Personality and Individual Differences 104 (2017) 6468

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Personality and Individual Differences

journal homepage: www.elsevier.com/locate/paid

Comparison of depression, anxiety, stress, quality of life, and alexithymia

between people with type II diabetes and non-diabetic counterparts
Marjan Shahi, Mohammad Ali Mohammadyfar
Department of Psychology, Semnan University, Semnan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: This study was an attempt to compare depression, anxiety, stress, quality of life, and alexithymia in
Received 16 April 2016 people with type II diabetes and their non-diabetic counterparts.
Received in revised form 9 June 2016 Material and methods: The present study was a causal-comparative study which falls into the category of descrip-
Accepted 25 July 2016 tive studies. All the people suffering from type II diabetes who referred to the clinics of Semnan in 2014 consti-
Available online xxxx
tuted the population of the study. From among the whole population, 60 patients (30 males and 30 females)
were selected via randomly sampling as the participants and, then, 60 healthy subjects were selected as the con-
Keywords:
Depression
trol group. The following instruments were used for data collection purposes: Depression, anxiety and stress
Anxiety scale, Toronto Alexithymia scale, and quality of life questionnaire. Data was analyzed by SPSS software 19 version.
Alexithymia Results: It was indicated that there was a signicant difference between the two groups in 12terms of all the var-
Diabetes iables under study.
Discussion: The results of this study showed that people with diabetes suffer from several mental disorders that
make it harder for them to continue living, regardless of the numerous 15difculties that they experience due to
this chronic disease.
2016 Elsevier Ltd. All rights reserved.

1. Background
Type II diabetes is a metabolic, chronic, and progressive disorder that
emerge due to lack of insulin secretion or resistance to insulin (Yu et al.,
2014). This condition requires ongoing medical care and self-manage-
ment education to reduce its long-term risk and acute side effects
(Zhao, Chen, Lin, & Signal, 2006). The International Diabetes Federation
has estimated that the number of adults with diabetes in Europe in 2011
was 35 million, and it is possible that the population of these patients
amounts to 43 million in 2030 (i.e., a 23%increase). From among the
25-to-64-year population in Iran, 7.7% (tantamount to 2 million people)
suffer from diabetes (MalekGavgani, Pourshari, & Aliasgarzadeh,
2010). In addition, the prevalence of diabetes is apparently increasing
(Zhao et al., 2006). With the increase in diabetes prevalence, the mortal-
ity of diabetes sufferers has become a serious problem in society
(Pildava, Strele, & Brigis, 2014). Chronic medical conditions are often ac-
companied by mental and emotional disorders (Hochung et al., 2014).
People with type II diabetes are at higher risk for developing cardiovas-
cular disease compared to healthy people, eye problems and blindness,
Corresponding author.
E-mail addresses: marjanshahi92@gmail.com (M. Shahi),
ali.mohammadyfar@yahoo.com, alimohammadyfar@semnan.ac.ir
(M.A. Mohammadyfar).
kidney problems, and amputation. In the same way, this disease is con-
sidered as risk factor for many infectious diseases due to the immunode-
ciency that creates in the body (Yu et al., 2014). However, this issue is
usually ignored during primary medical care (Hochung et al., 2014). Di-
abetes inuences people not only in biological terms but also in psycho-
logical and social terms (Van Olmen et al., 2014). In fact, particular
emotional stress can be dened as a range of emotional responses living
with diabetes, especially in people who need self-care or have treat-
ment regimen (Strandberg, Graue, Wentzel-Larsen, Peyrot, & Rokne,
2014). Depression is one of the mental disorders that is associated
with diabetes and a combination of genetic, biological, chemical, psy-
chological, social, and environmental factors may contribute to this dis-
order. Depression is often seen representative of the fact that the main
aspects of a person's life is in the balance. Many chronic and serious ill-
nesses such as cancer and diabetes may be associated with depression
(American Psychological Association, 2011).
For example, the results of the research done by Duivis, Vogelzangs,
Kupper, de Jonge, and Penninx (2013) showed that greater severity of
depression is positively associated with severe inammatory diseases.
Recent studies have shown that the prevalence of depression among pa-
tients with diabetes is 10% higher than that in other individuals
(Hochung et al., 2014). In general, patients with chronic medical condi-
tions are more likely to develop depression as much as twice to 3 times
(Mayers, Grannemann, Linqvay, & Trivedi, 2013). Shamsaei, Cheraghi,
and Allahverdipour (2006) reported the existence of a signicant rela-
tionship between diabetes and 8depression.

http://dx.doi.org/10.1016/j.paid.2016.07.035
0191-8869/ 2016 Elsevier Ltd. All rights reserved.
 M. Shahi, M.A. Mohammadyfar / Personality and Individual Differences 104 (2017) 6468
Anxiety disorders include those disorders that have extreme fear
and anxiety, and chaotic behavior common. Anxiety is in fact the predic-
tor of the occurrence of a threat in the future (American Psychiatric
Association, 2013). Anxiety can show itself in various forms of psychiat-
ric disorders, including anxiety, generalized anxiety disorder, phobia,
obsessive-compulsive disorder, post-traumatic stress disorder, and
panic (Chapman, Shuttleworth, & Huber, 2014). The relationship be-
tween anxiety and diabetes has been examined in several studies. In
studies done by Chapman et al. (2014) and Kaur, Tee, Ariaratnam,
Krishnapillai, and China (2013), the results showed that people with di-
abetic people obtained high scores on this scale.
The typical relationship between psychological stress and the clear
development of diabetes in diabetic patients is controversial (Shiloah
et al., 2003). Certainly, there is a stressful lifestyle accompanied by dia-
betes (Kaur et al., 2013). Lioyd et al. (1999) concluded that the intensity
of recent stressful issues in one's life is associated with poorer glycemic
control. Similarly, Kaur et al. (2013) reported the existence of a signi-
cant relationship between stress and diabetes.
Another variable that is associated with diabetes is alexithymia.
Alexithymia is a multifaceted personality structure that is characterized
by the difculty identifying and describing feelings and lack of internal
ideological orientation (Shishido, Gaher, & Simons, 2013). In a study
conducted by Housiaux, Luminet, Van Broeck, and Dorchy (2010), the
results showed that the children who have difculty expressing their
feelings to others lie at higher risk for poorer glycemic control. In addi-
tion, Lemche, Chaban, and Lemche (2014) reported a signicant rela-
tionship between alexithymia and diabetes.
Quality of life is another variable that is associated with type II diabe-
tes. Quality of life is one the most important areas that is examined in
relation to human welfare. This term was originally dened by the
World Health Organization as the human perception of their position
in the life, culture, and value system wherein they live (Beslerova &
Dzurickova, 2014). In a study done by Wahid, HussainBokhari, Butt &
Ali khan (2014), the results revealed no signicant difference between
diabetics and non-diabetics at some of the subscales of quality of life.
The prevalence of diabetes is increasing in all societies; in addition,
this diseases is correlated with high costs of health care since high
costs are annually spent on treating diabetes (Zhao et al., 2006). In addi-
tion to the substantial costs of diabetes, the sufferers of this disease do
not benet from proper mental health due to the confusion they
experience.
This study aimed to determine is there any signicant difference be-
tween diabetics and non-diabetics in terms of depression, anxiety,
stress, quality of life, and alexithymia?
2. Materials and methods
2.1. Population, sample, and sampling method
A causal-comparative research design was employed for this de-
scriptive study. Also this research method known as ex post facto re-
search. That is, diabetic patients compared to their non-diabetic
counterparts. In this type of research investigators attempt to determine
the cause or consequences of differences that already exist between or
among groups of individuals.
All the people suffering from type II diabetes who referred to the
clinics of Semnan in December of 2014 through May of 2015 constituted
the population of the study. By consideration of research method (caus-
al-comparative), type I error ( = 0.05), least difference (d), the
amount of standard deviation (SD), in the GPOWER software the num-
ber of sample determined 27 for each group and each gender. However,
60 patients (30 males and 30 females) were selected via randomly sam-
pling as the participants. That is the list of patients who were referred as
a type II diabetes in Semnan clinics provided in December of 2014
through May of 2015. In order to manage ethics of research everybody
who were selected as a sample lled agreement letter. Just 2 patients
65
did not agree and excluded and substituted by other random selected
patients.
2.2. Instrument
Depression, anxiety and stress scale (DASS): This questionnaire was
rst designed by Livibond & Livibond; this scale is a standardized ques-
tionnaire and consists of 21 questions with 3 subscales, namely depres-
sion, anxiety and stress. Each question is scored based on a 4-value
Likert scale from 0 to 3 points. The reliability coefcient of this subscale
was reported to be 0.7, 0.66, and 0.76 for the three subscales of depres-
sion, anxiety, and stress, respectively (AsadZandi, Sayari, Ebadi, &
Sanainasab, 2011).
Toronto alexithymia scale (TAS-20): This questionnaire was con-
structed by Taylor in 1986.
This questionnaire is a self-report scale, each item of which is scored
based on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly
agree). This questionnaire includes 20 items constituting the 3 follow-
ing subscales: difculty identifying feelings, difculty communicating
feelings, and externally orientated thinking (Besharat, Rostami,
Pourhosein, & Mirzamani, 2006).
Coefcient alpha for this scale lay in the range of 0.67 to 0.87. In
addition, the retest reliability of this scale after the interval of six
months ranged from 0.52 to 0.61 (Fernandez-Jimenez et al., 2013).
The validation of this questionnaire in Iran revealed the existence of
three subscales for it (Besharat, 2008). The results pertinent to the psy-
chometric characteristics of the questionnaire showed that the coef-
cient alpha for difculty identifying feelings, difculty communicating
feelings, and externally oriented thinking were 0.85, 0.82, and 0.45,
respectively, and this value for the total score of alexithymia scale was
0.72 (Besharat, 2008).
Quality of Life Questionnaire (QOL): This questionnaire is a self-re-
port scale consisting of 26 items which evaluate 4 dimensions, namely
physical health, psychological, social relationships, and life environ-
ment. For this scale, Cronbach's alpha coefcient and retest reliability
coefcient ranged from 0.9 to 0.94 and 0.80 to 0.93, respectively. In ad-
dition, there is a signicant correlation between this scale, EQ-5D, and
SF-36, which indicates the validity of the questionnaire (Garratt et al.,
2008).
3. Results
Since research method was causal-comparative, the two groups
should be the same in terms of age, education, socioeconomic, and mar-
ital status. The mean and standard deviation of the age of the diabetic
group were 57.82 and 10.46 years, respectively and these values 54.87
and 9.46 years for the control group, respectively. The results of inde-
pendent t-test for the two groups show no signicant difference in
terms of age (t = 1.619, P N 0.05). From the diabetic group, 3 people
were single, 50 people were married, and 7 people were widowed. In
addition, 6 people were single, 52 people were married, and 2 people
were widowed in the control group. Two variables Chi-square test
(Chi-Square for independence) results indicated no signicant differ-
ence between the two groups in terms of marital status (2 = 3.817,
P N 0.05). From the diabetic group, 3 patients were illiterate, 12 people
had passed primary school education, 23 people held diploma, and 22
people held associates degree. The illiterate of the number 2, 6 cycles,
17 Degree, Diploma and 35, respectively. As well, 2 people were illiter-
ate, 6 people had passed primary school education, 17 people held di-
ploma, and 35 people held associates degree. Chi-square test results
indicated no signicant difference between the two groups in terms of
education (2 = 6.592, P N 0.05). At the end, 3 people lay in low socio-
economic class, 32 ones lay in middle socioeconomic class, and 15
ones lay in high socioeconomic class from the diabetic group. Similarly,
from the control group, 7 people lay in low socioeconomic class, 42 ones
lay in middle socioeconomic class, and 10 ones lay in high
66 M. Shahi, M.A. Mohammadyfar / Personality and Individual Differences 104 (2017) 6468

Table 1 Table 3
Descriptive statistics of depression, anxiety, and stress for groups. Descriptive statistics of quality of life components for groups.

Variables Groups Mean SD N Variables Groups Mean SD N

Depression Diabetic 18.44 4.57 60 Physical Health Diabetic 17.79 4.82 60

Non-diabetic 11.10 3.09 60 Non-diabetic 24.83 4.45 60
Anxiety Diabetic 7.93 4.77 60 Psychological Health Diabetic 15.18 5.17 60
Non-diabetic 10.90 3.28 60 Non-diabetic 20.75 3.65 60
Stress Diabetic 17.68 4.46 60 Social Relationships Diabetic 6.77 2.63 60
Non-diabetic 12.61 3.64 60 Non-diabetic 9.77 2.68 60
Life Environment Diabetic 20.23 4.36 60
Non-diabetic 25.00 6.28 60

socioeconomic class. Chi-square test results indicated no signicant dif-

ference between the two groups in terms of socioeconomic class (2 =
6.292, P N 0.05). As we wanted to compare, healthy and diabetic groups,
they should not be matched on depression, anxiety, and stress. That is
these variables are dependent variables and we wanted to examine is
there any signicant difference between two groups on mentioned
variables?
Descriptive statistics pertaining to depression, anxiety, and stress are
presented for each group in Table 1.
Because the aim of present research was examine the difference be-
tween diabetic and non-diabetic group on the linear combination of de-
pression, anxiety, and stress scores MANOVA test should be employed.
This analysis can be controlled the type I error (). The equality of co-
variance matrices is one of the assumptions for using this parametric
test. Box's Test result showed that this assumption had not been met
(Box's M = 14.46, F = 2.335, P b 0.05). The other assumption of this
test is the equality of error variances. The results of Levene's test has
been indicated that assumption has been met only in stress while it
has not been met in depression and anxiety (P b 0.05). Due to the ab-
sence of these assumptions, Pillai's trace is considered as the multivari-
ate index. The results of MANOVA indicated the availability of a
signicant difference between the two groups (Pillai's trace = 0.468,
F = 32.117, P b 0.001). Univariate analysis of variance was used to ex-
amine differences in patterns as follows (see Table 2).
The results of univariate analysis show that there is a signicant dif-
ference between the two groups in all the components. According to the
descriptive statistics of the variables, it can be stated that the diabetic
group has obtained higher scores in all the components. Descriptive sta-
tistics of quality of life components are presented in Table 3.
MANOVA test was used to examine the differences between groups
in terms of the components of quality of life. One of the assumptions for
this parametric test is the equality of covariance matrices. The results of
this test implicated that this assumption has not been met (Box's M =
29.47, F = 2.822, P N 0.05). As well, Levene's test was used to check
the assumption of the equality of error variances. By Levene's test, it's
xed this assumption has not been met only with respect to life envi-
ronment while it has been met in physical health, psychological, and so-
cial relationships. Due to the absence of these assumptions, Pillai's trace
is considered as the multivariate index. The results of MANOVA indicat-
ed the availability of a signicant difference between the two groups
(Pillai's trace = 0.425, F = 18.261, P b 0.001). In addition, univariate
analysis of variance was used to examine differences in patterns as fol-
lows (Table 4).
As indicated in Table 4, there is a signicant difference between the
two groups in all the components. As per the descriptive statistics, it can
be stated that the control group received higher scores than the diabetic
group in all the components of quality of life.
The descriptive statistics of alexithymia components have been pre-
sented in Table 5.
MANOVA test (multivariate analysis of variance) should be
employed to examine the difference between the groups in alexithymia
components. There are some assumptions to be allowed to use this
analysis. Box's Test was used to check the assumption of equality of co-
variance matrices. The results of this test implicated the violation of this
assumption (Box's M = 14.297, F = 2.310, P b 05). As well, Levene's test
was used to check the assumption of the equality of error variances. By
Levene's test, it's xed, this assumption has been met for all the compo-
nents. Due to the absence of the rst assumption, Pillai's trace is consid-
ered as the multivariate index. The results of MANOVA implicated the
availability of a signicant difference between the two groups (Pillai's
trace = 0.552, F = 43.117, P b 0.001). Univariate analysis of variance
was used to examine differences in patterns as follows (Table 6).
As it is observed in Table 6, there is a signicant difference between
the two groups in all the components. As per the descriptive statistics, it
can be concluded that the diabetic group reported higher scores than
the control group in all the components of alexithymia.
4. Discussion
The results of this study showed that there was a signicant differ-
ence between the diabetic group and non-diabetic group in terms of de-
pression score in such a way that the diabetic group obtained
signicantly higher score on this scale than the non-diabetic group.
This result is consistent with that of the studies carried out by Ali,
Jyotsna, Kumar, and Mani (2013); Chapman et al. (2014); Kaur et al.
(2013); Nicholas and Brown (2003); and Zhao et al. (2006). This
means that some of these studies have concluded that there is a positive
correlation between depression and diabetes and some of the studies
have shown that people with diabetes receive higher scores on depres-
sion compared to their non-diabetic counterparts. In addition, the re-
sults of this study showed that anxiety issues are more tangible in
people with diabetes than non-diabetic individuals. This nding is con-
sistent with the results of the studies done by Tsenkova, Albert,
Georgiades, and Ryff (2011); Chapman et al. (2014); and Kaur et al.
(2013). These studies have found that people with diabetes are likely
to experience more severe anxiety. In terms of the comparison of stress
in diabetics and non-diabetics, the results of this study showed that the
diabetics experience more intense stress compared to their non-diabet-
ic counterparts. This nding is consistent with the ndings of the studies

Table 4
Table 2 The results of univariate analysis of variance representing difference patterns in the com-
The results of univariate analysis of variance representing difference patterns in depres- ponents of quality of life.
sion, anxiety, and stress.
Variables Mean square F Sig. Eta squared Statistic
Variables Mean square F Sig. Eta squared Statistic
Physical Health 1283.75 59.247 0.0005 0.367 1.00
Depression 1430.42 93.102 0.0005 0.47 1.00 Psychological Health 802.29 39.020 0.0005 0.277 1.00
Anxiety 1306.24 77.441 0.0005 0.43 1.00 Social Relationships 233.08 33.182 0.0005 0.245 1.00
Stress 680.88 40.886 0.0005 0.28 1.00 Life Environment 587.55 20.680 0.0005 0.169 0.995
 M. Shahi, M.A. Mohammadyfar / Personality and Individual Differences 104 (2017) 6468
Table 5
The descriptive statistics of alexithymia components for each group.
Variables Groups Mean SD
Difculty identifying feelings Diabetic 27.21 5.70
Non-diabetic 16.74 4.18
Difculty communicating feelings Diabetic 17.55 2.94
Non-diabetic 12.12 3.13
Externally orientated thinking Diabetic 24.81 3.63
Non-diabetic 20.35 4.30
conducted by Kaur et al. (2013) and Lioyd et al. (1999). To interpret the
nding that the severity of depression, anxiety, and stress is higher in
diabetic patients than non-diabetics, one can argue that the fear of prob-
lems associated with diabetes and the inability of diabetic patients to
avoid this disorder may be the logic behind the nding.
Depression may also cause immobilization, lack of exercise, and im-
proper nutrition, which, in turn, leads to the increase of diabetes. In ad-
dition, the high costs of treatment and the concluding problems
increase the possibility of depression and anxiety disorders. Some stud-
ies show that an increase in the activities of insulin hormone antago-
nists is also observed during severe depression (Mueller, Heninger, &
McDonald, 1969).
It is also likely that depression, anxiety, and stress interact with
each other at biological levels (Lustman, Grifth, & Clouse, 1988).
In addition, it should be noted that depression can have physical con-
sequences; for example, it reduces the alertness toward treatment,
the maintenance of a healthy diet, physical activity, and increases
smoking and the consequences of diabetes (Goldney, Phillips,
Fisher, & Wilson, 2004).
In addition, the results of this study showed that people with diabe-
tes experience more severe alexithymia than the non-diabetics. This
nding is consistent with the ndings of the studies done by Chatzi et
al. (2009) and Topsever et al. (2006) while it is not consistent with
the results of the study conducted by Damak et al. (2010). To interpret
this nding could, it can be stated that people who have difculty in
identifying and expressing their feelings, are at higher risk for weakness
and inability to control hyperglycemia. The problems with emotions
and poor glycemic control in these patients may be accounted for by
decits in social support. This means that both of these problematic is-
sues are caused by poor social environment and inappropriate health
services. In addition, it is possible that the status of glycemic control
has an impact on psychological factors in terms of causal and logical as-
pects (Housiaux et al., 2010).
The results of this study showed that people with diabetes benet
from lower and less desirable quality of life compared to their non-dia-
betic counterparts which is consistent with the ndings of the studies
undertaken by Wahid, HussainBokhari, Butt, and Alikhan (2014);
Thommasen and Zhang (2006); and Issa et al. (2014). To interpret this
nding, it can be stated that people experience great worries and under-
go stress and frustration arising from management problems after being
informed of suffering from diabetes (James & Marks, 2003). In fact, dia-
betes inuences all physical, psychological and social aspects of people
(Issa et al., 2014). These people are involved with daily self-manage-
ment problems. The diet of such people completely change after catch-
ing the disease. Thereafter, they have to be kept under treatment
throughout their lives. As well, this disorder is also accompanied by
Table 6
The results of univariate analysis of variance representing difference patterns in
alexithymia components.
Variables Mean F Sig. Eta
square squared
Difculty identifying feelings 2970.19 116.62 0.0005 0.552 1.00
Difculty communicating feelings 301.35 87.35 0.0005 0.449 1.00
Externally orientated thinking 539.18 34.45 0.0005 0.244
67
very complex problems such as blindness, kidney disease, cardiovascu-
lar disease, gastrointestinal problems, and sexual impotence and this
N can be very stressful and debilitating for patients (James & Marks,
60
2003; Issa et al., 2014).
60 The lack of easy access to diabetic people is one of the limitations of
60 this study. In addition, this study is causal-comparative and it is not pos-
60 sible to infer causal relationships from it. Similarly, the small sample size
60
of the study reduces the generalizability of these ndings. For future
60
studies, the employment of larger samples is suggested. Also, the con-
duct of experimental research in this area can provide us with more
comprehensive information on the relationship between diabetes and
mental disorders. Also, according to the results of this study and the pa-
tients' greater vulnerability to depression, anxiety, stress, and
alexithymia; it is suggested to pay more attention to psychological
problems of such people and help them promote their mental health
and well-being via planning for the treatment of depression and anxiety
they are suffering.
Based on the above ndings, it can be stated that people with diabe-
tes suffer from problems such as depression, anxiety, stress,
alexithymia, and poor quality of life more than healthy individuals. Peo-
ple with diabetes do not only experience the problems related to the
disease, but they also suffer from mental health problems and disorders.
This makes the tolerance of this disease more difcult and cumbersome
and involves them in intense problems of diabetes. However, they not
only need physical treatment, but also they need psychological treat-
ments for their depression, anxiety, and stress. As diabetic patients are
unable in understanding of reality and acceptance of disease, and after
aware of understanding of reality and problematic consequences of dis-
ease they will be feared and they will be under severe stress. As a matter
of fact, psychological treatments, and hardiness are important factors in
the treatment. That is, diabetic patients need multi stages treatment, for
physical and psychological problems.
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