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12-05-2018 | Diabetes distress | Editorial | Article

Diabetes distress: What’s in a name?

Authors:
Sanjay Kalra, Yatan Pal Singh Balhara

Author bios | Disclosures

Diabetes distress, an emotional response to diabetes, is characterized by extreme apprehension, discomfort or dejection, due to perceived inability in coping with the challenges and demands of living with diabetes.
Kalra et al. 2017 [1]

The above definition paraphrases concepts first discussed by authors such as Lawrence Fisher and William Polonsky. Since the term’s rise to prominence, numerous authors have offered similar descriptions. For instance, Kathryn Kreider has described diabetes distress as “an emotional state where people experience feelings such as stress, guilt, or denial that arise from living with diabetes and the burden of self-management” [2]. Fisher’s group, on the other hand, defines diabetes distress as a significant emotional reaction to the diagnosis, threat of complications, self-management demands, or unsupportive social structures surrounding diabetes [3].

A well-known entity

Diabetes distress is a fairly well-defined entity in the nomenclature of diabetes. It has accepted definitions, can be recognized by unambiguous symptoms, and can be diagnosed objectively by means of validated psychometric instruments. Ample research is available to describe its correlations and connections, and to point toward its complications if left untreated. There is broad consensus regarding the nature of its management, which is limited to non-pharmacological interventions [1–3]. However, randomized controlled trials have demonstrated the effectiveness of various therapeutic interventions in diabetes distress [4]. The 2018 Standards of Medical Care from the American Diabetes Association clearly mention the need to assess and manage diabetes distress, as this has been shown to improve outcomes [5].

Missing in the text

Despite being well known within the diabetes field, “diabetes distress” is yet to find a place in the language of psychiatry and psychology. The International Statistical Classification of Diseases and Related Health Conditions, 10th Revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [6,7] makes no mention of the term. In fact, even during discussion of “organic depressive disorder” (F06.32; listed under organic mood [affective] disorder) and “depressive disorder due to another medical condition, with depressive features,” the ICD-10 and DSM-5, respectively do not mention diabetes as an example of a medical condition that may be associated with depression. This omission is even more striking, given that the authors mention Cushing’s disease (not Cushing’s syndrome) and hypothyroidism as endocrine conditions that may be associated with depressive disorder. A similar omission is noted in the explanation of “organic anxiety disorder (F06.4)” and “anxiety disorder due to another medical condition” in the ICD-10 and DSM-5, respectively [6, 7].

Are we sowing the seed for clinical miscommunication?

We currently have a scenario whereby readers of the ICD-10 and DSM-5 may use terminology to describe diabetes distress that diabetes care professionals are not familiar with and vice versa. Such a situation carries the potential for miscommunication during referral, which may have downstream effects including misdiagnosis and inappropriate therapy [8]. Therefore, we feel that it is imperative that this linguistic challenge be addressed. Fortunately, objective definitions are available for all psychiatric disorders, and these lend themselves well to comparison and contrast with what we know as diabetes distress.

Similar disorders: ICD-10 and DSM-5

The ICD-10 and DSM-5 include disorders that are similar to, and may overlap with, existing descriptions of diabetes distress. These are listed in Table 1.

Table 1. ICD-10 and DSM-5 disorders that overlap with diabetes distress

ICD-10 Disorder

DSM-5 disorder

Organic depressive disorder (F06.32)

Depressive disorder due to another medical condition, with depressive feature (293.83)

Depressive episode, unspecified (F32.9)

Unspecified depressive disorder (311)

Generalized anxiety disorder (F41.1)

Generalized anxiety disorder (300.02)

Organic anxiety disorder (F06.4)

Anxiety disorder due to another medical condition (293.84)

Adjustment disorders (F43.2)
• Brief depressive reaction (F43.20)
• Prolonged depressive reaction (F43.21)
• Mixed anxiety and depressive reaction (F43.22)

Adjustment disorders (309)
• With depressed mood (309.0)
• With anxiety (309.24)
• With mixed anxiety and depressed mood (309.28)

DSM-5=Diagnostic and Statistical Manual of Mental Disorders, 5th edition; ICD-10=International Statistical Classification of Diseases and Related Health Conditions, 10th Revision.


Depressive disorders and anxiety disorders

In recent years, there have been calls to clarify the relationship between diabetes distress and depression [9–11]. While some feel that the conditions are unrelated, others suggest that they represent different ends of the same spectrum. It has been posited that distress is a forerunner of depression; however, there is now consensus that the symptomatology of diabetes distress is not severe enough to meet the diagnostic criteria for major depressive disorder [11]. Using the same yardstick for anxiety, Fisher et al have implied that diabetes distress should not be included as a part of depressive or anxiety disorders [12].

An adjustment disorder?

An important psychiatric morbidity to consider is the category of adjustment disorders. The definition of adjustment disorder is uncannily similar to that of diabetes distress. The ICD-10 description of adjustment disorders mentions that adjustment disorders are

 “…States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event (including the presence or possibility of serious physical illness)…

Individual predisposition or vulnerability plays a greater role in the risk of occurrence and the shaping of the manifestations of adjustment disorders… but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary, and include depressed mood, anxiety, worry (or a mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, and some degree of disability in the performance of daily routine.” (F43.2)

 

F43.2 Reprinted from: International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010. [6]

Diabetes adjustment disorder

The best fit for diabetes distress therefore, seems to be adjustment disorder. Use of this well-accepted term will convey the same meaning to professionals from mental health sciences as well as diabetology. Such use could minimize confusion, and deflect criticism about disease mongering and noun piling in endocrinology [13]. We propose the following diagnostic criteria diabetes adjustment:

Table 2. Adjustment disorder due to diabetes mellitus: Proposed diagnostic criteria

A. The development of emotional or behavioral symptoms in response to:

  • Diagnosis of diabetes/diabetes-related complications
  • Initiation/intensification of diabetes diagnostic/therapeutic interventions occurring within 3 months of the onset of the emotional or behavioral symptoms

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of:

  • Marked distress that is out of proportion to the severity/intensity of diabetes or its complications/proposed interventions
  • Significant impairment in self-care or social/occupational functioning

C. The stress-related disturbance does not meet the criteria for another mental disorder, and is not merely an exacerbation of a pre-existing mental disorder

D. The symptoms are not the result of bereavement

E. Once the stress or its consequences have terminated, the symptoms do not persist for more than an additional 6 months

Specify if:

  • With depressed mood
  • With anxiety
  • With mixed anxiety and depressed mood

We believe that using the revised term and associated criteria could make it much easier to understand, diagnose, communicate and manage diabetes distress. The diagnostic criteria proposed in Table 2 provide objectivity to the construct of diabetes distress, and serve as a useful teaching and clinical tool. The language used is such that it appeals to, and can easily be understood by, mental health and diabetes care professionals alike.

Differential diagnosis

We propose that the differential diagnoses of adjustment disorder due to diabetes mellitus (diabetes distress) are similar to those of adjustment disorder (Box 1).

Box 1. Differential diagnosis of adjustment disorder due to diabetes mellitus
  • Major depressive disorder
  • Personality disorders
  • Normative stress reactions
  • Altered cognitive function due to:
    • Hypoglycemia
    • Severe hyperglycemia
  • Type 3 diabetes (Alzheimer’s disease)
  • Drug-induced psychosis

These should be ruled out while dealing with adjustment disorder due to diabetes mellitus. Specific conditions such as type 3 diabetes (insulin resistance originating in the brain) should be evaluated carefully, before labeling a person as having adjustment disorder due to diabetes mellitus.

Summary

Diabetes distress is an emotional state, and this term has a distinct emotional appeal to it. It can help individuals living with diabetes and their caregivers identify with the symptoms and empathize with those affected. However, we need to bring diabetes care vocabulary into accordance with standardized medical terminology. This is especially important in the field of mental health, as there is significant overlap of morbidity and cross-referral between the two specialties. Hence, we suggest widespread adoption and usage of the term “adjustment disorder due to diabetes mellitus.”

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