Najat M. Al-Saffar, Dara A. Saeed Dept. of Medicine- Psychiatry unit, College of Medicine, Mosul University

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1 Generalized anxiety disorder in type 2 diabetes mellitus In Suleimaniya city Najat M. Al-Saffar, Dara A. Saeed Dept. of Medicine- Psychiatry unit, College of Medicine, Mosul University Abstract To determine the frequency of generalized anxiety disorder (GAD) among type 2 diabetes mellitus (Types 2 DM); to study the possible relationship of these symptoms and sociodemographic characteristic. Also to compare the results of the studied group patients with other studies in different cultures. Two hundred patients with type 2 DM (which are diagnosed by senior physician) were selected from attendants of out-patient clinic of Sulaymania General Teaching Hospital during the period from 1st March 2007 to 1st September The presence of GAD was diagnosed by using a semi-structural interview based on (ICD-10) criteria and GHQ-30. The studied group was matched for age, sex, occupation and marital state with (200) healthy control for comparison. Showed that the rate of GAD in patients with type 2 DM was (40%) which highly significant compared (18%) control (i.e P-value< 0.001). (38.3%) of our cases of type 2 DM with GAD were in the age group (50-59) years. The rate of GAD is higher among female (42.8%) than male (36.3%) P-value< The rate of GAD is higher among housewives (50%) versus (17%) control P-value< 0.05 and higher GAD among divorces (63.5%) widows (61.1%) compare to the control. The study revealed that high rate of GAD in type 2 diabetes mellitus, the result of the study are similar to some western study. Key Word: GAD, type 2 DM, healthy control group. Introduction Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to absolute or relative deficiency of insulin. This can arise in many different ways. Lack of insulin affects the metabolism of carbohydrate, protein, and fat, and causes a significant disturbance of water and, electrolyte homeostasis. Death may result from acute metabolic decompensation, while long standing metabolic derangement is frequently associated with permanent and irreversible functional and structural changes in the cells of the body, with those of the vascular system being particularly susceptible. These changes lead to the development of well- defined clinical entities, the so called complications of diabetes.( 1 ) An etiological classification of Diabetes mellitus Type 1 diabetes *Immune mediated *Idiopathic Type 2 diabetes Other specific type Genetic defect of B cell function. Symptoms of Generalized Anxiety Disorder: Worry and apprehension, Psychological arousal, Autonomic over-activity, Muscle tension, Hyperventilation, Sleep disturbances, Other feature: Include tiredness, depressive symptoms, obsessional symptoms, and depersonalization. Patients and Methods A case control study include 88 male patients (44%) and 112 female patients (%56) diagnosed as NIDDM attending the outpatient clinic of Suleimaniyah General-Teaching Hospital during the period between 1stMarch 2007 to 1st sep Tikrit Medical Journal 2009; 15(1):78-85

2 These patients were located and studied according to the method and technique described in the following: 1- Diagnosis of Diabetes Mellitus by Senior Physician. 2-The patient were interviewed by the use of semi structured psychiatric interview based on ICD -10 (WHO 1993). A period of at least 6months with prominent tension, worry, and feeling of apprehension, about every day events and problems, and determine which symptoms are usually present in that period, from the symptom list on this checklist, at least four symptoms from (1) to (22) must be present, at least one symptom must be from (1) to ( 4). 3- Sufficient detail about symptoms was obtained by use of CHQ Age between Years. 5- The period of the disease not less than six month. 6- Cluster of symptoms was used to arrange the symptoms in checklist. 7- Socio demographic information was obtained from the patients. : Include 200 normal subjects their ages range (25-79) years of different occupations, level of education and marital states.they are either patient s family member, relatives and other people who worked in the outpatient s clinic of General Medical Teaching Hospital. They were interviewed by the use of semi structured psychiatric interview based on ICD- 10 check list (WHO 1993). A period of at least 6 months with prominent tension, worry, and feeling of apprehension about everyday events and problems, and from the symptom list on the front page of the checklist, at least four symptoms from (1) to (22) must be present, at least one symptom must be from (1) to (4). The socio demographic characteristic: (Table 1) Age: The age distribution of type 2 DM group, their age range (25-79 year). Sex: The sex distribution of patients with type 2 DM, the sample Consist of 110 Male (36.37%) and 90 Female (40.1%) control group with the same distribution. Marital status: The majority of diabetic sample are married (148), 74%. Small number are single (52), 26% other widow and divorce, and control group has similar distribution. Occupation: The majority of female in both diabetic and control group are housewives: while the male of both groups are distributed as government employer, retired, unemployed, and private sector worker. Education: The females in the diabetic group most of them of low education (primary school 57.1%,illiterate 33.3 %) while the male of the same group show no such variation, control group also show this variation between female and male but to lesser extent. Statistical Analysis: The statistical analysis involves the application of simple descriptive and t- test significant at the p- value level of: p<0.05 is significant. Also Chi- square test was performed for other tables. Ages of patients were expressed as mean ±SD. Results On the basis of GHQ-30, the results reveal that (40%) of type 2 DM had generalized anxiety disorder, while the control group (18%) had generalized anxiety disorder. On the basis of the semi- structured interview based on ICD- 10 check list (2). The same results were obtained (40%) of type 2DM had generalized anxiety disorder and the control group had (18%). GAD in type 2 diabetes mellitus and the control group reveal that 40%of the patients were cases of anxiety while in the control groups (18%) were cases of anxiety in both questioners'. Age: Anxiety state according to the age show in (Table 4), there is slightly higher among age group years (48.3%) in Tikrit Medical Journal 2009; 15(1):

3 type 2 DM while (27.4%) in control group so P-value<o.o5 so this is significant Statistically. Sex: Anxiety state was higher among female patients group (42.8%) versus (36.3%) in the male groups. While female of control groups was (23.2%) and male of control groups was (11.3%), P-value was this difference is statistically significant Table 5 show sex distribution between male and female, there is increase the rate of anxiety in female than male for cases of anxiety state in type 2 Diabetes mellitus and also control groups, this is statistically Significant so P- value < o.o5. Marital status: Anxiety state was higher among single patients followed by divorce, widow and married patients, there is significant higher rate of anxiety for married patients when compared with married control (Table 7). Occupation: There is significant difference among different occupation in the Patients group and when compared between the two groups, there is Significant increase in the rate of anxiety of the of housewife, retired and unemployed (Table 6). Educational level: There is no significant difference among different grade of educational Level in the patients and control groups, the postgraduate field has Small number and it is not representative (Table8). Duration of illness: The rate of the Anxiety in type 2 Diabetes Mellitus increase with increase of duration of the disease and the increase is not significant (Table9). Discussion The present study revealed that the rate of Generalized anxiety disorder in patients with type 2DM was (40%) compared with, (18%) among their matched control (i.e. p< 0.001), this mean that Diabetes patients were highly significantly more prone to Generalized anxiety disorder than their matched control. This result is concomitant with many other studies throughout the world, in spite of different methodology and different diagnostic tools, as shown in table (10). In this study the mean age of GAD with type 2 DM was which is inconsistent with the study of Skinner TC, Davies MJ who report higher mean age ( ) years in their retrospective study (11). This discrepancy may be due to the small sample size which may result in the reduction of our patients mean age in addition to difficulties faced by the family to bring an elderly patient to the out- patient clinic which may result in this restriction in the mean age. Our study revealed that younger age group ( years) were of small percentage 33.3% compared with other age groups and this study may be attributed to following reasons ; first : most of these patient are not diagnosed because type 2 DM less frequent below 25 years and because of small sample size in the study. Many of our patients with generalized anxiety disorder in type 2 Diabetes Mellitus were in the age group ( ) years than other age groups this finding is consistent with the study of Fellaton BJ. (7) Who reported a similar age group in their study. These age group (50-59) years more prone to get type 2 DM, because type 2 DM mostly occur in middle ages due to insufficient amount of insulin or resistance which occur in the cells receptor to insulin action. The finding of a higher rate of Generalized anxiety disorder in female s type 2 Diabetes Mellitus % 40.1 versus % 36.3 of male with type 2 DM, which is consistent to the study of Lloyd CE, (6 ). Dyer PH This increase could be due to in part to a greater readiness in woman to admit Generalized anxiety disorder symptoms, it is possible that some men 80 Tikrit Medical Journal 2009; 15(1):78-85

4 with generalized anxiety disorder misuse alcohol and, diagnosed as a suffering from alcohol related disorder rather than anxiety disorder, also in many societies women are subject to various kind of social disadvantage this may predispose to get many psychiatric condition like generalized anxiety disorder. (12) The majority of patients with Generalized anxiety disorder were married which may be due to the difficult life circumstances faced by married patients, this is consistent with studies of Cafvelc, Lithner E, Borjeson (10) Although the rate of Generalized anxiety disorder was high rate in divorced, separated and widows, this is consistent with a number of studies like Cafvelc, LithnerE, Borjeson. This may be due to the difficulty which faced these peoples due to lack of support and low self esteem which faced them and trouble about their future, and their children s life. (10) Regarding to the occupation (table 6): In this study, there was a strong association between occupation and Generalized anxiety disorder in type 2 Diabetes Mellitus specially housewife female to become more anxious in compare with other occupations this may be due to the difficulties that she faced in home and caring her children, heavy work. This is consistent with the study of Peyrot M, Rubbin RR. (5) Regarding the educational level in this study, there is no significant relation between the rate of Generalized anxiety disorder and educational level, this is consistent with the study of Jalenques I,.( 9) Longaret D, Thieblot p Although the higher rate of generalized anxiety disorder noticed in unemployed and retired patient with type 2 diabetes mellitus, this may be as a result of difficulty which faced unemployed patient in their daily lives towards themselves and their families, and coasty lives and thinking about themselves and their children's future and can not care themselves and neglect their state. (10) Regarding the relation between generalized anxiety disorder and duration of type 2 DM (table 9): There was no significant relation in our study between the duration of type 2 Diabetes Mellitus and Generalized anxiety disorder. This may be due to coping with the state when the condition prolonged and patient may adjust with the disease. The present study concludes that generalized Anxiety disorder was more present among type 2 DM (40%) than (18%). And this significant difference reflects a strong association, this mean, that type 2 diabetes mellitus may be a precipitating factor for the many psychiatric illness. Also, the finding of the study has provided the knowledge that although the basic symptom of anxiety in Diabetic is similar to some Western studies, while, the frequency and manifestation of symptom are different. As a recommendation; 1. Psychiatric assessment should form a principle aspect of the management of each patient with type2 DM. 2. Awareness should increase for detection of psychiatric disorders by the general and family physicians, to avoid delay management of such disorders. 3. Adequate psychiatric consultation and management is necessary. References 1. Haslett, C., Edwin R., Nicholas A. Boon, Nicki R. Colledge, John A. A. Hunter, B.M FRIER, B.M 2. World Health Organization ( 1993 ), International classification of disease ( diagnostic criteria for research ), 10 th,ed. Geneva. 3.Schweiger E, Rickles K, Stratigies of treatment of Generalized Anxiety disorder in primary care setting J clin Psychiatry 1997 ;58( suppl3) ; Tikrit Medical Journal 2009; 15(1):

5 4. Robin LN, Regier DA, Psychiatric disorder in America, The epidemiological catchment area: New York free press, 1998; 10: Peyrot M, Rubin RR: Level and risks of Anxiety & depression Symptomatology among diabetic adult; Diabetes care 2000 Sep, ; 23 (9) Lioyd CE,Dyer PH, Barnrt AH. Prevalence of symptom of depression and anxiety in diabetes clinic population Mar ; 2000 Mar 17(3) : Felton BJ,Revenson TA: Age difference in coping with chronic diseases ; 1997Jun ;2 ( 2) : Skinner TC, Davies MJ,Khundik ;Diabetes screening anxiety and belief ;2005 Nov. ;22( 11), Jalenques I,Langaret D, Thieblot P Prevalance of Generalized anxiety disorder in Diabetes Mellitus 1993Aug ;113(8):: Skinner TC, Davies MJ, Khundik ; Diabetes screening and belief anxiety ;2005Nov. ;22( 11) ; Gelder M, Gath D, Mayou R, Cowen P( eds). Generalized anxiety disorder PP" Oxford Textbook of Psychiatry" 5 th edition, Oxford university press 2005; Table (1) Socio demographic - Characteristic of the study samples Patients group Character Male Female Total Male Female Total Sex Age Marital status Married Unmarried Occupation Housewife Government employer Retired Unemployed Private secretor work Education Graduate Secondary school Primary school Illiterate Tikrit Medical Journal 2009; 15(1):78-85

6 Table (2) Generalized anxiety disorder in type 2DM and control group according to GHQ-30 Case % Non case % Total Type 2DM group 80 40% % % % 200 Table (3) Generalized Anxiety disorder among Patients With type 2 DM & Control Group according to semi structured interview (ICD- 10) Type 2DM group Case % Non case % Total P- value 80 40% % % % significant Table (4) The relation between Generalized Anxiety disorders in type 2 DM and control Groups According to Ages Age Patient with type2dm No. Case % No. Case % Significance Of the difference P- value % % <0.005 significant % % <0.005 significant % % <0.005 significant % % <0.005 significant % % <0.005 significant % % <0.005 significant Tikrit Medical Journal 2009; 15(1):

7 Table (5) Relation of the generalized anxiety disorder in type 2 diabetes and control group according to the Sex Sex Type 2DM patients No. Cases % No. Cases % P - value Male % % significant Female % % significant Total % % Chi- square Df P- value Table (6) the relation between Generalized Anxiety disorder in Type (2) DM and control group according to the occupation Patient group Occupation No. Case % No. Case % P- value House wife % % significant Official staff % % significant Retired % % significant Unemployed % % significant Private sector work % significant Chi- square Df P-value Table (7) The relation between generalized anxiety disorder in type2 DM and control group according to marital states Patient with type 2 DM Marital status No. Case % No. Case % P- value Single % % s. Married % % s. Widow % % s. Divorce % % s. Other Total % % Chi- square =16.47 DF =3 P-value= Tikrit Medical Journal 2009; 15(1):78-85

8 Table (8) The relation of generalized anxiety disorder in type 2 DM and according to the education: Patients group Education No. Case % No. Case % P- value Graduate % % Non- significant 2ndary school % % Non- significant Primary school % % Non significant Illiterate % % Chi- square=1.79 DF= 4 P- value= Table (9) Generalized anxiety disorder in type 2 DM according to duration of diabetes. Duration of type 2DM No. of type2 DM. No. case % P-value 1mounth- 1 year % Non- significant 2 10 years % Non- significant years % Non- significant 21 years & above % Non- significant Chi square DF P- value Table (10) Rate of GAD in regard to authors Researcher Year Rate of GAD Comment A ten primaria(3) HibbsED,Liakopoutom(4) Peyrot M, Rubbin RR( 5) Lloyd CE,Dyer ph ( 6) Fellaton BJ ( 7) Skinner TC,Davies MJ( 8 ) Jalenques I, Lonjaret D, Thieblot P (9 ) Cafvelc, Lithner, E, Borjeson( 10 ) % 40.6% 45.3% 38.2% 42.1% 45.3% 39.6% 80.2% GAD in divorces Tikrit Medical Journal 2009; 15(1):