear of hypoglycaemiacan have a signi®cant impact on an individual's physicaland psychological wellbeing. This man developed a severepsychological disability with agoraphobia and panicdisorder, and his avoidance of hypoglycaemia led todeterioration in metabolic control. The management ofhis diabetes was made more complex as a result of thephobia. Treatment of the phobia was far less straight-

288 L. Green et al.

Copyright # 2000 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2000; 16: 287±293.

forward than for agoraphobia in general because of thedif®culty in distinguishing between symptoms of hypo-glycaemia and anxiety, and because of the real danger ofhypoglycaemia occurring while he was driving.

Phobic disorders

Fear is a normal, evolutionarily advantageous response tothreat. Fear and moderate anxiety also have an importantrole in enhancing performance. In phobic disorders

anxiety is evoked mostly by well-de®ned situationswhich are not objectively dangerous. Phobic anxiety isindistinguishable subjectively, and physiologically, fromother types of anxiety and may vary in severity. Marks [6]identi®ed criteria for phobia as follows: Fear is out ofproportion to the demands of the situation; it cannot beexplained or reasoned away; it is not under voluntarycontrol; and the fear leads to avoidance of the situation.Typical symptoms that occur when the individual entersthe phobic situation are outlined in Table 1. These can

Figure 1. Model for the development of phobia associated with fear of hypoglycaemia

Figure 2. Example of panic diary

Phobic Disorders in Diabetes 289


also occur prior to encountering the feared circumstances(anticipatory anxiety).

Phobias can be (a) speci®c (or simple), where anxietyoccurs only in the presence of a particular object orsituation, for example the sight of blood; (b) social

phobia, where anxiety occurs predominantly in socialsituations and the fear is of scrutiny and criticism by otherpeople; or (c) agoraphobia, where the anxiety includes atleast two of the following situations: crowds, publicplaces, travelling away from home and travelling alone,and typical thoughts include fear of collapsing and beingleft helpless in a public place. Agoraphobia can occur withor without panic disorder. In all phobias avoidance of thephobic situation is a key diagnostic feature.

A number of studies have reported an increasedprevalence of phobias in patients with diabetes. Lustmanet al. [7] reported lifetime prevalence rates for phobias in arandomly selected sample of people with diabetes to be:simple phobia 26%, agoraphobia 16% and social phobia11%. Signi®cantly higher rates of overall lifetime andrecent psychiatric illness were identi®ed in patients withpoorer metabolic control. Popkin et al. [8], consideringonly patients with Type 1 diabetes, identi®ed lifetimeprevalences of 21% for simple phobia, 11% for agora-phobia and 7% for social phobia. In the general populationlifetime prevalence has been rated as 11% for simplephobia and 6% for agoraphobia [9]. Lifetime prevalencerates for social phobia vary from 2% to 5% [10].

Few authors have considered the onset of phobicdisorders in diabetes in relation to onset of diabetes. Inpeople with Type 1 diabetes, simple phobia and socialphobia have been found to precede the onset of diabetesin 80% of cases [11]. Agoraphobia occurred in the earlyphase of treatment in two-thirds of cases.

Phobias and glycaemic controlThere is con¯icting evidence regarding the relationshipbetween anxiety disorders and glycaemic control. In across-sectional study involving 102 patients with Type 1diabetes, Berlin et al. [12] found that patients with poorglycaemic control had higher scores for symptoms ofagoraphobia and fear of blood or injury, but not for socialphobia. Patients with fear of blood and injury performed

fewer blood glucose measurements and this was asso-ciated with poor glycaemic control. In contrast, Friedmanet al. [11] found that poor metabolic control wasassociated with social phobia, but not simple phobia oragoraphobia. An association was identi®ed between socialphobia and poor compliance with dietary regimen,particularly extra snacking.

Fear of hypoglycaemia

Severe hypoglycaemia can be very disruptive andimpinges on every aspect of daily life. Fear of hypogly-caemia is therefore common in people with insulin-treateddiabetes, especially if severe hypoglycaemia has occurredin potentially dangerous situations (e.g. while driving) orhas caused serious morbidity. In some cases the fear is soextreme that patients meet the criteria for phobia, withavoidance of hypoglycaemia per se and of situations inwhich hypoglycaemic episodes have occurred previously,in addition to exhibiting signi®cant interference withfunctioning. Irvine et al. [13] found that frequency of pasthypoglycaemia was signi®cantly related to the Hypogly-caemia Fear Survey (HFS) behaviour subscale score [14],suggesting that the adversity of these experiences may bemotivating individuals to avoid future episodes. A link hasbeen proposed between fear of hypoglycaemia andavoidance of this by deliberate maintenance of elevatedblood glucose concentrations [14,15]. Weiner and Skipper[16] found that fear of hypoglycaemia led to pooradherence to the therapeutic regimen for diabetes.

Polonsky et al. [17] examined the relationship betweenanxiety and fear of hypoglycaemia in both Type 1 andType 2 diabetes. Higher scores on the HFS-W (worrysubscale) were associated with higher levels of traitanxiety and fear. People with Type 1 diabetes had higherlevels of hypoglycaemic fear and their HFS-W scores werepositively associated with past hypoglycaemic experience,frequency of hypoglycaemia, and dif®culty differentiatingbetween symptoms of anxiety and hypoglycaemia. Theseauthors suggested two possible sequences of events. First,hypoglycaemic fear may result from recurrent hypogly-caemia, leading to dif®culty with symptom discriminationand the development of more pervasive and chronicanxiety and fear. Alternatively, chronically anxiousindividuals may be more likely either to fail to perceivethe initial warning signs of hypoglycaemia or to confusethese with anxiety. This may lead to increased anxiety anduncertainty concerning the onset of hypoglycaemia.When hypoglycaemic episodes are frequent a conditionedfear response may develop.

Management of phobias in people withdiabetes

There is little evidence-based research relating speci®callyto the treatment of phobias in diabetic patients. Thepresent discussion focuses on established psychologicaland pharmacological treatments for phobic disorders inpatients who do not necessarily have chronic medical

Table 1. Typical symptoms occurring in phobia

Physical symptoms Thoughts Behaviour Emotion

Palpitationsa Catastrophic thoughts Avoidance of FearSweating such as: phobic situations AnxietyTremor Ì am going to die' Escape from PanicBreathlessness Ì am going to collapse' situationsDif®culty swallowing Ì am going to make a Safety seekingMuscular tension fool of myself' behaviour, e.g.Numbness Ì am going to lose not going intoTingling control' situation aloneNauseaDizziness Overestimation ofDry mouth dangerEtc

aIn fear of blood and injury, bradycardia and hypotension occur which can leadto fainting.

290 L. Green et al.


illness, and will highlight the areas in which diabetes andfear of hypoglycaemia make management more compli-cated than usual.

Identi®cation and diagnosisPatients attending a diabetes outpatient clinic maypresent a wide variety of problems and may not readilyvolunteer symptoms of anxiety as an issue for discussion.However, symptoms of anxiety are common and caninterfere signi®cantly with diabetes management, forexample leading to avoidance of insulin injections [18].Both patients and doctors may have dif®culty discrimi-nating between symptoms of anxiety and hypoglycaemiaas there is considerable overlap. Piaggesi et al. [20]reported on two patients, with previously well-controlleddiabetes, who experienced frequent episodes of sweating,anxiety, tremor, tachycardia and confusion. These wereinterpreted as hypoglycaemia, leading to an increasedintake of re®ned sugar and deterioration in metaboliccontrol. Psychiatric assessment revealed an underlyingpanic disorder.

It is important that physicians are vigilant and consideranxiety disorders as a diagnostic possibility, especially inpatients with recurrent hypoglycaemia or those with poormetabolic control who may be deliberately maintainingchronic hyperglycaemia to avoid hypoglycaemia. If ananxiety disorder is suspected, referral should be made to aclinical psychologist or a psychiatrist, who preferably hasexperience of managing psychological problems inpatients with diabetes. Close collaboration between thediabetes and psychological medicine teams should bemaintained [19].

An initial psychological assessment should focus ondetermining the precise nature of the phobia by obtaininga detailed account of the development of the problem, thesituations which are feared and the patient's physicalsymptoms, associated thoughts and behaviour whenfaced with these situations. It is also important toconsider the extent to which the problem interfereswith the patient's functioning. As avoidance is a crucialdiagnostic feature, has an important role in maintainingthe phobia, and is a key factor in determining thetreatment plan, it is essential to discuss this in detail.Other maintaining factors should also be discussed,including thoughts about how dangerous the phobicsituations may be, and other co-existing psychiatricdisorders such as depression. Coping skills, which makephobic situations easier to handle, should be identi®ed,with particular attention to potentially harmful strategiessuch as alcohol or benzodiazepine use. Substance misuseor dependence and other co-morbid psychiatric disordersmay need to be addressed prior to treating the phobia.The patient's attitude to treatment and willingness to bean active participant in this should also be considered.

In patients with diabetes who present with phobicdisorders, it is obviously important to discuss theirexperience of diabetes in general and the way that thephobia affects glycaemic control. A needle or bloodphobia may present as a problem relatively soon after

diagnosis. If so it is important to explore the patient'sreaction to ®nding that they have diabetes, as it is likelythat this will have an impact on their willingness toengage in treatment for the phobia.

Psychological interventionsBehavioural and cognitive behavioural therapies haveproven ef®cacy in the treatment of phobic disorders withgains maintained in the long term [21±26], although nospeci®c evidence is available in relation to diabetes.

The focus of treatment in behavioural therapy ofphobias is on altering problematical behaviour, predomi-nantly phobic avoidance. A behavioural analysis isconstructed using evidence recorded by the patient.Speci®c aspects of situations that trigger avoidance, aswell as coping mechanisms, are identi®ed. Gradedexposure (described below) is used to help patientsapproach avoided situations gradually and thereby reducetheir anxiety symptoms. Cognitive behavioural therapy(CBT) pays more attention to identifying and challengingthoughts, which result in anxiety and avoidance, inaddition to using behavioural techniques such asexposure. In our experience, complicated presentationssuch as the case described, require the use of CBT whichwill therefore be considered further.

The cognitive behavioural model of phobia Butler [27] hasdescribed the cognitive behavioural model of phobia indetail. A trigger event leads to physical symptoms ofanxiety, catastrophic thoughts (e.g. Ì'm going to die' orÌ'll make a complete fool of myself') and behaviour (e.g.leaving the situation). Reactions to the event include fearand dread of returning to a similar situation and a strongdesire to avoid such situations. Avoidance of the fearedsituation maintains anxiety because patients never ®ndout whether it is as dangerous as they think. The prospectof returning to the situation causes ànticipatory anxiety'with a return of physical symptoms and catastrophicthoughts, reinforcing the need to avoid the fearedsituation. External factors may also maintain thephobia. For example, in the present case a colleagueaccompanied the patient while he was driving in busytraf®c to work.

Agoraphobia can be accompanied by panic attacks. Thecognitive model of panic [28,29] states that individualsexperience panic attacks because of a tendency tointerpret a range of bodily sensations, mostly thoseinvolved in a normal anxiety response, in a catastrophicfashion. When an external event (e.g. a situation in whichpanic has previously been experienced) or internal trigger(bodily sensation, image or thought) is perceived asthreatening a wide range of physical symptoms occur(Table 1). If these are interpreted catastrophically,apprehension followed by a further increase in bodilysensations occurs and a vicious circle ensues. The processis more likely to occur on subsequent occasions for tworeasons. First, hypervigilance makes patients repeatedlyscan their bodies so they notice more symptoms, which inturn trigger further panic attacks. Second, avoidance of



situations in which panic attacks have previously occurredmaintains negative interpretations.

Agree a formulation with the patient A formulation isessentially a hypothesis about the problem which takesinto account predisposing, precipitating and perpetuatingfactors. Sharing the formulation with the patient makes itclear that their problem has been understood and ismanageable. The cognitive model is explained using thepatient's own symptoms to demonstrate how viciouscircles are established and maintained. The problem ofavoidance should be discussed, explaining that if this isreversed gradually, in manageable steps, the fear willsubside.

It is usual to explain that anxiety is unpleasant butactually does no harm. However, if a patient has dif®cultydistinguishing between symptoms of panic and those ofhypoglycaemia, they can not be reassured that theirsymptoms are harmless.

The cognitive model relies on the de®nition that inphobia fear is disproportional to the situation. Clearly fora patient who experiences hypoglycaemia while drivingthe danger is very real. It is important to explain to apatient such as the one described in the present reportthat there is considerable overlap between the symptomsof anxiety and those of hypoglycaemia. When faced withthe prospect of entering a situation in which a hypogly-caemic episode has occurred previously, fear andphysiological symptoms of anxiety occur. These symp-toms are interpreted as representing hypoglycaemiarather than anxiety and are accompanied by catastrophicthoughts such as `I'm going to collapse and cause a majoraccident'. In addition, frequent episodes of what are infact panic attacks are interpreted as hypoglycaemia andthe affected individual believes that hypoglycaemia isoccurring far more frequently than actually is the case.The patient therefore tries to avoid hypoglycaemia bymaintaining a raised blood glucose. He also becomes veryafraid of future hypoglycaemic episodes occurring eitherwhile driving, which could result in an accident, or in aplace where nobody would know he has diabetes, inwhich case he may not receive treatment with potentiallyfatal consequences.

Steel et al. [30] describe two women with Type 1diabetes whose symptoms of hyperventilation provedindistinguishable from hyperglycaemia. They discuss thedif®culty of using the usual cognitive therapy techniquesin patients who have been `conditioned to think in termsof diabetes control' and therefore may ®nd it dif®cult toconsider other possibilities, despite education abouthyperventilation and reassurance about the non-threatening nature of these symptoms. They also stressthe importance of acknowledging that reattribution ofsymptoms to hyperventilation and consequent reassur-ance cannot be taken for granted. Their approach was toinstruct patients to manage episodes initially as possiblehypoglycaemia and to introduce relaxation techniques iftesting excluded low blood glucose levels or if testingproved to be impractical. This reinforced that hyper-

ventilation, although unpleasant, is essentially harmlessand re-established a sense of control and security.

Exposure and other aspects of CBT Treatment is designedto reduce anxiety and avoidance by exposing patientssystematically to feared situations. Exposure is de®ned asfacing something that has been avoided because itprovokes anxiety [27]. It provides an opportunity tolearn that the situation is not in fact dangerous and breaksthe vicious circles that maintain symptoms.

First a `graded hierarchy' is constructed. This isessentially a list of phobic situations, ranked accordingto the amount of anxiety each provokes. It is used to guideexposure and to monitor progress. Exposure begins withthe task rated as easiest to attempt and patients areprogressively exposed to more challenging situations. Themost effective exposure should be of prolonged duration[31] and regularly practised with self-exposure home-work tasks [32].

A number of procedures facilitate exposure. Relaxationtechniques help patients to control anxiety symptoms. Inblood/injury phobia there is an atypical symptom patternin which an initial increase in heart rate and bloodpressure occurs, followed by a sudden sharp drop andoften fainting. Applied tension [33] in which muscles aretensed, but not relaxed, prevents this occurring. Distrac-tion techniques, which involve focusing on externalfactors, divert attention from the anxiety symptoms,reduce hypervigilance and help to break the vicious circle.Modelling is a technique whereby the therapist models anactivity that the patient is afraid to perform and thepatient follows suit, for example the demonstration ofself-injection to somebody with a needle phobia.

Identifying and challenging thoughts associated withanxiety symptoms helps to reduce anticipatory anxietyand catastrophisation. A written daily record of situationsin which anxiety symptoms occur, with ratings of severityand associated thoughts can help to monitor change in thefrequency and severity of the phobia. Patients can alsorate the amount of anxiety they expect to experiencewhen entering a particular situation and test out theirpredictions. For patients with diabetes, blood glucoseresults can be recorded on each occasion as a meansof distinguishing between symptoms of anxiety andhypoglycaemia.

Pharmacological interventions

Benzodiazepines Benzodiazepines reduce arousal levelsand may make exposure less unpleasant. However,patients may attribute the success of exposure to themedication. State-dependent learning could preventgeneralisation of new learning from the drug to thenon-drug state [34]. A small dose of a benzodiazepine justbefore exposure does help some patients overcomeavoidance. It should be made clear that medication willnot be prescribed in the long term because of theproblems of tolerance and dependence and that its mainuse is to reduce anxiety until CBT has taken effect.

292 L. Green et al.


Beta-adrenoceptor blockers Beta-blockers control tremorand palpitations which are often the most distressingsymptoms, especially in social phobia [35]. The evidenceis con¯icting regarding the ef®cacy of beta-blockers inphobic disorders. However, as non-selective beta-blockersmay interfere with metabolic and autonomic responses tohypoglycaemia their use has not been recommended indiabetic patients with phobic disorders.

Antidepressants Antidepressants are considered to be themost effective pharmacological treatment for agorapho-bia with panic [22]. However, there is a high rate ofrelapse when this treatment is stopped [36]. In a meta-analysis, Boyer [37] found that Selective SerotoninReuptake Inhibitors (SSRIs) were superior to imipramine.A variety of antidepressants have proven ef®cacy in thetreatment of social phobia with some evidence for thesuperiority of SSRIs [26].

Goodnick et al. [38], in a review of the treatment ofdepression in diabetes, concluded that SSRIs are gen-erally preferred to tricyclic antidepressants or monoamineoxidase inhibitors (MAOIs) for patients with diabetes.SSRIs and MAOIs may decrease blood glucose, by 30%and 35%, respectively. Tricyclic antidepressants mayincrease blood glucose by 150%. Antidepressants mayalso affect weight and appetite which may be undesirablein people with diabetes.

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Fears and phobias in people with diabetes

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