Getting to grips with fear of hypoglycaemia

Though not much talked about, fear of hypoglycaemia can have devastating implications for the wellbeing and health of people with diabetes. In his new module, Professor Frank Snoek examines the challenges fear of hypoglycaemia present for people with diabetes and the options available to healthcare professionals to identify, prevent and treat it.

Balancing the risk of long-term complications against the short-term risk of hypoglycaemia is a central dilemma for people with diabetes. But what happens when distress associated with hypoglycaemia tips people too far in favour of a determination to avoid hypos?

This is far from being a merely academic question. Studies have shown that people with diabetes’ worry about severe hypoglycaemia almost as much as they do about blindness, and more than they do about other complications such as nephropathy. The consequences include potentially damaging active behaviours, such as excessive self-monitoring of blood glucose, lowering insulin dosage and defensive snacking in order to keep levels of blood glucose higher. Other passive behaviours associated with it, such as avoiding driving, going out, exercise – even sex – can exact a heavy toll on people’s quality of life.

Professor Snoek is careful to distinguish between ‘adaptive’ fear responses to hypoglycaemia and phobia. There are, after all, good reasons why people should avoid hypoglycaemia. “The question is,” he observes, “when is fear of hypolgycaemia a normal response, an adaptive response, and when does it become maladaptive or a phobia. To think clearly about this, we need to take into account the actual risk that the person runs to have a hypoglycaemic event against the fear level. In the ideal situation, the fear is proportional to the actual risk.”

One aspect of fear of hypoglycaemia on which this module is particularly interesting and useful is that of conditioned responses. As per Pavlov’s dog, a sign, symptom or thought may be enough to provoke a strong fear response in the absence of an actual low blood glucose. Avoidance behaviours may make people feel safe, while actually reinforcing their anxiety. In this way, Professor Snoek points out, supportive family members and partners may even act as ‘phobic companions’, unintentionally strengthening the person with diabetes’ fear by providing security.

It’s a topic freighted with a great deal of nuance and sometimes counter-intuitive phenomena. But it’s one that healthcare professionals really need to get to grips with – and this module provides extensive practical guidance, not only on how to identify and treat fear of hypoglycaemia but also the ways in which support for people with fear of hypoglycaemia can be integrated into routine care.

Module 3 of our ‘Hypoglycaemia’ course, ‘Fear of hypoglycaemia’ will be launching on Wednesday 29th September. The launch will be marked by a live presentation and Q&A session at the EASD Annual Meeting at 12.00-13.30 CET.