Anxiety and Panic Attacks Solution

Panic Away Program

Psychologists agree that when a person has anxiety of a certain situation, he may suffer from a panic attack. This person then fears that specific location or event. When he find himself in a similar situation, he fears the onset of an attack and essentially cause himself to have an anxiety attack in the process. The One Move method teaches you how to conquer these fears and end this vicious cycle. Panic Away provides a number of specific applications of the 21-7 Technique that relates to everyday life like how to deal with panic attacks while driving, leaving home, anxiety caused by the fear of flying and the fear of public speaking. Panic Away by Barry McDonagh, in my experience can help reduce panic and in the very least substantially reduce anxiety. It is simple and can be used anywhere and anytime. Once you Get that you no longer have to fear the thought of a panic attack, anything can happen. More here...

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Anxiety Disorders Are Common Among People With Diabetes

While little is known about the rate of anxiety disorder among people with diabetes, one study45 suggests that people who have diabetes may suffer from this disorder as frequently as they do from depression, and at much higher rates than people who do not have diabetes. This study of over 600 people with diabetes found that women, African-Americans, and those with less education were more likely to report symptoms consistent with a clinically significant anxiety disorder. The only diabetes-related predictor of significant anxiety disorder symptons was the presence of two or more long-term diabetes complications. Type of diabetes, duration of diabetes, and glycohaemoglobin level were not associated with an increased risk for anxiety symptomatology. Prevalence studies using structured diagnostic interviews have reported an increased incidence of anxiety disorders, especially generalized anxiety disorder and simple phobia, in people with diabetes53'66. The health care provider can screen...

Relationship of Anxiety to Medical Outcomes

Furthermore, a meta-analysis assessing evidence of a relationship between anxiety and metabolic control found that, while overall results did not support a significant relationship, in studies using interviews to evaluate anxiety, anxiety did show significant relationship to glycemic control (54). It appears that when more rigorous assessment was utilized, a relationship between anxiety and hyperglycemia was detectable, although not supported by studies employing questionnaire assessment of anxiety (54).

Treatment for Comorbid Anxiety and Diabetes

While very few empirical studies have evaluated efficacy of treatment for anxiety among adults with DM1, one case study has demonstrated that cognitive-behavioral therapies (CBT) may be useful, suggesting that CBT may be as effective for this population as for others (55). Since anxiety greatly affects quality of life, since studies utilizing interview assessment of anxiety indicate that it interferes with medical outcomes for those with DM1 (54), and since diabetes-specific anxiety and hypoglycemic fear may interfere with glycemic control, interventions to treat anxiety among those with DM1 are greatly needed (50,51). Despite the fewer studies regarding treatment of anxiety among those with DM1 compared to the literature addressing depression, the existing evidence suggests that clinicians should have a high suspicion for anxiety among adults with DM1. In addition, the potential detriment regarding metabolic outcomes suggests that therapies to ameliorate anxiety are imperative.

Effective Treatment For Anxiety Disorders In People With Diabetes

Anxiety disorders in some people with diabetes may be responsive to psychotherapy and related treatments. Studies10 of people with type 2 diabetes report improved glucose tolerance and reduced long-term hyper-glycaemia after biofeedback-assisted relaxation training (BART). The effectiveness of BART for those with type 1 diabetes is less clear-cut, although some studies68 have reported positive findings. Based largely on studies of people who do not have diabetes, anxiety disorders in diabetes are probably treatable with psychopharmacological agents. Unfortunately, very little information is available on the use of these drugs in people with diabetes. Lustman69 reported improved glycaemic control in patients treated with alprazolam (Xanax), regardless of whether or not they had a formal diagnosis of anxiety disorder. Treatment with fludiazepam (Erispan), a benzodiazepine, in a small group of patients with type 2 diabetes, resulted in decreased anxiety ratings as well as an increase in...

Managing Anxiety

Everyone feels nervous or anxious from time to time, especially in a stressful situation. This is normal and, often, even helpful. Anxiety is a survival mechanism that can help you get through a difficult situation. If you are face-to-face with a man-eating bear or have to give a lecture before 1,000 people, for example, feeling a little anxious can help you get through the ordeal. But if you find that you feel nervous or anxious in situations that are not stressful to most people or if your anxiety is so intense and long-lasting that it interferes with day-to-day living, you may have a more serious problem called an anxiety disorder. The issue is not that your worries are unfounded, but that your worries are more intense, frequent, or last longer than others experience in a similar situation. Feelings of anxiety can coexist with feelings of depression. If you experience any of the following, you may have an anxiety disorder If your worries or concerns are beginning to interfere with...


Immediately after the diagnosis, a commonly experienced reaction is anxiety. Anxiety is a problem not only because it is intrinsically distressing, but also because it can interfere with good functioning. Anxious patients may be debilitated by their Anxiety is high when people are waiting for test results, receiving diagnoses or waiting for medical procedures and anticipating the adverse side-effects of treatment. Anxiety is also high when people expect substantial lifestyle changes to result from an illness or its treatment, when they feel dependent on health professionals, and when they lack information about the nature of the illness and its treatment. While anxiety that is directly attributable to the illness may decrease over time, anxiety about possible complications, the disease's implications for the future and its impact on work and social activities may actually increase.

Session complications and the future

The third session starts with a review of homework assignments, in the same way as described in Session two. The theme 'complications and worries about the future' is introduced after the break. First, it is explained that fear and anxiety are 'normal' and adaptive, i.e. protect us from harm. Several ways to cope with fear and worries are discussed, with two ends of the continuum being from not thinking about it at all, i.e. trying to push away anxious thoughts whenever they surface, to actual confrontation, i.e. 'thinking through' anxiety provoking thoughts. The latter approach involves reflection on 'how realistic are my fears ' 'What can I do when my fears become truth ' By doing so, the thought loses much of its threat, while pushing anxious thoughts away usually is not effective in reducing fear and takes a lot of energy. An anxiety-exploration exercise is performed individually, where participants indicate what fears they have (see Table 8.1). This is used to start group...

Psychosocial Recommendations To Health Care Providers

It is essential that health care providers who work in paediatric diabetes appreciate and address the many stresses and demands confronting parents of infants, toddlers and preschoolers with diabetes by promoting the development of clinical services, childcare referral sources, educational materials and support groups for families living with diabetes at these earliest developmental periods. Parents have reported a need for understanding from and collaboration with a health care team16'22. Managing diabetes in young children requires an integrated multi-disciplinary team approach in order to address adequately the complex physiological and psychosocial needs of the children and their families3. Support groups and educational materials targeted towards families of very young children can also help parents feel less alone and can normalize feelings of guilt, anxiety and fear3. The health care team must create a supportive environment by providing 24-hour on-call coverage to help parents...

Psychosocial Effects Fear of Hypoglycaemia

Many people with insulin-treated diabetes who have experienced frequent severe hypogly-caemia suffer higher levels of psychological distress, including increased anxiety, depression and fear of future hypoglycaemia (Wredling et al., 1992 Gold et al., 1994a). Fear of hypoglycaemia is also a common source of anxiety for relatives, and may strain marital and family relationships. Spouses have a greater fear of hypoglycaemia, and report experiencing sleep disturbance through worrying about nocturnal hypoglycaemia when compared with the spouses of those who do not suffer severe hypoglycaemia (Gonder-Frederick et al., 1997 Jorgensen et al., 2003). The negative consequences of hypoglycaemia not only affect spouses, but also the parents of children with type 1 diabetes (Clarke et al., 1998), the children of diabetic parents and other family members. Two thirds of a group of 60 spouses of people with type 1 diabetes said that the risk of severe hypoglycaemia was a major source of concern to...

Benefits Of Group Psychoeducation Incorporating Coping Skills Training

The benefits of the educational programme, which incorporates the coping skills training intervention I have just described, are wide-ranging and robust. Six months after the educational intervention, programme participants improved significantly on several measures of emotional well-being (including self-esteem, diabetes self-efficacy, depression, and anxiety) several measures of self-care behaviour (including SMBG frequency, medication adherence and adjustment, diet and exercise) and glycaemic control (assessed by HbAlc assay), as compared with their levels at the outset of the program43. Improvements in glycaemic control and self-regulation behaviours (SMBG and medication adherence and adjustment) were maintained The Johns Hopkins Diabetes Center educational programme is integrated and multi-faceted, so it is impossible to determine which aspects of the intervention, alone or in combination, were responsible for the benefits I have just noted. The coping skills training component...

How do you feel about having diabetes

Immediately after diagnosis, people are often in a state of shock. They find that their usual ways of coping with problems do not work, at least temporarily, and they may experience intense feelings of disorganisation, anxiety, fear and other emotions. Eventually this crisis phase passes and people begin to develop a sense of how the diabetes will alter their lives and can be integrated into them. At this point, more long-term difficulties that require ongoing attention may become apparent.

Illness Representations

A more immediate consequence of managing diabetes is the problem of severe hypoglycaemia. With the risk of coma or even death, it is not surprising that Green and colleagues58, in a replication of adult work, found that those adolescents who were more worried about hypoglycaemia had poorer metabolic control of glycated haemoglobin. However, whether this is a function of self-management to avoid hypos, or the effects of increased anxiety has not been established. Those young people who worry excessively about hypoglycaemia, and seek to avoid it, may especially benefit from Blood Glucose Awareness Training (see Chapter 8), to have more confidence in their ability to detect the early signs of hypoglycaemia and take earlier remedial action to prevent it97. Although perceptions about the consequences of diabetes have been inconsistently related to self-care or metabolic control, these perceptions are consistently associated with psychological adjustment54'55'57'59-61. This suggests that...

Cognitivebehavioural Therapy In Diabetes And Other Somatic Disorders

Beneficial effects of coping-oriented group interventions were demonstrated in adults, including improvements in self-reported compliance and self-confidence66. The number of participants in this study was, however, very small and there was no formal evaluation. A behavioural group programme developed by Zettler and colleagues67, teaching participants strategies to cope with complications, was aimed at reducing anxiety and avoidance behaviour, encouraging adherence, and preparing patients with type 1 diabetes for crises. Analysis of dysfunctional health beliefs was used as a cognitive strategy. The intervention resulted in a reduction of fear and an enhanced acceptance of the disease. Rubin and colleagues68 added two sessions of diabetes-specific coping skills training, focusing on attitudes and beliefs underlying self-care, to an outpatient education programme. This training, containing cognitive-behavioural elements, resulted in an improvement of emotional well-being and HbAlc, an...

Dorothy Nutritional Supplements to Treat Cancer

Abram Hoffer, M.D., Ph.D., one of the pioneers in vitamin therapy, initially began treating cancer patients for depression and anxiety. He soon found that patients taking large dosages of vitamin C and other vitamins and minerals were living longer than those who did not. When his cases were analyzed by Nobel laureate Linus Pauling, Ph.D., it became clear that cancer patients were living several times longer (postdiagnosis) when they took supplements, compared with patients who chose not to take supplements.

Management Of Pregnancy In Diabetes

A complicating factor in diabetic pregnancy that has attracted increasing attention concerns the risk of (severe) hypoglycaemia in strictly regulated diabetic pregnancy, partly related to the suppression of counter-regulatory hormones20. Severe hypoglycaemia, be it as a result of pregnancy or improved metabolic control, can cause high levels of anxiety, confronting the mother-to-be with a serious dilemma. On the one hand, she strives for optimal glycaemic control to reduce the risk of birth defects on the other hand she is fearful of hypoglycaemia, both for herself and because of the possible harm that hypoglycaemia may cause to the fetus. Impaired hypo-glycaemia awareness and related worries about severe hypoglycaemia can lead the pregnant woman to accept 'safe' levels of blood glucose, thereby compromising glycaemic control. Hypoglycaemia may be one of the major reasons why women do not reach near-normal glycaemic control during pregnancy21. This may be particularly true for women...

Clinical findings and differential diagnosis

Most children who present with type 2 diabetes are in puberty. This is most likely to be due to the temporary insulin resistance during pubertal maturation in which a 30 per cent reduction in insulin action compared with prepubertal children or adults has been reported (Amiel et al., 1986). Children and young people with type 2 diabetes may present on a spectrum from being an incidental finding to severe diabetic ketoacidosis. The child may have symptoms suggestive of type 1 diabetes, including thirst, polyuria, hyperventilation, weight loss, vomiting and dehydration. Episodes of ketonuria may occur intermittently with intercurrent illnesses. However, the majority of children are probably relatively asymptomatic. In one reported series, 50 per cent of children with type 2 diabetes were referred only because of glycosuria noted during routine tests for other reasons 39 per cent initially had polyuria, polydipsia, and weight loss, and only 11 per cent had mild ketoacidosis (Glaser and...

Psychiatric Comorbidity In Diabetes Mellitus Is There A Relationship With Cognitive Impairment

The prevalence of psychiatric disorders, in particular depression and anxiety disorders which are known to have a negative effect on cognition (28, 29), is increased in type 1 diabetes. In a recent meta-analysis, odds ratios and prevalence of depression were estimated for both type 1 and type 2 diabetes, from 42 studies having a combined sample size of 21,351 subjects (30). The main conclusion is that diabetes doubles the odds ratio. A difference in the prevalence of depression in type 1 compared to type 2 diabetes could not be established. Although it is assumed that even mild-to-moderately severe levels of psychological distress have a negative impact on neuropsychological performance, the empirical evidence in diabetes suggests otherwise. The finding that psychological distress, cognitive functioning, and MRI abnormalities do not correlate (10) is in agreement with recent studies in healthy persons (39), as well as with clinical studies of patients with chronic diseases such as...

Cerebral Edema In Dka Pathophysiology

Some studies in humans also suggest that cerebral hypoperfusion may be associated with increased risk for cerebral edema-related DKA (28, 37, 38). Patients with DKA with higher serum urea nitrogen levels (a marker of dehydration) are at increased risk for cerebral edema. Hypocapnia, present in DKA, results from hyperventilation and can cause cerebral vasoconstriction. DKA-related cerebral hypoperfusion prior to treatment may lead to subsequent vasogenic edema with reperfusion (38).

Advice for Parents of Children with Diabetes

Your child's self image and self esteem are threatened by diabetes. Be understanding and supportive. Try to avoid unnecessary anxiety about cheating. You don't want to cause guilt feelings, or make your child think he or she is bad. Children who think are bad may act accordingly. Help your child plan ahead. No child can should be expected to assume complete responsibility for diabetes control at too early an age. But, ultimately, responsibility for eating properly, injecting insulin, testing blood sugar, and planning exercise will be the child's. Maturity, independence, self control, and self esteem will grow as your child learns self-care.

Mechanical Ventilation In Diabetic Ketoacidosis

In diabetic ketoacidosis, very frequently severe hyperventilation with deep respiratory breaths are observed, also called Kussmaul-respiration. This is a compensatory mechanism aiming to get rid of CO2 in cases of severe metabolic acidosis. The blood gases show severely lowered pCO2, a relatively high pO2 with relatively high hemoglobin O2 saturation as well as low standard bicarbonate. Respiratory compensation by hyperventilation is a compensatory mechanism this is the reason why medications which can decrease respiratory capacity or compensatory mechanisms, like sedatives, should be avoided as long as possible. The indication for tracheal intubation of a patient with diabetic coma is mainly the potential of aspiration in the case of severe coma and vomiting. In most cases it is sufficient and most sensible to let the patient respirate by himself after intubation with a closed cuff to prevent aspiration. In case the patient has to be ventilated mechanically, one should take care to...

Implications And Future Directions

There is some evidence that BGAT can reduce emotional fear of hypoglycae-mia, patients with a history of traumatic experiences related to low BG or high levels of anxiety about their ability to cope with hypoglycaemia may benefit. BGATs potential effects on hyperglycaemia detection, frequency and severity of high BG excursions and metabolic control also suggest that it may be useful for patients with poor diabetes control. Finally, BGAT studies have repeatedly shown that those patients who are very poor at estimating glucose levels can benefit greatly. Therefore, it should be useful for patients who are frequently 'surprised' to find out that their BG is far too low or high, or who are unaware of the extreme range of their glucose fluctuations.

Metabolic And Other Problems Induced By Surgery

Anxiety, anaesthetic drugs and possibly the underlying disease requiring surgery may all contribute to metabolic destabilization in the diabetic surgical patient. The most important factors, however, are starvation and the pathophysiological metabolic and humoral response to trauma. All but the most minor of operations involve some interruption of normal food intake, and this may not infrequently last for several days. This poses obvious practical difficulties for diabetic patients whose tablets or insulin injections must be accompanied by food. Of more sinister note, however, is that starvation leads to catabolism, and in the presence of

Biomedical Risk Factors

In addition to the biomedical risk factors described above, one needs to entertain the possibility that some of the neurocognitive problems noted in children may be exacerbated (or obscured) by the occurrence of anxiety and mood disorders - most typically depression and anxiety - that are often (33, 35,117) although not invariably (118) seen in children and adolescents with diabetes. A growing literature on nondiabetic children has demonstrated that depression is associated with reductions in whole brain volumes, with changes particularly apparent in the frontal lobes (119), the amygdala (120), and the basal ganglia (121) whether the hippocampus is affected remains unresolved (120, 122). Generalized anxiety disorders are also associated with structural changes, with one study reporting increases in white- and gray-matter volumes in the superior temporal gyrus (123). It is noteworthy that young adults with a childhood onset of diabetes manifest changes in this same brain region,...

Hyperglycemia Causing Cardiac Conduction Defect

Hypoglycemia Schematic Diagram

Those with diabetes and in their relatives. Fear of hypoglycemia causes anxiety and psychological distress and is so great in some people that it provokes behavioral change and may negatively influence their approach to self-management (59). This may underlie the resistance shown by some patients to therapeutic recommendations to intensify treatment to achieve strict glycemic control. Hypoglycemia can affect personal relationships (sometimes causing marital tension), employment prospects, driving, recreational activities including exercise and sport, travel, and holidays, and acceptance for insurance. Detailed accounts of the everyday problems of living with hypoglycemia, and how these may be addressed, are available elsewhere ( 60, 61).

The Importance of Communication

Don't be afraid to bring up sexual or personal topics. Your team members are professionals and are prepared to help you deal with even the most sensitive topics. Your emotional health is critical to your well-being. Let your provider know if you are struggling. Don't be afraid to discuss money. Health care professionals realize that financial worries can contribute to patient anxiety, and most will be willing to discuss payment options. Tell your provider if you are having trouble paying for your medications or diabetes care supplies, even if you are not asked.

Therapeutic Interventions In Dkarelated Cerebral Edema

If cerebral edema is suspected, treatment should begin immediately by reducing intravenous fluid administration (1, 57) and by providing supportive care. Mannitol may be administered intravenously as 0.25-1.0 g kg over 20min in impending respiratory failure, while hypertonic saline (3 , 5-10 ml kg over 30min) may be used as an alternative. In cases of respiratory failure or alterations in sensorium, intubation and ventilation may be necessary. Assisted hyperventilation has resulted in poor outcomes in children with DKA-related cerebral edema (58). Although a detailed review of DKA treatment is beyond the scope of this chapter, Fig. 2 illustrates general guidelines.

Physiology and Pathophysiology

Guanil Cyclase

A good clinical history and physical examination are the basis of assessment. It is important to establish the nature of the erectile problem and to distinguish it from other forms of sexual difficulty such as penile curvature or premature ejaculation. An interview with the partner is advisable and will confirm the problem but may also reveal other causes of the difficulties, e.g., vaginal dryness. The relative importance of psychological and organic factors may be determined from the history. Drugs which may be associated with ED include tranquillizers (phenothiazines, benzodiazepines), antidepressants (tricyclics, SSRI), and antihypertensives (P-blockers, vasodilators, central sympathomimetics, ganglion blockers, diuretics, ACE inhibitors) (100). In most patients sophisticated investigation is not indicated. A three-step diagnostic approach is shown in Table 9. A detailed history is most important, and for many patients examination can be limited to the regular monitoring of...

Distinguishing the severity levels of hypoglycemia

I Moderate hypoglycemia, which is marked by a blood glucose of about 65 mg dl, is treated by the caretaker by giving two to three glucose tablets, waiting 20 minutes, and testing to make sure the glucose is back to normal. If it isn't normal, more glucose is given. It's recognized as the patient begins to feel the adrenergic symptoms, including rapid heartbeat and anxiety. Moderate hypoglycemia leaves the person unable to function he doesn't recognize the need for glucose and must be helped.

Neurochemical Findings Associated With Depression And Diabetes

Characterizes the actions of this pathway (66). Mice are exposed to a different aggressor each day for 10 days, screened for social behavior, and then exposed to an unfamiliar mouse enclosed in a wire mesh cage. Social approach toward the unfamiliar mouse is then measured. Control mice spend most of the time interacting socially. The defeated mice displayed intensive aversive responses. This response persisted for up to 4 weeks following the stressor. Social interactions in these defeated mice improved with chronic administration of fluoxetine or imipramine, but not chlordiazepox-ide, suggesting that depression and not anxiety was primarily mediating the response. The social defeat exposure increased brain-derived neurotrophic factor (BDNF), a key regulator of the mesolimbic dopamine pathway, in the nucleus accumbens. The source of BDNF is thought to be the ventral tegmental area since BDNF mRNA is expressed in high levels there, but is barely detectable in the nucleus accumbens...

Depression Treatment Considerations For Diabetic Patients

CRH antagonists CRH acts through CRH1 receptors to produce a number of anxiety- and depression-like symptoms, which have led to the consideration of CRH1 receptors as potential drug targets. Several small non-peptide molecules that are able to pass the blood-brain barrier have entered clinical development. One agent, NBI-30775 R121919, was reported to have a clinical profile comparable to paroxetine (87). This compound was administered to 24 patients with a major depressive episode primarily for a safety and tolerability study. The drug was found to be tolerated by patients and did not interfere with cortisol secretion at baseline or following an exogenous CRH challenge (88). Significant reductions in both patient- and clinician-rated depression and anxiety scores were found. Of interest is that mood symptoms worsened following drug discontinuation. CRH1 receptor antagonism for the treatment of depression has demonstrated potential therapeutic value and merits further examination....

Diagnosis and Clinical Presentation

DKA usually develops over a short period of time, generally in less than 24 h. There may have been some antecedent days with general malaise and poor metabolic control. Depending on the degree of hyperglycaemia, the history will include symptoms of polydipsia and polyuria. Specific symptoms depend on precipitating factors and co-morbidity. Physical examination may reveal poor skin turgor, hyperventilation (Kussmaul), hypotension, tachycardia and impairment of mental status. Many patients have infection, but patients may present with normothermia or even hypothermia due to peripheral vasodilation caused by the acidemia.

Epidemiology Of Diabetes And Depression

Psychiatric illnesses in general may be more common among persons with diabetes than in community-based samples, specifically affective and anxiety-related disorders (4). Persons with diabetes are twice as likely to have depression as non-diabetic persons (5). A review of 20 studies on the

Cognitivebehavioural Therapy

Cognitive therapy, originally developed to treat depression45 and anxiety46, has been successfully applied to a wide array of psychological problems, ranging from personality disorders to eating disorders and substance abuse47. Cognitive therapy is described as A therapeutic approach that is closely related to the work of Beck and stems from the same period, is rational-emotive therapy (RET), developed by Albert Ellis. Identical to CBT, Ellis states that thinking, feeling and acting are in constant interaction. One of the statements most central to Ellis's work is the phrase by the ancient Greek, Epictetus49 'People are disturbed not by things, but by the views they take of them'. Dysfunctional beliefs in RET are termed 'irrational beliefs' and can, according to Ellis, be classified in three main categories (a) demandingness towards the self ('I must, under all circumstances, perform well and have the approval of others if not, that is awful and makes me an incompetent and unworthy...

Psychological Models To Help Understand Selfmanagement

Diabetes-related losses that a person experiences84. There may be other reasons for low mood, such as negative life events, but whatever the aetiology it will have a major impact upon the person's capacity to self-manage. Screening to detect depressed mood may be helpful in patients who are attempting significant lifestyle change. A simple scale, such as the Hospital Anxiety and Depression Scale 5, can screen out patients who should either be excluded from behaviour change counselling, or need help for their problems as a precursor to work on self-management. It would then be important for the person to receive the appropriate treatment, either pharmacologically or with cognitive therapy.

Impact Of Hypoglycemia

Iatrogenic hypoglycemia causes both physical morbidity (and some mortality) and psychosocial morbidity (6). While estimates of hypoglycemic mortality rates in type 2 diabetes are not available, deaths caused by sulfonylurea-induced hypoglycemia (like insulin-induced hypoglycemia) are well documented (14). The mortality of a given episode of severe sulfonylurea-induced hypoglycemia has been reported to be as high as 10 (14,15). The physical morbidity of an episode of hypoglycemia ranges from unpleasant neurogenic (autonomic) symptoms, such as sweating, hunger, palpitations, tremor and anxiety, to neuroglycopenic manifestations. The latter range from cognitive impairments and behavioral changes to seizures and coma (and rarely death). Transient focal neurological deficits occur occasionally. While seemingly complete neurological recovery is the rule following an episode of hypoglycemia, prolonged severe hypoglycemia can cause permanent neurological damage. The extent to which the latter...

QoL And Neuropathic Pain

Until recently, the studies which reported that neuropathy can have a negative impact on the functioning and QoL relied upon generic instruments, which do not describe the condition-specific features of neuropathy. Thus, Vileikyte et al. (24) developed the first neuropathy-specific QoL instrument, NeuroQoL, which investigates the impact of symptoms and or foot ulceration as a consequence of neuropathy on QoL. The results of this study demonstrated that patients experiencing neuropathic symptoms reported severe restrictions in activities of daily living (e.g., leisure, daily tasks), problems with interpersonal relationships, and changes in self perception. It therefore appears that neuropathic pain and changes in self perception as a result of foot complications have the most devastating effect on the individual's QoL. Finally, recent research suggests that not only do painful neuropathic symptoms have an effect on qualify of life, but also generate symptoms of anxiety (23).

Metformin and Repaglinide

A4 enzyme system, drugs that are metabolized through this system (Rifampin, barbiturates, carbamazepine, certain statin drugs, amiodarone, benzodiazepines, sildenafil (Viagra), theophylline, and certain selective serotonin reuptake inhibitors) may increase repaglinide metabolism (19). Although in vitro data indicate that repaglinide metabolism may be inhibited by antifungal agents (such as ketoconazole and miconazole) or antibacterial agents (such as clarithromycin), systematically acquired data is not available on increased or decreased plasma levels with other cytochrome P-450 3-A4 inhibitors or inducers.

Normal Glucose Counterregulation

Neuroglycopenic symptoms (25) such as behavioral changes, confusion, fatigue, seizure, and loss of consciousness are the direct result of widespread central nervous system (CNS) neuronal glucose deprivation. If hypoglycemia is prolonged and severe, this mechanism can cause permanent brain damage and even death. Neurogenic (auto-nomic) symptoms (25) are the result of the perception of physiological changes caused by the CNS-mediated autonomic (sympathochromaffin) discharge triggered by glucose deprivation from glucose-sensitive neurons in the brain (and perhaps in other sites, including the portal vein). They include both adrenergic (adrenomedullary epineph-rine-mediated and sympathetic neural or adrenomedullary norepinephrine-mediated) symptoms such as palpitations, tremor and anxiety, and cholinergic (sympathetic neural acetylcholine-mediated) symptoms such as sweating, hunger, and paresthesias.

Cognitive Function And Depression

Older people with diabetes who are subject to major lifestyle changes, vascular complications and chronic ill-health may well have symptoms of clinical depression. It is important to exclude depression as a cause of cognitive impairment, as people with diabetes are more likely to be depressed (Sinclair and Croxson 1998). Indeed, the presence of depression appears to increase the risk of diabetes two-fold (Eaton et al 1996). In the presence of depressed mood, anxiety symptoms, withdrawal phenomena, and anorexia, depression must be excluded. Simple screening tests such as the Geriatric Depression Score can be used. Other explanations of cognitive impairment in diabetes can include cerebral atrophy and cerebrovascular disease (Tarcot et al

Eating Disorders And Depression Screening And Treatment

There are no published guidelines regarding choice of antidepressant therapy for individuals with DM1 or DM2. However, differences in metabolic side effects, including changes in weight, insulin sensitivity, and lipid profile, can guide medication choice to some extent. The selective serotonin reuptake inhibitors (SSRIs), the serotonin and norepinephrine reuptake inhibitors (SNRIs e.g., venlafaxine and duloxetine), mirtazapine, moclobemide, monoamine oxidase inhibitors, tricyclic agents and bupropion are all indicated for the treatment of depression (132). The SSRIs and SNRIs are also first-line agents for the treatment of anxiety disorders, and so these agents should likely be used in cases that involve both depression and an anxiety disorder (132).

Eating Disorders And Depression An Introduction

The comorbid association of eating disorders and depression could arise for a variety of reasons. Negative emotional states, including intense feelings of depression, anger or anxiety, may precipitate the full range of disturbed eating behavior (11, 12), in addition to other maladaptive behavior. It has also been suggested that binge eating, vomiting, extreme food restriction and other weight-control behavior may be used to help modulate or to distract oneself from depressed mood, or to give the illusion of control or mastery by focusing on a specific aspect of self-regulation (11, 12). Severe eating disorders are also associated with frequent medical complications and a significant mortality rate. In a meta-analysis of outcome studies of anorexia nervosa, crude mortality rate was found to be 5 at 4-10-year follow-up, and 9 at follow-up after 10 years (13).

Summary And Conclusions

In this chapter I have reviewed counselling and psychotherapeutic interventions for patients with diabetes who are having difficulties coping with the day-to-day demands of life with diabetes, and for patients with diabetes who suffer from frank psychopathology, specifically depression, anxiety disorder or eating disorder. Since the effects of coping problems and psychological disorders may be especially malevolent for people with diabetes, effective psychological treatment is especially important for these individuals. Psychological problems of any magnitude may affect metabolic control directly via the neuroendocrine and physiological effects of stress, or indirectly via a cascade of events, including worsened self-care and deteriorating metabolic control, which may in turn exert a negative reciprocal effect

Eating disorders in diabetes may be particularly devastating

This control, which they feel they will be pressured to do if they acknowledge their disorder. For these reasons, the health care provider must be alert to signs that a patient may be suffering from an eating disorder, especially when the patient is a young woman. These signs include frequent diabetic ketoacidosis (DKA), elevated glycohaemoglobin levels in a knowledgeable patient, anxiety about or avoidance of being weighed, frequent and severe hypoglycaemia, bingeing with alcohol, or severe stress in the family.

Treatment for Comorbid Diabetes and Dysregulated Eating

One small study compared 9 young women with bulimia nervosa who were receiving in-patient treatment to 10 young women with bulimia nervosa who were not. These patients were reassessed 3 years after treatment by examining their body mass index, HbA1c results, and psychological test scores. Patients who had received inpatient treatment had lower HbA1c results and demonstrated lower scores on measures assessing depression, anxiety, and binge eating and purging behaviors (80). Although the small sample size of this study makes it difficult to discern how generalizable the results are, these preliminary findings do suggest that inpatient treatment may be a more helpful form of treatment for women with diabetes who are suffering from bulimia nervosa.

Symptoms Of Hypoglycemia

The two categories of hypoglycemic symptoms are neurogenic and neuroglycopenic. The neurogenic symptoms are activated by the ANS (usually occur at 60 mg dL in nondiabetic individuals) and are mediated in part by sympathoadrenal release of cate-cholamines (norepinephrine and epinephrine) from the adrenal medullae and acetylcholine from postsynaptic sympathetic nerve endings (7-9). These symptoms are triggered by a falling glucose. This defense is critical for the recognition of symptoms that will alert the individual to treat the hypoglycemic episode. Neurogenic signs and symptoms include shakiness, anxiety, nervousness, palpitations, sweating, dry mouth and pallor, and pupil dilation (7,10,20). Cholinergic-medicated neurogenic symptoms include diaphoresis, hunger, and paresthesias (Table 1) (3,7,20). Recent work by Aftab-Guy et al. (12) has demonstrated that simulating epinephrine levels found during moderate hypoglycemia on a background of hyperinsulinemic euglycemia only produces...

Measurement of symptoms

Symptoms of hypoglycaemia were first reported in relation to tumours of the pancreas (Wilder 1927). As early as 1927, the symptoms of hypoglycaemia were recognised as forming two groups the first occurring during mild reactions comprising anxiety, weakness, sweating, hunger, tremor and palpitations and the second more severe group including mood changes, speech and visual disturbances, drowsiness, convulsions and coma (Harrop 1927). It was also noted that some patients did not experience the usual symptoms of hypoglycaemia until their blood glucose had reached much lower concentrations (Lawrence 1941). Symptom profiles provoked by hypoglycaemia are idiosyncratic and vary in character, pattern and intensity between individuals and even within individuals over time (Pennebaker et al. 1981).

Methodological Considerations

It is also critically important for researchers to be able to delineate, in a meaningful and reliable fashion, the neurocognitive characteristics of each child and any acute state - depression, anxiety, low blood glucose values -that might influence cognitive performance at the time of that assessment. Ordinarily, this is accomplished by administering a battery of psychome-trically sound neuropsychological tests, assessing mood state, and measuring blood glucose periodically during the assessment session. Unfortunately, there are no universally agreed upon standards for selecting such tests, particularly when assessing children (or adults ) with diabetes, despite pleas for the establishment of a core battery (5), as has happened in research with other neurocognitive disorders like dementia (6, 7). Lack of consistency in neuropsychological assessment across research groups challenges our ability to rationally aggregate results from many smaller cross-sectional studies.

Cognitive Functioning

While mild and severe hypoglycemia rates are lower in type 2 diabetes compared with type 1, due to residual insulin production in type 2, patients who use sulfonylureas or progress to insulin therapy can experience acute low blood sugars (113). Such episodes cause both autonomic and neuroglycopenic changes. Neuroglycopenia appears to impact the cerebral cortex more than the deeper brain structures, in terms of cognitive functioning. Complex, attention-demanding and speed-dependent responses are most impaired, with accuracy often preserved at the expense of speed. Cognitive function does not recover fully until 40 to 90 min after blood glucose is returned to normal. Hypoglycemia also provokes changes in mood, including anxiety and depression, and increases fear of further hypoglycemia, which in turn can modify self-care behavior (e.g., over-treating with food) and thus blood sugar control (114).

The impact of diabetes upon the family

The discovery of diabetes in a child can cause major stresses within a family. If a parent has it, there may be much self-blame. The pattern of family life may be interrupted by the mechanics of diabetes care. Other siblings may feel left out as much attention and anxiety is lavished upon their brother or sister. They may also be frightened, especially if their sibling was rushed to hospital very ill. 'Is Johnny going to die Am I going to catch diabetes '

Avoiding Lows after

Your provider will evaluate your concerns and help you sort out the causes. There are many factors that can result in sexual difficulties, including medications, hormonal changes, problems caused by diabetes, and your emotional health. If your sexual problem appears to be due to a physical cause, you may be referred to a gynecologist or urologist. If stress or anxiety is contributing to your problem, a visit with a mental health professional may be in order. Depression, which is more common among people with diabetes, can also contribute to problems with sexual fulfillment and performance.

Education And Rehabilitation

Education can have a number of objectives relevant to rehabilitation. It promotes good metabolic control and behaviours that prevent further impairment and minimize disability and handicap. Furthermore, participation in education programs can foster autonomy, improve self-esteem and coping skills and reduce anxiety and depression (Rubin, Peyrotand Sandek 1989). In other words, education can reduce the psychological handicap resulting from diabetes. Support groups or self-help groups can also have a major impact on psychological rehabilitation, though it is valuable to have input from a health professional, preferably one with some training in psychotherapy (Toth and James 1992).

Management Of Hypoglycaemia

In conclusion, hypoglycaemia continues to be a common problem in the management of individuals with type 1 diabetes. The use of newer technologies of continuous glucose monitoring has highlighted that it is almost impossible to eliminate hypoglycaemia completely with present insulin therapy, although understanding moderating factors such as alcohol and including them as a component of education programmes for people with insulin-treated diabetes may help to alleviate some of the anxiety associated with the risk of living constantly with the threat of hypoglycaemia.

Exercise and Pregnancy

If you exercise regularly with type 1 or type 2 diabetes, pregnancy is no reason to stop working out, but you may need to lower your workout intensity. If you have gestational diabetes, exercise lowers your blood glucose level and so is considered an effective part of your treatment plan. Staying physically fit during your pregnancy will help you prepare for the work of labor and baby care that lies ahead. Exercise can also moderate your weight gain, increase your strength and stamina, and lower your anxiety level. In some cases, it may help you avoid or delay the start of using insulin.

Levels of hypoglycemia

1 Moderate hypoglycemia This level is achieved when the blood glucose is found to be around 65 mg dl. The patient begins to feel the adrenergic symptoms described above, especially anxiety and a rapid heartbeat. Patients who have moderate hypoglycemia may not recognize they need glucose and have to be helped by someone else.

Practical Implications For Diabetes Care

When you do make contact, don't make diabetes the be-all and end-all of the exchange. Adolescents, as do adults, have a life outside of their diabetes, and in some cases diabetes may be temporarily dropped from their list of life concerns. Be prepared to let go of the diabetes agenda, and focus on whatever issue is of greatest concern to the adolescents. Although this may not improve their blood glucose control directly, helping them deal with the problems in their lives, in addition to maintaining a trusting relationship, can also help them learn problem-solving skills which may be transferred into their diabetes management. Furthermore, if a problem is causing anxiety or stress, supporting a young person as he she seeks a way through a dilemma may help to reduce these levels of anxiety and stress, and for some this may have a direct physiological effect on their blood glucose control. Adolescents will undoubtedly feel the extra stress that is inherent in living with diabetes, and...

What about children with diabetes

It is very common for parents and families to have trouble coping with a child's illness and therefore good rapport and communication with the health-care professionals involved in your child's diabetes care is essential. Support groups and educational materials targeted towards families of very young children can help parents and families to feel less alone and can normalise feelings of guilt, anxiety and fear. It is important to accept the fact that diabetes won't just 'go away', but remember that diabetes management must not take over your family's life. Love, guide and discipline your child as if diabetes were not a factor and tell yourself that a diagnosis of diabetes does not have to be totally negative people grow and change not only when things are going well, but also when they are not

Dealing with Your Own Feelings

Don't forget that your child is looking to you for guidance. Your attitude will have a direct impact on how your child sees himself and how he comes to terms with his new lifestyle. If you take your child's diabetes in stride, it will be easier for your child to accept it. If you react with anxiety, apprehension, and fear, so will he. Deal with diabetes in a matter-of-fact way. Don't downplay your child's fears or concerns, but address them in a straightforward fashion.

Diabetes In Toddlers And Preschoolers

Given the toddler's and preschooler's normal developmental tasks of establishing his her independence from the parent, diabetes only fuels the parent-child conflicts so typical of these stages. Unfortunately, in previous research studies, infants and toddlers with diabetes have been grouped with children under 6 years of age, and studied as a 'preschool sample', yielding little data on these stages specifically. One empirical research study by Wysocki and colleagues11 has studied the psychological adjustment of very young children from the mothers' perspective, with a sample of 20 children, 2-6 years of age, with a mean age of approximately 4 years. The authors indicated that mothers reported that their children showed significantly more 'internalizing' behaviour problems on the standardized Child Behaviour Checklist (CBCL)18, such as symptoms of depression, anxiety, sleep problems, somatic complaints, or withdrawal. However, the authors emphasize that mothers did not rate their...

Clinical Features and Risk Factors

As the blood glucose level falls, the patient characteristically displays sympathetic effects such as sweating, tachycardia, anxiety, etc. If the plasma glucose continues to fall, neuroglycopenia ensues with decreased consciousness level, confusion and possibly fits. Jaap et al (1998) reviewed 132 subjects with Type 2 diabetes aged 70 or more, of whom 102 had had hypoglycaemia in the preceding 2 months. Patients seemed to have three different clusterings of symptoms, autonomic (e.g. sweating and trembling), general neuroglycopenic (e.g. weakness and confusion) and specific neuroglycopenic with poor coordination and articulation (e.g. unsteadiness, incoordination, light-headedness, and slurred speech). Importantly, all clusterings were just as common, but the third specific neuroglycopenic group of symptoms are obviously liable to diagnostic confusion in the elderly. Indeed, an important problem in the elderly is that hypoglycaemic episodes ('hypos') will be misdiagnosed as stroke,...

Your Mental Health Counselor

A clinical psychologist usually has a master's or doctoral degree in psychology and is trained in individual, group, and family psychology. You may visit a clinical psychologist to help you through a particularly stressful period over the course of several weeks or months, or on a longer-term basis to work through depression, anxiety, or other problems.

Hypoglycemia Unawareness

HU is a major limiting factor in the management of adults with T1DM. Recommendation of strict glycemic goals may not be appropriate for patients experiencing HU because it may contribute to an increased prevalence of severe hypoglycemia. HU is characterized by the loss of autonomic warning symptoms that defend against the development of neuroglycope-nia. This failure to perceive autonomic warning signals like sweating, anxiety, or tremor, has been proposed to contribute to the increased frequency and severity of hypoglycemia in patients with T1DM. Duration of diabetes, antecedent hypoglycemia, and tight glycemic control are known risk factors for HU. The mechanism responsible for HU remains controversial. Work from Boyle et al. (21) has demonstrated that somewhat paradoxically, brain glucose uptake during hypoglycemia is increased in intensively treated patients with T1DM as compared with patients with poor metabolic control or healthy subjects. The explanation for this finding is...

Recent Developments

2 States of insulin resistance, including PCOS, are associated with a number of risk factors for cardiovascular disease. This forms the basis for the current approach to treatment, but can provoke anxiety in generally healthy young women. It is not clear whether PCOS per se is actually associated with a marked increase in cardiovascular complications, and the risk profiles of PCOS patients may not differ substantially from age- and body weight-matched controls.4


Understanding and managing this disease. A well-developed literature has investigated the comorbidity between DM1 and several psychiatric diseases, and has shown that individuals with DM have a disproportionately higher rate of psychiatric disorders. Depression, anxiety, and dysregulated eating appear more prevalent among those with DM1, interfere with important outcomes such as quality of life, self-management, and glycemic control. In addition, psychological factors interact with adjustment to DM1, self-management, and metabolic control, even at subdiagnostic levels of symptomatology. Indeed, it appears nearly impossible to optimize medical outcomes without addressing the role of knowledge, coping, anxiety and mood, and dysregulated eating in the adult DM1 population. Diabetes treatment teams must maintain a high suspicion for these factors among adults with DM1, screen carefully, and treat aggressively, so as to prevent these nonpathophysiological factors from rendering treatment...

Rimonabant Acomplia

Rimonabant is an antagonist that is, it prevents the CB1 receptor from being stimulated and reduces appetite. Over a one-year period, patients on 20 mg of rimonabant had an eleven-pound weight loss, and when followed for a second year maintained the weight loss, whereas those who came off the drug regained the weight. The main side effects were nausea, anxiety, and depression. About 40 percent of the subjects did not complete the trial. It is too early to say how useful this medication will be in helping weight control.

Insulin treatment

For many people, having diabetes means insulin injections. From the moment they learn that they have diabetes their thoughts may be occupied by the terror of having to inject themselves. They think that these injections will start on their first visit to the diabetic clinic. Sometimes this unexpressed anxiety can impede communication. This may be an unfounded fear, but unfortunately some people do need insulin, and, at present, this has to be given by injection.


The relationship between diabetes and clinical psychiatric disorders has received increased attention over the past 15 years. According to some estimates, almost half of all people with diabetes have a diagnosable psychiatric disorder at some point during their lifetimes45. Depression and anxiety disorders are the most common diagnoses and occur far more often in people with diabetes than in the general US population46. These The number of documented cases of eating disorders among people with diabetes appears to be growing47'48. While it is not clear whether these disorders are more prevalent among people with diabetes than they are in the general population49, eating disorders have been associated with poor glycaemic control and an increased risk for retinopathy48. Depression, anxiety disorders and eating disorders can be treated effectively, but all tend to recur and require repeated treatment. A detailed discussion of depression, anxiety disorders and eating disorders among people...


Each person's responses to a diagnosis of diabetes are different. Even your own reactions to the condition will vary from time to time. This chapter will discuss, first, how people attempt to make sense of the diagnosis and try to understand the implications of having diabetes, and then consider some of the common emotional reactions to diagnosis including denial, anxiety, relief, depression, anger and stress, providing some helpful tips for coping with these common emotional reactions.


It is very common to feel overwhelmed after learning that you have a condition such as diabetes there is no easy way to accept the fact that your life is going to change. When first diagnosed, you may not be able to react at all, since it may not seem 'real' to you, especially if you don't have any noticeable symptoms. As the full impact of the diagnosis sets in, you may experience a whole variety of feelings ranging from sadness and anxiety to anger and frustration. You may feel upset because you will need to make some lifestyle changes, and you may be afraid that you will never adjust to living with diabetes.


There is certainly reluctance to attempt strict glucose control in those newly diagnosed, partly based on a reasonable wish not to add to the burden of diabetes at this early stage of the disease. The culture of diabetes care varies more between countries than the reader of a text on evidence-based medicine might imagine, but there is something quintessentially British about the desire not to provoke anxiety about future unpleasantness until the opportunity of doing anything useful to prevent it has lapsed. Further investigation of the feasibility, costs and benefits of early aggressive insulin therapy from diagnosis would clearly be justified. It is also clear that trials of immune intervention need to be carefully standardised for glucose control - a powerful reason for insisting on blinded trials wherever feasible in this situation.


The extent that this may impact on health and diabetes control will vary from one child to another and may be manifest as an increased risk of severe hypoglycemia, deteriorating HbAlc levels, and episodes of ketoacidosis. A reluctance to do more than a minimum of blood glucose tests, erratic meals, and missed insulin doses are common (60) and may all contribute to this. The adolescent may feel that the less attention that is paid to diabetes management, the less intrusive it is on their life. Parental anxiety and threats or discipline tend to make matters worse, as the adolescent is already well aware of the long-term consequences of poor control, is abundantly reminded of parental concerns, and resents interference in their task of maintaining the complex balance of keeping healthy and growing up in conformity with their social environment.

Establish Rapport

Open discussion provides valuable insight into the attitudes, beliefs and lifestyle that have influenced patients' eating behaviour. They may have encountered different messages, approaches and attitudes towards diabetes, weight and eating in the past. These will have influenced their behaviour and need exploring (23). While information-giving can improve confidence and reduce anxiety, be clear why information is being given, find out what the patient already knows, ask patients' views before giving your own (20). Patients need to be given the opportunity to talk and the environment should be conducive towards this. Acknowledge the patient's expectations and allay their anxieties. The key to any good discussion is an understanding of the patient's current situation. How are they coping with the diagnosis, are they ready to make changes, and what is the level of personal responsibility for the management of their diabetes (24) These factors will determine the type of responses that are...


Several potential risks of prevention programs are not yet fully understood. Reports in other diseases note a psychological stress or anxiety impact related to screening itself and to false positives in screening tests in particular. At this point, we do not adequately know what impact this may have in screening for type 1 diabetes. What are the


Metabolic acidosis stimulates chemoreceptors in the CNS, which results in partial correction of the metabolic acidosis via hyperventilation and a decrease in the partial pressure of CO2. There is a linear relationship between serum bicarbonate concentration and pCO2, and this relationship suggests that end-tidal CO2 measurements may be used as a rapid screen for acidosis in children who have suspected DKA or to follow the course of acidosis in children who have DKA (Fig. 4) 61 .

Choreiform Movements

Blood glucose control, neuroleptics, and benzodiazepines are the mainstays of therapy for this neurological complication. Ventral thalamotomy has been used successfully in one case (76). Abnormal movements usually resolve or improve after hyperglycemia treatment in the majority of patients (76).

Changes In Brain

Series of studies that were conducted not only with fMRI but also using magnetic resonance spectroscopy (MRS) indicate that cortical circuitry underlying chronic pain is distinct from that observed in acute pain, and preferentially involves orbital prefrontal cortex. More specifically regional brain chemistry changes in patients with chronic low back pain were examined and when compared with age- and gendermatched healthy control subjects, these subjects were found to have decreased brain chemical concentrations for multiple chemicals in both DLPFC and orbital frontal cortex and no detectable changes in primary sensory-motor cortex, ACC, insular cortex, or thalamus. Relationships between brain chemicals disrupted in patients with chronic low back pain, in a unique pattern the relation to pain as compared with anxiety were demonstrated in the analysis across number of brain regions. In addition to abnormalities of brain chemistry there was a decreased cortical gray matter size, as well...

Inhaled Insulin

Subcutaneous injection has been the only route of insulin administration for daily use by patients with T1DM for the past 80 years. A barrier to insulin therapy relates among other things to patient fears and anxiety about insulin injections. Although needles have become smaller and sharper, thereby causing less painful injections some people consider needles and injections a perceived stigma for diabetic subjects. It is only recently that alternative routes of insulin administration are becoming viable. Many avenues of insulin administration have been explored including oral, buccal and pulmonary routes 34,35 . Among non-invasive candidates, inhaled insulin (INH) appears to be the most promising. The lung offers a large surface area (75 m2) and the alveolar epithelium is approximately 0.1-0.5 im thick, allowing rapid absorption of inhaled drugs.

Erectile Dysfunction

Neuroendocrine Control Penile Erection

Diabetes was as high as in the older groups without diabetes (60-80 years). Thus, in presence of diabetes the development of ED starts around 20 years earlier than in the nondiabetic population. The crude incidence rate of ED in the MMAS was 26 cases 1000 man-years in 847 men aged 40-69 without ED at baseline who were followed for an average of 8.8 years (19). Population projections for men in this age group suggest an estimate of 617.715 new cases of ED per year for the United States. The age adjusted risk of ED was higher for men with lower education, diabetes, heart disease, and hypertension. The incidence rate of ED in men with diabetes was twofold increased, with 50 cases 1000 man-years. In a population based study from southern Wisconsin the prevalence of ED among 365 patients with type 1 diabetes increased with increasing age from 1.1 in those aged 21-30 years to 47.1 in those 43 years of age or older and with increasing duration of diabetes (20). In a study from Italy...

Cerebral Edema

Acidosis with inadequate hyperventilation the level of urea concentration in serum in the beginning of treatment. Pathogenetically, both factors can be seen as indicators of cerebral hyperperfusion and hypoxia. Hyperventilation and hypocapnia enhance cerebral vasoconstriction in children and young adults. The elevation of urea is an indicator for extreme dehydration with consecutive reduced cerebral perfusion. A further risk factor for cerebral edema was bicarbonate therapy. Animal experiments have indicated that bicarbonate can induce ZNS-hypoxia (36). Also, correction of bicarbonate in the treatment of extracellular acidosis can lead to activation of the sodium hydrogen transport which can lead to potassium influx with cellular swelling. Finally, it was shown that bicarbonate increases even ketogenesis. Cerebral edema begins with headache followed by neurological deficits (37). Early signs are severe headache, incontinence or lowered mental status. In this situation, an early...

Eye Pain

Jessie Healy, middle aged and in good health otherwise, had carried the anxiety of having inherited retinitis pigmentosa for forty years. Now her drivers' license was in jeopardy due to fast progression of her disease. Numerous heavy metals had accumulated in her retina, including cerium from dental floss, arsenic from pesticide, tin from health food brand deodorant, PCB from skin salve, cobalt from dish detergent and indium from tooth metal. She had eight parasites in the retina including Toxoplasma from association with cats years ago. Removal of dental metal alone arrested the disease process. Two years later she was slightly improved and still driving her car.


A recent study compared patients with DM1 and bulimia, to those with DM1 and binge eating disorder. Although both of these are serious forms of disordered eating, the study found that the presence of bulimia nervosa was highly associated with severe disturbances related to depression, anxiety, and eating disorders. In addition, the group with bulimia nervosa showed an overall higher rate or co-occurring mental disorders, psychosocial dysfunction and poorer overall glycemic control (77).

Clinical Features

Polyuria, polydipsia, and weight loss are nearly always present historically in a patient with DKA. Metabolic acidosis initiates hyperventilation to compensate for aci- The classical patient with DKA is characterized by dehydration, acidosis with hyperventilation, with varying degrees of cerebral obtundation, and peripheral circulatory compromise. Again, the most common precipitating factors following initial presentation are omission of insulin, infection, and, in adults, typical or atypical myocardial infarction (1,7).


The benefits of breastfeeding are discussed in Chap. 22 and include improved bonding, reduced maternal anxiety, monetary savings, decreased risk for postmenopausal hip fractures, and decreased infant illness with improved cognitive function of the newborn (28). Breastfeeding may lower the child's risk of developing diabetes and helps to prevent many infant and childhood illnesses such as otitis media, gastroenteritis, asthma, respiratory tract infection, obesity, and sudden infant death syndrome (SIDS) (28). Maternal weight loss is also a benefit. Calorie requirements are increased during lactation and are the same as calories needed in the third trimester with a recommended carbohydrate intake of 210 g per day (11). The estimated calorie expended in milk production is 500 kcal per day during the first 6 months and 400 kcal per day during the second 6 months of breastfeeding.


Chromium depletion can lead to symptoms including increased blood cholesterol, problems with sugar metabolism, fatigue, an increased accumulation of plaque in the aorta, increased blood pressure, anxiety, impaired physical growth in the young, slower healing time after surgery or injury, atherosclerosis, decreased glucose tolerance, reduced conversion of thyroxine to triiodothyronine in the periphery, and possibly decreased fertility and longevity.

Benefits Of Activity

The psychological benefits of exercise are equally important for the obese individual with Type 2 diabetes. Reductions in anxiety levels, improved body image and higher self-esteem promote greater self-efficacy and help the individual to cope with stressful situations which often result in overeating and relapses (71,72).

Odds Ends

In an ideal world, it would be best to get everyone in quickly just to be safe. It will relieve the patient's anxiety, and you may occasionally have a chance to get some laser in before a hemorrhage spreads around, or you may rarely find something unexpected like a retinal tear. Practically speaking, however, if you have a lot of diabetic patients you could bring your practice to a standstill trying to get everyone in immediately something that is usually not necessary for patients who have already had occasional hemorrhages and who have longstanding disease that is otherwise well controlled. You will even find that diabetics who have intermittent hemorrhages will ask you if it is okay to not call when they have a hemorrhage so they don't have to keep coming in all the time.*

Mental effects

Elderly people may think more slowly than youngsters and can be completely overwhelmed by the torrent of information pouring over them at diagnosis of diabetes. This can cause confusion and distress and produces much anxiety. Such patients need step-wise education, away from the bustle of a big clinic, and preferably in their own home. Treatment can often be started gently to avoid early side-effects. It is usually wise to include a close relative in the discussions with the patient's permission.


A well-developed literature has investigated the comorbidity between DM1 and depression, and the relationship of depression to medical outcomes among those with DM1. It has been shown that individuals with DM have a disproportionately higher rate of psychiatric disorders (16), with affective and anxiety disorders being more commonly diagnosed than in the general population (17,18). In one study of DM1 and type 2 (DM2) inpatients, 52 presented with at least one lifetime psychiatric disorder, and 41.3 presented with a diagnosis within the past 6 months (17). In this sample, affective and anxiety disorders represented 83 of the psychiatric diagnoses. Another study of DM1 outpatients showed rates of anxiety and depressive disorders at 44 and 41.5 , respectively (18).


Population projections for men in this age group suggest an estimate of 617,715 new cases of ED per year for the United States. The age-adjusted risk of ED was higher for men with lower education, diabetes, heart disease, and hypertension. The incidence rate of ED in diabetic men was twofold increased, with 50 cases 1000 person-years. In a population-based study from southern Wisconsin the prevalence of ED among 365 type 1 diabetic patients increased with increasing age from 1.1 in those aged 21 to 30 years to 47.1 in those 43 years of age or older and with increasing duration of diabetes (105). In a study from Italy including 9868 men with diabetes, 45.5 of those aged 59 years reported ED. Risk factors and clinical correlates included the following OR (95 CI) autonomic neuropathy 5.0 (3.9-6.4) , diabetic foot 4.0 2.9-5.5) , peripheral neuropathy 3.3 (2.9-3.8) , peripheral arterial disease 2.8 (2.4-3.3) , nephropathy (2.3 (1.9-2.8) , poor glycemic control 2.3 (2.0-2.6) , retinopathy...

Handling Emergencies

Recommended blood glucose levels are different for children and adults, because of children's high risk and vulnerability to hypoglycemia, relatively low risk of complications before puberty, and developmental and psychological issues. The blood glucose levels at which hypoglycemia is treated are also often higher than the standard recommendations for adults. Any time your child's blood glucose level falls below the value you have established, he or she may have hypo-glycemia. Signs of hypoglycemia include nervousness, shaki-ness, sweating, irritability, impatience, chills, clamminess, rapid heartbeat, anxiety, light-headedness, and hunger. When hypo-glycemia begins to affect the brain, your child may also appear sleepy, angry, uncoordinated, or sad. She may also experience nausea, blurred vision, tingling or numbness in the lips or tongue, nightmares, crying out during sleep, headaches, or strange behavior. In severe stages, confusion, delirium, personality changes, and...

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