I have strong memories of hypoglycemia anxiety from my early days of living with Type 1 diabetes. I would wake up anxious throughout the night. I was dreaming. I had always hated math, but after weeks of constant carb counting, recording my blood glucose levels, and noting my insulin doses, I had numbers in my head all night. That made me anxious, and so did the fear of hypoglycemia. Sometimes early in the morning, my blood sugar would drop low, making me shaky and sweaty. Those are the symptoms of a panic attack, but also of low blood sugar.
Every day people with diabetes (PWD) who use insulin risk hypoglycemia (a low blood sugar level). Each time they check their blood glucose, PWD have to examine the reading and decide how to proceed. We are balancing the need to maintain good blood glucose control with the fear of hypoglycemia. This fear is well founded. Hypoglycemia is not just unpleasant and embarrassing- it can be fatal.
I counsel people with Type 1 diabetes, and one of the most stressful parts of diabetes for many people is the experience of being hypoglycemic. I have met a number of people who let their blood sugar levels run high in order to have a break from the lows. Many of them live with substantial guilt about this coping strategy. They often worry about the long-term effects of their elevated blood glucose levels. The fact that they choose the guilt and worry over the risk of going low shows how intensely they fear hypoglycemia.
Hypoglycemia anxiety can diminish their quality of life, and often results in an ongoing elevated blood glucose level that causes other health issues. However, we can treat hypoglycemia anxiety and find the courage and motivation to maintain good blood glucose control. There are effective methods to reduce and manage anxiety. Cognitive interventions (focusing on changing thoughts) can eliminate panic attacks, as well as reduce the occurrence of less acute anxiety. Many people also find relaxation training, imagery and behavioral methods helpful in controlling their anxiety.
Cognitive Restructuring (changing our thoughts)
Anxiety becomes problematic when we overestimate the dangers that surround us, and underestimate our ability to cope. We can reduce anxiety by developing a more realistic perception of the dangers we face, and of our ability to cope with them. Patients in my practice with very high blood glucose levels have learned to look at the evidence and develop more balanced thoughts about the likelihood of a dangerous low. If they note that accurate carbohydrate counting and insulin dosing keeps them in safe range, coupled with testing BG regularly and carrying sources of sugar for lows, then they become more willing to gradually reduce their blood glucose levels. This can be done in conversation with a therapist or by writing down negative thoughts and challenging the thoughts using thought records (see Mind over Mood by Christine Padesky and Dennis Greenberger for a patient’s guide to cognitive behavioral therapy).
When anxious, we tend to focus on the thoughts and sensations that are connected to our feeling of anxiety. Distraction reduces the severity of anxiety by shifting our attention away from these thoughts and sensations. Your negative thoughts are providing the fuel for your anxiety, and if you distract yourself from these thoughts by absorbing yourself in other activities or thoughts, then you cut off the fuel supply for your anxiety. The more distracted you become, the more you will decrease your anxiety level. Many people find distraction to be the most effective coping strategy for very high levels of anxiety, and other relaxation methods may be more effective for lower levels of anxiety. One of my patients would ask her husband to chat with her in the evening so she could keep her mind off her blood sugar for a little while. This allowed her to keep her BG levels in a normal range for longer periods of time, without giving in to the impulse to snack and boost them higher to get rid of the hypoglycemia anxiety she felt.
Physical Relaxation Training
Relaxation training is helpful because the body and mind cannot be relaxed and anxious at the same time. There are relaxation methods that focus on mental relaxation, and others that focus on physical relaxation. A few examples of physical relaxation training include controlled breathing and progressive muscle relaxation. If you develop the ability to relax before or during a stressful situation, you can reduce the intensity and duration of the anxiety you experience. This can be helpful when patients are becoming accustomed to a healthier range of blood glucose levels after having lived with higher readings due to the fear of hypoglycemia.
I have had many patients describe feeling “low” when their blood glucose readings are actually in the normal range. Many believe this is because they are on their way to a low and will just keep dropping. However, the symptoms they feel may be due to anxiety, which is coming from their negative thoughts about having these lower readings. Using breathing exercises can help patients experiment with staying in that normal range a little longer, so that they start to gain confidence that as they reduce their anxiety, the physical symptoms will diminish. Of course, it is also possible that their bodies need to physically adapt to these lower readings, but that will not happen without exposure to the new blood glucose level.
Controlled breathing is a type of relaxation training that can be practiced anywhere at any time. When anxious, many people do not breathe properly and the resulting imbalance of oxygen and carbon dioxide in the body can produce the physical symptoms of anxiety. Try breathing in to count of 4 and then out to a count of 4. Keep one hand on your upper chest and one on your stomach. The hand on your stomach moves out as you breathe in. Try to continue this breathing for four minutes to see if you become more relaxed. You can breathe in the way you are most comfortable: through your mouth or through your nose. Practicing yoga is an excellent way to improve one’s breathing, too. However, you should use whatever time you have. For example, take some deep breaths every time you sit down to eat a meal or to catch up on email.
We all naturally tend to avoid the things that make us anxious. This initially provides some relief, but then over time our anxiety escalates because we send ourselves the message that we cannot cope with whatever it is we are avoiding. To overcome anxiety, we must face these situations, people or other sources of anxiety. This is very true when facing the fear of hypoglycemia. I have met patients who have underlying worries about the long-term effects of their high blood sugar, but it just never seems like the right time to change their way of coping. For example, a young nursing student might tell herself she cannot risk going low during her classes or hospital work. Then in the evenings when she is home alone she would rather boost her sugar because there is no one around to help her if she drops low. And of course she does not want to go low during the night. The end result is that her blood glucose levels are constantly high.
For those with high levels of anxiety, it can be helpful to develop a hierarchy (list) of fears. Start with the most intense sources of anxiety at the top of the list and the least feared situations, events or people at the bottom. Work your way up the list gradually, gathering evidence about your ability to confront yours fears until you are able to tackle the most intense ones on the list. You can use imagery to imagine feared events beforehand, and prepare yourself to confront them by using cognitive restructuring or relaxation methods. It would be a good idea to work with your doctor, a psychologist or diabetes nurse educator in developing this plan. Perhaps a supportive parent or spouse could also help.
For example, the nursing student may decide the least anxiety-producing situation is her class time and she decides to experiment with lowering her blood glucose levels during class first. Once she has become more comfortable with that situation, she tackles her time at home alone. Next is to manage her levels during her hospital work and finally, overnight. Not every patient will have the same goals or target blood glucose readings. Maybe this nursing student will always be a little higher than normal during the nights because she lives alone. She is in charge of her health, and she is allowed to make those kinds of choices. Every improvement in diabetes management matters.
It is not easy to expose yourself to the very situations that make you most anxious. For example, our nursing student has a belief that lowering her blood sugars means she will go low and when she goes low, she will eventually have a situation that she does not recover from and will die. Unfortunately, I cannot tell her that I know for sure she is wrong. But I can suggest we explore her underlying assumptions and figure out if this belief is very realistic. I work on gathering evidence to develop new, more balanced beliefs with patients who are overcome with anxiety about hypoglycemia.
The nursing student starts to look at factual evidence to challenge her belief she will go low and die. She balances the knowledge that some PWD do die from hypoglycemia with her awareness of steps she can take to manage her blood sugar better. She can start with lowering her blood sugar slightly before trying to get closer to the target range. She can assess the likelihood other people can help her if she is low and may realize she has been underestimating that support. It is important to develop confidence in her ability to cope with hypoglycemia… yes, it is best to prevent lows when possible, but she can treat the lows quickly and recover from them. Once she becomes more confident in her ability to maintain a steady blood glucose range in one situation, she will be motivated to address the next item on her list.
If you are struggling with anxiety, or someone you care about who has diabetes is struggling with anxiety, maybe you can try some of the techniques described here. Of course, all of these techniques need to be used in conjunction with support from family and health care professionals. If you are worried about a family member with diabetes, ask how you can be supportive before you focus on reducing their blood sugar. Listening to their worries is a great place to start.
If your hypoglycaemia anxiety is so high that these ideas seem out of reach for you, then please consider accessing professional support. It is a good idea to speak to your diabetes educator or endocrinologist for support and possibly referral information. If you choose to see a psychologist or social worker, I recommend someone who practices CBT, which is an evidence-based clinical approach. I have seen patients reduce their levels of anxiety and greatly improve their quality of life. It is absolutely worth the effort.
Michelle Sorensen is a member of the Ontario College of Psychologists and has a private practice in Clinical Psychology in Ottawa. She is a regular contributor to ASweetLife. For more on Michelle click here.