Background: Patients with both type 1 diabetes mellitus (T1DM) and generalized anxiety disorder (GAD) are known to be at increased risk for hypoglycemic events, long-term hyperglycemia, weight gain and vascular disease. However, little research has been conducted regarding management of anxiety in patients with T1DM.
Clinical case: A 27 year old female with T1DM (controlled on an insulin pump), GAD, PTSD, and history of benzodiazepine abuse presented to the emergency department after experiencing multiple panic attacks the day of admission. Recently, patient had multiple bouts of emesis in addition to decreased oral intake. On admission, blood sugar was 54, which increased to 164 after administration of 1 amp of dextrose-50. Patient was obtunded and unable to provide much history. Overnight, insulin was not given due to patient’s poor oral intake. The following morning, patient had one cup of juice for breakfast. Accu-check shortly after revealed a blood glucose level over 500 and patient developed diabetic ketoacidosis (DKA) and was admitted to the ICU on our hospital DKA protocol. Once anion gap closed, patient was transferred out of the ICU for continued management of her diabetes. Patient went on to have multiple panic attacks for the duration of her hospitalization which were controlled with scheduled diazepam, valproic acid, lorazepam and quetiapine. Psychiatry was consulted and found that a major contributing factor to her developing recurrent DKA was her struggle with anxiety surrounding the responsibilities of managing her diabetes and its associated complications including gastroparesis and neuropathy. Further conversation revealed that her psychiatrist had passed away a few months prior to admission and that she had not established care with a new psychiatrist yet.
Discussion: Given the life changing nature of T1DM, it is not uncommon for these patients to have difficulty coping with the daily challenges required to optimally treat their condition. It can be frustrating when the slightest shift in caloric intake or exogenous insulin leads to life-threatening situations such as DKA. The above case sheds light on the profound medical consequences and setbacks that poorly controlled anxiety can have on diabetic patients. Therefore, recognizing the impact of anxiety on our patients with diabetes is critical in preventing further complications, especially microvascular, macrovascular and potentially other life-threatening events.