Trait Naxiety And State Anxiety Among Diabetic Patients

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1. INTRODUCTION
Developed countries have made many advances to control infectious diseases thereby
resulting in increased life expectancy of individuals, whereas non-infectious chronic
diseases have not received the same attention. Diabetes is one of those chronic diseases
which has now become a major global health problem. It is both progressive and life
threatening with potentially devastating consequences for health
(Suresh, 2006). The International Diabetes Federation (IDA) estimated at least 285
Million people worldwide are suffering from diabetes disease (about 6.4% of adults),
and it is predicted to reach up to 435 million by 2030 (IDA, 2010). Asia is one of the
regions that has experienced high prevalence of diabetes mellitus. For example, the Iranian
Diabetes Society (IDS) estimated that at present there are 5 million diabetics in Iran, while
less than 100,000 of them participated in Diabetes Patient Education (IDS, 2010).
Unfortunately 50% of all the diabetic patients are unaware of their condition or do not have
awareness about their disease, and they do not register themselves at the diabetes
associations and clinics for patient education (IDA, 2010).
Diabetes can have a significant impact on both physical and psychological functioning
which can impair people’s quality of life. In terms of psychological functioning, the demands of
diabetes care can have potent impact on mood, both short – term and long-term. Adjustment to
diabetes is often accompanied by a variety of negative emotional responses, including anger,
guilt, frustration, denial, and loneliness. Frequent hypoglycemic episodes can be exhausting,
discouraging and frightening. In addition, chronically elevated blood gluc ose levels may lead to
persistent fatigue, which can exacerbate depressed mood. Psychological stress can also affect
diabetes control and the release of counter regulatory hormones often results in elevated glucose
levels. In addition stress can disrupt diabetes control indirectly through its impact on diet,
exercise and other self-care behaviors.
Both long-term and short-term complications can negatively affect physical functioning.

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The development of complications can result in sickness absence, disability, premature
retirement or premature mortality with loss in earnings and negative impact on quality of life
of the person with diabetes and his or her family. The ongoing threat of complications can
also be worrying and depressing. When the patients suffer vision loss, kidney damage,
significant heart diseases, sexual relationship problems through erectile dysfunction,
peripheral neuropathy resulting in chronic pain, amputation, and /or difficulty in walking, or
any of host of automatic neuropathy problems, there is likely to be a significant drop in
perceived quality of life. The patient may become unable or less able to work, to complete
household tasks, or to enjoy leisure activities or normal family life. The patient’s ability to
function independently may also be impaired. Psychologists can play an important role in
helping people live well with diabetes. Diabetes presents a significant challenge and stress
for diabetics and those around them. Psychologists are well trained in behavior change
interventions. They understand the problems in diabetes self-care, and can help the
individual to overcome the difficulties and to change their behavior. In addition to the
behavioral demands of diabetes there are emotional and social problems that can arise.
Diabetes is often perceived as a burden. It can be hard to accept the disease, and feelings of
depression (feeling overwhelmed), anxiety (fear of complications or hypoglycemia) and
frustration (with the demands of self-care, or the medical system) are common. Young
people, especially young women with Type 1 diabetes, are at risk for developing eating
disorders (weight loss through insulin omission). Social problems can result from diabetes
as well. Many individuals who do not have diabetes find it difficult to understand the needs
of someone with diabetes. Even if they mean well, often those without diabetes act in ways
that are notsupportive. For example, friends can encourage a person with diabetes to eat
something they shouldn't because ''once can't hurt". Psychologists work with individuals
with diabetes in a number of ways. They can help the newly diagnosed individual to
understand the impact of diagnosis and their role in managing it. They can help them learn

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the daily behaviors needed for successful maintenance. They are trained to recognize and
treat psychological distress, including depression and anxiety that can develop when living
with an unpredictable disease. Psychologists can be helpful in assisting the individual to
develop and maintain the motivation needed to follow the daily routine of self-care. As well,
family therapy and strategies to deal with social pressures are often beneficial to those with
diabetes and their loved ones. Many people think that diabetes treatment is very simple,
once the right amount of medication or insulin has been determined. Unfortunately,
management is much more complicated. Psychological wellbeing is an important goal of
medical care, and psychosocial factors are relevant to nearly all aspects of diabetes
management. They can help the newly diagnosed individual to understand the impact of
diagnosis, and their role in managing it. They are trained to recognize and treat
psychological distress, including depression and anxiety that can develop when living with
an unpredictable disease. Psychologists can be helpful in assisting the individual to develop
and maintain the motivation needed to follow the daily routine of self-care. As well, family
therapy and strategies to deal with social pressures are often beneficial to those with diabetes
and their loved ones (Suresh, 2006).

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Diabetes
Definitions and description
Diabetes is a chronic disease that occurs when the pancreas does not produce
enough insulin, or when the body cannot effectively use the insulin it produces. Insulin is
a hormone that regulates blood sugar. Hyperglycemia, or raised blood sugar, is a
common effect of uncontrolled diabetes and over time leads to serious damage to many
of the body's systems, especially the nerves and blood vessels. After a meal, the portion
of the food a person eats is broken down into sugar (glucose). The sugar then passes into
the bloodstream and to the body’s cells via a hormone (called insulin) that is produced by
the pancreas. Normally, the pancreas produces the right amount of insulin to
accommodate the quantity of sugar; however, when the person has diabetes, either the
pancreas produces little or no insulin or the cells do not respond normally to the insulin.
Sugar builds up in the blood, overflows into the urine, and the passes from the body
unused (WHO, 2010).
Diabetes facts
 Diabetes deaths are likely to increase by more than 50% in the next 10 years
without urgent action.
 In 2004, an estimated 3.4 million people died from consequences of high blood
sugar.
 Most people with diabetes in low and middle income countries are middle-
aged (45-64), not elderly (65+).
 Diabetes causes about 5% of all deaths globally each year.
 Almost half of diabetes deaths occur in people under the age of 70 years; 55%
of diabetes deaths are in women.
 Healthy diet, regular physical activity, maintaining a normal body weight and
avoiding tobacco use can prevent or delay the onset of diabetes (WHO, 2010).

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Epidemiology and prevalence
The International Diabetes Federation (IDA) estimated at least 285 million
people worldwide are suffering from diabetes disease (about 6.4% of adults), with 46%
of all those affected in the 40-59 age group; it is however predicted that it may reach up
to 435 million by 2025 (IDA, 2010). Asia is a one of the regions that has high prevalence
of diabetes mellitus. Indian Diabetes Association estimated that there are approximately
31.1million diabetics in India. (IDA, 2010) and it will be around 100 million mark in
2030.
Type of diabetes
There are three main types of diabetes:
Type 1 diabetes (previously known as insulin-dependent, juvenile orchildhood-onset) is
characterized by deficient insulin production and requires daily administration of insulin.
Type 2 diabetes (formerly called non-insulin-dependent or adult-onset)results from the
body’s ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes
around the world, and is largely the result of excess body weight and physical inactivity.
Until recently, this type of diabetes was seen only in adults but it is now also occurring in
children.
Gestational diabetes is hyperglycemia with onset or first recognition during
pregnancy. Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational
diabetes is most often diagnosed through prenatal screening, rather than reported
symptoms.

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Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) are intermediate
conditions in the transition between normality and diabetes. People with IGT or IFG are
at high risk of progressing to Type 2 diabetes, although this is not inevitable (WHO,
2010).
Sign and Symptoms
The onset of Type 2 diabetes is gradual and therefore hard to detect. Indeed, some
people with Type 2 diabetes show no obvious symptoms early on. These people are often
diagnosed several years later, when various complications are already present.
 The onset of Type 2 diabetes can include symptoms such as:
 Abnormal thirst and a dry mouth
 Frequent urination
 Extreme tiredness/lack of energy
 Sudden weight loss
 Slow-healing wounds
 Recurrent infections
 Blurred vision.
Risk factors for type 2 diabetes: (Etiology)
Age
90-95% of people with diabetes have type 2 diabetes. This type usually occurs
in people over the age of 40 but is now also affecting children and adolescents to a
greater extent. The older you are, the greater your risk of diabetes.

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Obesity
Over 80 per cent of people with type 2 diabetes are overweight. The more
overweight you are, the greater your risk of diabetes.
A family history of diabetes
Research has shown that people are more at risk if there is a history of diabetes in
close family members. The closer the relative, the greater your risk of diabetes.
Physical inactivity
Research has shown that people who do not lead an active life are more at risk
of developing type 2 diabetes. The less exercise you do, the greater your chances of
developing diabetes.
Impaired glucose tolerance (IGT)
A healthy person’s blood sugar is usually between 70 and 110 mg/dL
(milligrams of glucose in 100 milliliters of blood) or, in millions, between 3.9 and 6.0
mmol/L. Impaired glucose tolerance is a level of blood glucose which is higher than
normal, but not high enough to be in the range where doctors classify this as diabetes.
Race/ethnicity
As far as we know, race and ethnicity are important in determining the
possibility of a person developing diabetes. Little research, however, has been undertaken
outside of the United States. Within that population, African-Americans, Hispanic
Americans, Native Americans, Asian-Americans and Pacific Islanders are more likely to
have diabetes.

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Diabetes during pregnancy
Some women develop a temporary type of diabetes called 'gestational diabetes'
when they are pregnant. Gestational diabetes develops in 2-5% of all pregnancies, but
usually disappears when the pregnancy is over. However, women who have had
gestational diabetes or who have given birth to a large baby (4kg/2lb or greater) are at a
greater risk of developing type 2 diabetes at a later stage in their lives (IDA, 2010).
Complications
Many adults have had diabetes for several years before their symptoms are
recognized. By the time they are diagnosed, a great many have already started to develop
the complications of diabetes - visual impairment, kidney failure, heart disease, stroke
and nerve damage. In many parts of the world, people with diabetes are not diagnosed at
all. Spotting diabetes early means that it can be treated and the risk of the serious
complications can be greatly reduced. (IDA, 2010)
Complications of diabetes
Short-term complications
Low blood sugar (hypoglycemia)
A person who takes insulin is going to face the problem of their blood sugar
falling too low at some point (because they have overestimated the insulin they need,
have exercised more than anticipated or have not eaten enough). Hypoglycemia can be
corrected rapidly by eating some sugar. If it is not corrected it can lead to the person
losing consciousness. It is important that the person with diabetes recognizes the signs of
hypoglycemia.

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Ketoacidosis
When the body breaks down fats, acidic waste products called ketones are
produced. The body cannot tolerate large amounts of ketones and will try to get rid of
them through the urine. However, the body cannot release all the ketones, and they build
up in your blood causing ketoacidosis which is a severe condition caused by lack of
insulin. It mainly affects people with Type 1 diabetes.
Lactic acidosis
Lactic acidosis is the buildup of lactic acid in the body. Cells make lactic acid
when they use glucose for energy. If too much lactic acid stays in the body, the balance
tips, and the person begins to feel ill. Lactic acidosis is rare and mainly affects people
with Type 2 diabetes.
Bacterial/fungal infections
People with diabetes are more prone to bacterial and fungal infections.
Bacterial infections include sties and boils. Fungal infections include athlete’s foot,
ringworm and vaginal infections.
Long-term complications
Eye disease (retinopathy)
Eye disease, or retinopathy, is the leading cause of blindness and visual
impairment in adults in developed societies. About 2% of all people who have had
diabetes for 15 years become blind, while about 10% develop a severe visual impairment.
In fact, in developed countries, diabetes is often discovered when people get routine eye
exams, and the ophthalmologist discovers intraocular pressure from glaucoma caused by
Type 2 diabetes.

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Kidney disease (nephropathy)
Diabetes is the leading cause of kidney disease (nephropathy). About one third
of all people with diabetes develop kidney disease and approximately 20% of people with
Type 1 diabetes develop kidney failure.
Nerve disease (neuropathy)
Diabetic nerve disease or neuropathy affects at least half of all people with
diabetes. There are different types of nerve disease which can result in a loss of sensation in
the feet or in some cases the hands, pain in the foot and problems with the functioning of
different parts of the body including the heart, the eye, the stomach, the bladder and the
penis. A lack of sensation in the feet can lead to people with diabetes injuring their feet
without realizing it. These injuries can lead to ulcers and possibly amputation.
Diseases of the circulatory system
Disease of the circulatory system, or cardiovascular disease, accounts for 75%
of all deaths among people with diabetes of European origin. In the USA, corny heart
disease is present in between 8% and 20% of people with diabetes over 45 years of age.
Their risk of heart disease is 2-4 times higher than those who do not have diabetes. It is
the main cause of disability and death for people with Type 2 diabetes in industrialized
countries.
Amputation
Diabetes is the most common cause of amputation that is not the result of an
accident. People with diabetes are 15 to 40 times more likely to require lower-limb
amputation compared to the general population.

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Heart disease and stroke
Diabetes increases the risk of heart disease and stroke. 50% of people with
diabetes die of cardiovascular disease (primarily heart disease and stroke). The overall
risk of dying among people with diabetes is at least double the risk of their peers without
diabetes (WHO, 2010).
Anxiety
Anxiety is an unpleasant emotional state consisting of psycho physiological
responses to anticipation of unreal or imagined danger, ostensibly resulting from
unrecognized intrapsychic conflict. Physiological concomitants include increased heart
rate, altered respiration rate, sweating, trembling, weakness and fatigue; psychological
concomitants include feelings of impending danger, apprehension and tension (Corsini,
1999).
Diabetes-related Anxiety
Patients with diabetes often worry about lasting complications of the disease,
how to manage the cost of the disease, and how it will affect their families or their jobs.
A meta-analysis of anxiety prevalence among individuals with diabetes, with combined
sample of 2,584 participants with diabetes and 1492 non-diabetes, indicated that 14 % of
those with diabetes experienced generalized anxiety disorder, and that 40% experienced
elevated anxiety symptoms (Grigsby et al., 2002). In addition, 13% of youth diagnosed
with diabetes developed an anxiety disorder within ten years after the diabetes diagnosis
(kovacs et al., 1997). Although anxiety symptoms were higher among women than men,
a meta-analysis of 11 studies which assessed the relationship between anxiety and control
of blood sugar found that anxiety rates for

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those with Type 1 and Type 2 diabetes were similar. However, when only studies that
utilized diagnostic interviews to assess anxiety were included, anxiety was significantly
related to glycemic control with a significant effect size (Anderson et al., 2002). Some
individuals have exhibited diabetes-specific anxiety, such as fear of hypoglycemia (FH).
Studies have found relationships between FH and poor glycemic control, (Cox et al.,
1987), higher trait anxiety and post hypoglycemic experiences, difficulty distinguishing
between anxiety and hypoglycemia (Polonsky et al., 1992), as well as higher perceived
Stress, frequency of past hypoglycemic episodes, and greater daily variations in blood
sugar (Irvin et al.,1992). Some individuals attempt to avoid this fear hypoglycemia,
compromising their glycemic control by administering lower insulin dosage/maintaining
higher blood sugar levels (Surwit et al., 1982), or over eating in response to early sighs of
hypoglycemia if individuals engage in this avoidance behaviors they may increase risk
for the long-term medical complications associated with hyperglycemia (Cox et al.,
1987).
Early and intensive treatment can influence patients’ psychological outcomes,
thereby leading to relatively more anxiety and less self-efficacy in the 1st year after diagnosis
(Thoolen et al., 2006). Because some individuals 1) report ongoing intrusive worry about
hypoglycemia; 2) become anxious in response to this intrusive ideation, even when blood
sugar is not low; and 3) react with avoidance behaviors that compromise their diabetes
regimen and pose serious long-term health risks, the authors evaluated the full post traumatic
stress symptomatology among individuals using thigh control regimens. About 25% of
patients reported symptoms consistent with current post traumatic stress disorder (PTSD)
about hypoglycemia (Myerset al., 2007).

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Diabetes –related Depression
The co-morbidity of diabetes and depression has received enough empirical
investigation to generate several meta analytic studies to summarize the findings, first a
meta analysis of nine studies published prior to January, 2005 that assessed
therelationship of depression to the subsequent development of Type 2 diabetes suggests
that depressed adults are 37% more likely than those without depression to develop Type
2 diabetes (Knol et al, 2006).
In addition, depression appears more common among individuals who have
diabetes than those without diabetes. Although some studies have found depression to be
six times higher among those with diabetes (Lustman et al., 1986), a meta- analysis of 42
studies indicates an odds ratio of 2:1, that is, depression is twice the prevalence among
those with diabetes compared to those without diabetes. In another study, depression
rates for those with diabetes were 28% among women and 18% among men, with rates as
high as 32% in sample seeking clinical services (Anderson et al., 2001). Major
depression in another sample was present in at least 15% of patients with diabetes
(Garvard et al., 1993).
Depression is associated with poorer glycemic control, health complications,
decreased quality of life and increased healthcare costs (Egede et al., 2002). Although
women showed higher absolute rates of depression than men, the odds ratio was
consistent for sexes as well as for Type 1 and Type 2 diabetes, women had twice the rate
of depression than that of men. A review of depression prevalence among individuals
with Type I diabetes that included five studies since the Anderson and colleagues meta-
analysis (2001) indicated 125 of persons with diabetes has co-morbid depression,
compared to a 3.2 % rate of depression for those without diabetes (Barnard et al., 2006).

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Perceived Stress
The perceived stress is the degree to which situations in one’s life are
appraised as stressful. It showed that people to tap how unpredictable, uncontrollable,
and overloaded respondents find their lives (Cohen, Kamarck, &Mermelstein, 1983).
Diabetes related to stress
It is hard to dispute that most of people live life at breakneck speed. It is the
nature of a fast-paced society, where numerous family, social, and work obligations can
easily overpower precious time and resources. But for people with diabetes, both physical
and emotional stress can take a greater toll on health. Patients with diabetes commonly
experience long-term stress or depression. It often is a direct result of the disease itself
due to the emotional ups and downs patients experience during chronic management. The
disease itself can be overwhelming and often leaves a patient wondering, "Why me?"
Identifying these patients and helping them with tips to manage stress effectively can
have a positive impact, not only on their emotional well-being, but on their long-term
clinical outcomes as well. Sources of stress can be physical or mental. Examples of
physical stresses include infections, trauma, injuries, or sickness. Mental stresses include
relationship difficulties/ financial concerns, and pressure from a stressful job.
Physiologically the body responds to stressors by secreting the counter-regulatory
hormones such as epinephrine, cortisol, and glucagon. These hormones, although helpful
to boost energy when needed, can work counterproductively to keep the body at a
constant state of arousal. Think of the fight-or-flight response. We cannot fight danger
when our blood sugar is low, so it rises to help meet the challenge. Both physical and
emotional stress can prompt an increase in these hormones, resulting in an increase in
blood sugars (Suresh, 2006).

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the stressful life events appropriate for middle-age and elderly adults showed that
somatic illness of self has great importance for people. The Social Readjustment Rating
Scale (SRRS) developed by Holmes and Rahe (1967) showed that the sixth item of
stressful life events for people is personal injury or illness. Stress is one of the risk
factors among people with Diabetes Type 2 (IDA, 2010).
Title of the Research
Prevalence of Trait anxiety and State anxiety among Diabetic patients
Need and Significance of the study
Being diagnosed and living with diabetes can affect people in very different ways.
While some may find coping with diabetes has very little impact on day-to-day life,
others may find that it has turned their lives upside down. Finding diabetes difficult to
cope with does not mean that you are doing something wrong. Many people with diabetes
who we speak to feel that at some point in their lives, their diabetes causes them to feel
like they are not coping. Many feel alone.
The physical impact of diabetes is well reported but the emotional impact is still not
always recognized. Diabetes can have an emotional impact, especially around diagnosis,
starting insulin, and on developing complications. Many people find their own personal
way to deal with these feelings, but for some they continue to struggle to come to terms
with how their diabetes making them anxious and leads to stressful situation. The
unawareness about the disease may also leads to the unwanted anxiety and stress. For
some people with diabetes these feelings can develop into depression. This study will

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help to clarify the relation between types of anxiety among diabetic patients. The levels
of anxiety can be elaborated through this study and remedial measures can be formulated.
Statement of the problem
Diabetes is a chronic health problem with devastating, yet preventable
consequences. It is characterized by high blood glucose levels resulting from defects in
insulin production, insulin action, or both. Globally, rates of type 2 diabetes were 15.1
million in 2000; the number of people with diabetes worldwide is projected to increase to
36.6 million by 2030. This rate is expected to increase greatly over the next half century.
Along with the increase in incidence of diabetes, both individual and societal
expectations concerning the management of diabetes have also increased, Patients with
diabetes often worry about lasting complications of the disease, how to manage the cost
of the disease, and how it will affect their families or their jobs. Other research has
focused on the cumulative effect of attitudes, preferences and conceptualizations in the
form of identity, measuring the impact identification with the illness has on social
relationships with others, including health care providers, and how this identity can
influence certain behaviors. However, these existing studies do not sufficiently examine
the level of state anxiety in diabetic patients. This study will examine the state and trait
anxiety level of diabetic patients and the impact of certain factors on the anxiety level of
them.
Operational Definitions
1. Diabetes
Diabetes also called Diabetes Mellitus, a disorder of carbohydrate metabolism,
usually occurring in genetically predisposed individuals, characterized by inadequate

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production or utilization of insulin and resulting in excessive amount of glucose in the
blood and urine.
2. Patient
An individual who is receiving needed professional services that are directed by a
licensed practitioner of the healing arts toward maintenance, improvement or protection of
health or lessening of illness, disability or pain.
3. Trait Anxiety
Trait anxiety refers to a general level of stress that is characteristic of an individual,
that is, a trait related to personality. Trait anxiety varies according to how individuals have
conditioned themselves to respond to and manage the stress.
4. State Anxiety
State anxiety is characterized by a state by heightened emotions that develop in
response to a fear or danger of a particular situation. State anxiety can contribute to a
degree of physical or mental paralysis, preventing performance of a task or where
performance is severely affected.
Variables
Data regarding the following variables age, education, diabetic related
diseases, food control, type of treatment, and discussion with peer, state anxiety, and trait
anxiety were collected. The responses are recorded in printed questionnaire format

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Specific Objectives of the research
1. To know about the prevalence of trait anxiety and state anxiety among diabetic
patients.
2. To find out the level of state anxiety among diabetic patients.
3. To compare their state anxiety in the context of their gender.
4. To find out the influence of gender, educational qualification, frequency of
consultation on state anxiety of diabetic patients.
5. To find out the relation between Trait anxiety and State anxiety of diabetic
patients.
Hypothesis
Following hypotheses are formulated that are to be tested in the present study.
It is Null Hypothesis:
Ho1 There is no significant effect of ‘sex’ on state anxiety of the diabetic patients
Ho2 There is no significant effect of ‘Prevalence of other diseases ‘on state anxiety
of diabetic patients.
Ho3 There is no significant effect of ‘Food control’ on state anxiety of diabetic
patients
Ho4 There is no significant effect of type of their treatment on state anxiety of
diabetic patients.
Ho5 There is no significant effect of ‘discussion about disease with their peer’ on
state anxiety of diabetic patients.
Ho6 There is no significant effect of ‘educational qualifications’ on state anxiety of
the diabetic patients.

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Ho7 There is no significant effect of ‘diabetic patients whose family members have
diabetes’ on state anxiety.
Ho8 There is no significant effect of ‘frequency of consultation for treatment’ on
state anxiety of the diabetic patients.
Ho9 There is no significant effect of ‘means of getting knowledge about the
disease’ on state anxiety of diabetic patients.
Ho10 There is no significant relation between trait anxiety and state anxiety.

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Chapter II
REVIEW OF RELATED LITERATURES

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LITERATURE REVIEW
Introduction:
In order to do work of research properly, the researcher decided the Problem of
research, Objectives, Hypothesis, Importance and Limitationsof the Study, Definition of the
Terms, Variables of the Study, etc. in theprevious chapter. Study of related literature made
this research accurate.
Anderson et al., 2002.Anderson and colleagues (2002) performed a meta-analytic
review of the literature to determine the relationship between anxiety and glycemic control
in T1DM and T2DM. Investigators located all studies published from 1975 to 2002 that
examined either self-reported anxiety symptoms and/or anxiety disorders and glycemic
control in diabetes patients. Their review identified 11 studies meeting criteria for inclusion
in the meta-analysis, for a total of 1413 participants. Self-report inventories included the
SCL, 90-item version (SCL-90; Derogatis, Lipman, &Covis, 1973), the Zung Self-Rating
Anxiety Inventory (ZSRA; Zung, 1971), the HADS, the State Trait Anxiety Inventory
(STAI; Spielberger, Gorsuch, &Lorshene, 1970) and the Taylor Manifest Anxiety Scale
(TMAS; Taylor, 1953). Investigators converted study findings to a common metric,
examining both the overall association between anxiety and HbA1c, as well as associations
broken down by various categories, such as inclusion of diagnostic interviews.
The significant effect size for the association between anxiety disorders and
HbA1C can be interpreted in two primary ways. First, patients with anxiety disorders may
have greater difficulty adhering to their self-care regimen and managing their diabetes, thus
leading to higher blood glucose levels. Or, conversely, the higher levels of blood glucose

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may contribute to the patient’s anxiety symptoms, given the overlap in autonomic arousal
and nonspecific anxiety/depression symptoms, thereby making these patients more likely to
receive a diagnosis of anxiety disorders. The investigators also hypothesize that anxiety
could contribute to hyperglycemia directly, through activation of the sympathetic nervous
system and hypothalamic-pituitary adrenal axis, although this link has been more
thoroughly established in animal models than in human models of diabetes. In fact, more
evidence has accumulated suggesting that anxiety and acute stress do not reliably affect
glucose in humans.
Khuwaja AK, et al (2010), conducted cross-sectional, multi-center study in four
out-patient clinics in Karachi in Pakistan (n= 889) in adults with type-2 diabetes. Anxiety
and depression were measured by using the Hospital Anxiety and Depression Scale
(HADS). Overall, 57.9% (95% CI = 54.7%-61.2%) and 43.5% (95% CI = 40.3%- 46.8%)
of study, participants had anxiety and depression respectively. This study identified that a
large proportion of adults with type 2 diabetes mellitus had anxiety and/or depression.
These results identified for the treatment anxiety and depression as common components of
diabetes care
Allison B Grigsbya, Ryan J Anderson conducted a study on Prevalence of
anxiety in adults with diabetes Eighteen studies having a combined population (N) of 4076
(2584 diabetic subjects, 1492 controls) satisfied the inclusion criteria. Most did not adjust
for the effects of moderator variables such as gender, and only one was community-based.
Generalized anxiety disorder (GAD) was present in 14% of patients with diabetes. The
subsyndromal presentation of anxiety disorder not otherwise specified and of elevated
anxiety symptoms were found in 27% and 40%, respectively, of patients with diabetes. The
prevalence of elevated symptoms was significantly higher in women compared to men
(55.3% vs. 32.9%, P<.0001) and similar in patients with Type 1 vs. Type 2 diabetes (41.3%

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vs. 42.2%, P=.80). GAD is present in 14% and elevated symptoms of anxiety in 40% of
patients with diabetes who participate in clinical studies. Additional epidemiological studies
are needed to determine the prevalence of anxiety in the broader population of persons with
diabetes.
Lustman, 1988. The finding that self-report assessment of anxiety symptoms is
not associated with hyperglycemia suggests that certain anxiety symptoms typically
associated with hyperglycemia are more strongly related to anxiety than to blood glucose
levels. In addition, these findings are consistent with those of Friedman et al., 1998,
suggesting a stronger relationship between diagnoses of anxiety disorders and HbA1c levels
than between self-reported anxiety symptoms and HbA1c level.
Gilmore SL & Rosenthal MJ: (2007), examined the effects of Jacobson
Progressive Muscle Relaxation technique on acute glucose disposal in depression with type
2 diabetic mellitus subjects (n=20), as measured by glucose tolerance and pre-post
technique versus wait-list experimental design. Effects were assessed and measured by
State Anxiety, and significant changes in physiological measures of muscle activity and
skin conductance compared to the control condition. The major implication of this study is
that relaxation training (JPMR) to directly improve diabetic control in mildly stressed
noninsulin using type 2 diabetes mellitus patients
Engum A (2007), in his prospective population based study (n=37,291)
investigate the risk of Depression and anxiety in the event of type 2 diabetes mellitus and
examined the mediating factors association. The author concluded that diabetes mellitus did
not predict symptoms of depression or anxiety but symptoms of depression and anxiety
emerged as risk factors onset to type 2 diabetes mellitus. Independent significance

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established the risk of, type 2 diabetes mellitus such as socioeconomic factors, lifestyle
factors and makers of the metabolic syndrome. The co morbidity between depression and
anxiety may be the most important factors.
Dellora et al (2007), in their open uncontrolled trial anxious patients with type 1
diabetes mellitus were allotted to receive Jacobson Progressive Muscle Relaxation (JPMR)
techniques (n=143). Duration of relaxation therapy was 6 weeks and they were followed up
one month of after completion of JPMR techniques. Significant reduction of anxiety was
observed in state anxiety and trait anxiety. The authors concluded that, Jacobson
Progressive Muscle Relaxation (JPMR) technique may be effective technique in improving
the psychological health and quality of life in anxious type 1 diabetes mellitus patients.
Hermanns, N., Kulzer, B., Krichbaum, M., Kubiak, T., Haak, T conducted a
research on ‘Affective and anxiety disorders in a German sample of diabetic patients:
prevalence, comorbidity and risk factors’ Four hundred and twenty diabetic patients (36.9%
Type 1; 24.7% Type 2; 38.4% Type 2 with insulin) participated in a questionnaire-based
screening survey. Those who screened positive received a diagnostic interview. Prevalence
of clinical affective disorders was 12.6%, with an additional 18.8% of patients reporting
depressive symptoms without fulfilling all criteria for a clinical affective disorder. The
prevalence of anxiety disorders was 5.9%, with an additional 19.3% of patients reporting
some anxiety symptoms. The comorbidity rate of affective and anxiety disorders was 1.8%,
whereas 21.4% of the diabetic patients reported elevated affective as well as anxiety
symptomatology. Logistic regression established demographic variables such as age, female
gender and living alone as well as diabetes-specific parameters such as insulin treatment in
Type 2 diabetes, hypoglycaemia problems and poor glycaemic control as risk factors for
affective disorders. For anxiety symptoms female gender, younger age and Type 2 diabetes

26
were significant independent variables. The prevalence of affective disorders in diabetic
patients was twofold higher than in the non-diabetic population, whereas prevalence for
anxiety disorders was not increased. Analysis of risk factors can facilitate the identification
of patients who are at a greater risk for these disorders.
Grigsby, A., Anderson, R., Freedland, K., Clouse, R., Lustman, P conducted a
study on ‘Prevalence of anxiety in adults with diabetes: a systematic review‘Eighteen
studies having a combined population (N) of 4076 (2584 diabetic subjects, 1492 controls)
satisfied the inclusion criteria. Most did not adjust for the effects of moderator variables
such as gender, and only one was community-based. Generalized anxiety disorder (GAD)
was present in 14% of patients with diabetes. The subsyndromal presentation of anxiety
disorder not otherwise specified and of elevated anxiety symptoms were found in 27% and
40%, respectively, of patients with diabetes. The prevalence of elevated symptoms was
significantly higher in women compared to men (55.3% vs. 32.9%, P<.0001) and similar in
patients with Type 1 vs. Type 2 diabetes (41.3% vs. 42.2%, P=.80). GAD is present in 14%
and elevated symptoms of anxiety in 40% of patients with diabetes who participate in
clinical studies. Additional epidemiological studies are needed to determine the prevalence
of anxiety in the broader population of persons with diabetes.
Farvid, M., Qi, L., Hu, F., Kawachi, I., Okereke, O.I., Kubzansky, L.D., Willett,
W.C. made a study on ‘Phobic anxiety symptom scores and incidence of type 2 diabetes in
US men and women’. They followed 30,791 men in the Health Professional’s Follow-Up
Study (HPFS) (1988–2008), 68,904 women in the Nurses’ Health Study (NHS) (1988–
2008), and 79,960 women in the Nurses’ Health Study II (NHS II) (1993–2011). Phobic
anxiety symptom scores, as measured by the Crown–Crisp index (CCI), calculated from 8
questions, were administered at baseline and updated in 2004 for NHS, in 2005 for NHS II,
and in 2000 for HPFS. Incident T2D was confirmed by a validated supplementary

27
questionnaire. We used Cox proportional hazards analysis to evaluate associations with
incident T2D. During 3,099,651 person-years of follow-up, we documented 12,831 incident
T2D cases. In multivariate Cox proportional-hazards models with adjustment for major
lifestyle and dietary risk factors, the hazard ratios (HRs) of T2D across categories of
increasing levels of CCI (scores = 2 to <3, 3 to <4, 4 to <6, ⩾6), compared with a score of
<2, were increased significantly by 6%, 10%, 10% and 13% (Ptrend = 0.001) for NHS; and
by 19%, 11%, 21%, and 29% (Ptrend < 0.0001) for NHS II. Each score increment in CCI
was associated with 2% higher risk of T2D in NHS (HRs, 1.02, 95% confidence intervals:
1.01–1.03) and 4% higher risk of T2D in NHS II (HRs, 1.04, 95% confidence intervals:
1.02–1.05). Further adjustment for depression did not change the results. In HPFS, the
association between CCI and T2D was not significant after adjusting for lifestyle variables.
Results suggest that higher phobic anxiety symptoms are associated with an increased risk
of T2D in women.
Feingold MN, et al (2008) explained the effects of Jacobson Progressive Muscle
Relaxation (JPMR) technique on patients with poorly controlled type 2 diabetes mellitus
with anxiety(n=10). No improvement occurred in glucose tolerance test or blood glucose
test after one week. Daily insulin therapy and practicing the Jacobson Progressive Muscle
Relaxation (JPMR) techniques at home was very effective (80 %). After six weeks of
practicing JPMR technique enhancing blood glucose control in patients with type 2 diabetes
mellitus.
Kamel K et al (2008), in their cross sectional study examined the association of
depression anxiety and stress with type 2 diabetes mellitus .(DA&S-21) Depression ,anxiety
and Stress Scale was administered to type 2 diabetes mellitus patients in 132 Heath Centers

28
In Bahrain an Island country with very high prevalence of type 2 diabetes mellitus. Logistic
regression analysis had shown significant association of type 2 diabetes mellitus with
anxiety, depression and stress.
A recent study of 2,672 individuals with diabetes found that 14% reported mild
depression symptoms, 8.6% reported moderate or severe depression symptoms, and that
greater depression was associated with hyperglycemia and frequency of emergency medical
visits. At particularly high risk for depression within this study were males with juvenile
Type 2 diabetes and women with Type 1 diabetes who had co-morbidities (compared to
women without comorbidities; Lawrence et al., 2006). Twenty-seven percent of individuals
diagnosed with diabetes in childhood or adolescence experienced a major depressive
episode within ten years after the diabetes diagnosis (Kovacs et al., 1997). In addition, meta-
analytic studies have shown significant and consistent relationships between depression and
poor glycemic control ( Lustman et al., 2000; Lustman& Clouse, 2005) and increased
diabetic complications (de Groot et al., 2001).
Diabetics who are battling with depression sometimes do not have the energy to
do all the minor things it takes to control diabetes. They may not have a healthy diet, do not
take their medications on time, or do the exercise they need. This alone could go a long way
towards explaining why depressed people with diabetes are more likely to develop blindness
and other complications depression can affect patients' control of their diabetes in indirect
ways. For example, these patients may have a lack of concern for taking care of themselves.
They often do not sleep well, or they sleep too much and are not as attentive to their basic
daily needs as they should be. They also often are unconcerned about daily diabetic
requirements, such as eating properly, taking the proper medications, or performing regular
self-monitoring of blood glucose. People who are not diabetic have compensatory

29
mechanisms to keep blood sugar from swinging out of control; however, for people with
diabetes, those mechanisms are either lacking or blunted, so they cannot keep their blood
sugar under control (Suresh, 2006).

31
Introduction
In this chapter, the research methodology adopted for the study is discussed. The
methodology of the research includes the research design,population, sample, sampling
technique and development of the tool, procedure for data collection and plan for data
analysis. The present study was aimed to analyze the Prevalence of Trait anxiety and State
anxiety in Diabetic patients.
Research Design
The research design using for the study is Descriptive research design.
Universe of the study
The universe of the study will be the diabetic patients in Trivandrum district as per
the data from Directorate of Health Services. As per the data, between January 2015 up to
June 2015 there are 35640 diabetic patients in Trivandrum district alone
Inclusion Criteria
Diabetes patients irrespective of age, gender and those who are willing to give
information were only be included in data collection procedure.
Exclusion Criteria
Those who are other than diabetic patients are excluded from the data collection
procedure.
Sampling
Simple random sampling is used in this study. A total of 71 samples were collected.
Duration of time

32
The duration of the research was 2 months. The proposed time for data collection was
3 weeks.
Tools for data collection
The tool used to measure the anxiety level is the State-Trait Anxiety Inventory,
developed by Dr.Govind Tiwari and Dr.Roma Pal.1995. The scale has been designed in
Malayalam for diabetic patients. The scale has total 60 items which measure the anxiety
level in school students in two areas
State anxiety
Trait anxiety
Each item has three options: Always, Sometimes, Never. There were both positive
and negative questions in the tool. Three point scale was used in the tool Positive questions
were rated as 3, 2, 1 respectively and negative question were rated as 1, 2, 3 respectively
PILOT STUDY
A pilot study is a small-scale replica and rehearsal of the main study. Pilot study is
conducted before going deep into the study. Pilot study was conducted in order to check the
feasibility of the study. Researcher meets ten diabetic patients in Thiruvananthapuram
district and collected the information. Pilot study helped to found that the proposed study
was feasible.
Data collection procedure
The participants are selected by purposive sampling method. The objective of the
study was discussed with the diabetic patients and verbal consent was be taken for
participation in the study. The questionnaire was asked in structured manner to the patients
and recorded in the printed format.
Data Analysis Procedure
Data analysis has been done by using SPSS software (version 22). The collected data
were entered into SPSS and descriptive, means, t test and one way ANOVA were carried out
to test the hypothesis.

33
Chapter IV
DATA ANALYSIS AND INTRPRETATION

34
DATA ANALYSIS & INTERPRETATION
Table 1: Distribution of diabetic patients with respect to sex.
Sex Frequency Percent
Male 53 74.6
Female 18 25.4
Total 71 100
From the table it is observed that, 74.6% of respondents are Males and 25.4% are
females
Fig 1 Pie diagram showing the sex wise distribution of respondents
75%
25%
Percent
Male
Female

35
Table 2: Distribution of respondents with respect to Educational
qualifications
Educational qualifications Frequency Percent
SSLC & below 47 66.2
Plus two 23 32.4
Degree & above 1 1.4
Total 71 100
The table shows that, 66.2% of the respondents have SSLC & below, 32.4% have plus
two and only 1.4% have degree & above educational qualification
Fig 2: Histogram showing the distribution of respondents with
respect of educational qualifications
0
10
20
30
40
50
60
70
Educational
qualifications
SSLC & below Plustwo Degree & above
66.2
32.4
1.4
Percent

36
Table 3: Distribution of respondents with respect to the prevalence of
other diseases
Disease Status Frequency Percent
Presence of other
diseases
63 88.7
Absence of other
diseases
8 11.3
Total 71 100.0
From the table, it is observed that 88.7% have other related diseases and 11.3% do not
have any other related diseases.
Fig 3: Pie diagram of respondents with respect to prevalence of other
diseases
89%
11%
Presence of other diseases
Absence of other diseases

37
Table 4: Distribution of respondents with respect to food control
The table shows that, 64.8% haves food control and 35.2% don’t have any food
control
Fig 4: Pie diagram showing the distribution of respondents with
respect to food control
64.8
35.2
Percent
Having food control
Having no food control
food control Frequency Percent
Having food control 46 64.8
Having no food control 25 35.2
Total 71 100.0
64.2%

38
Table 5: Distribution of respondents with respect to type of treatment
From the table it is observed that, 83.1% of respondents are having Insulin treatment
and 16.9% are having tablets.
respect to type of treatment
.
0
10
20
30
40
50
60
70
80
90
Percent
83.1
16.9
Insulin
Tablet
Type of treatment Frequency Percent
Insulin 59 83.1
Tablet 12 16.9
Total 71 100.0

39
Table 6: Distribution of diabetic patients with respect to the
frequency of their consultation for treatment
Frequency of consultation Frequency Percent
weekly 9 12.7
twice a month 3 4.2
once a month 41 57.7
once in three months 17 23.9
once in six months 1 1.4
Total 71 100.0
The table shows that 57.7% once a month, 23.9% once in three months, 12.7%
weekly, 4.2% twice a month and 1.4% once in a month makes consultation to doctor.
respect to frequency of their consultations
0
10
20
30
40
50
60
weekly twice a
month
once a
month
once in
three
months
once in six
months
12.7
4.2
57.7
23.9
1.4
Percent
Percent

40
Table7: Distribution of respondents with respect to discussion with
peer about disease
Discussion Frequency Percent
Having discussion 43 60.6
Having no discussion 28 39.4
Total 71 100.0
From the table, it is observed that 60.6% discuss about the disease with their peer,
while 39.4% do not.
Fig 7: Pie diagram showing the distribution of respondents with
respect to discussion about disease with their peer
60.6
39.4
Percent
Having discussion
Having no discussion

41
Table 8: Comparison of mean and standard deviation of Trait anxiety
and State anxiety of diabetic patients in Trivandrum district
Anxiety Mean Std. Deviation
Trait Anxiety 54.87 3.295
State Anxiety 58.72 4.633
The table clearly shows that, the state anxiety level (58.72) is higher than the trait
anxiety level (54.87) of diabetic patients in Trivandrum district.
respect to mean value of trait anxiety
52
53
54
55
56
57
58
59
Trait anxiety state anxiety
54.87
58.72
mean

42
Table 9: Trait anxiety status of the diabetic patients in
Thiruvananthapuram district
Trait anxiety level Frequency Percent
Low (<55-58) 60 84.5
Medium (59-62) 10 14.1
High (63->65) 1 1.4
Total 71 100.0
The table shows that 84.5% of the diabetic patients have low level of trait anxiety and
14.1% have medium level of trait anxiety and only 1.4% has high level of trait
anxiety.
respect to level of Trait anxiety
0
10
20
30
40
50
60
70
80
90
Low(<55-58) Medium (59-62) High (63->65)
84.5
14.1
1.4
Percent

43
Table 10: Distribution of diabetic patients according to level of state
anxiety
State anxiety level Frequency Percent
Low(<59-63) 61 85.9
Medium(64-68) 8 11.3
High(69->72) 2 2.8
Total 71 100.0
The table shows that even though diabetic patients have state anxiety, only 2.8% have
high level of state anxiety and 11.3% have medium level state anxiety and 85.9% have
low level state anxiety.
respect to level of State anxiety
0
10
20
30
40
50
60
70
80
90
Low(<59-63) Medium(64-68) High(69->72)
85.9
11.3
2.8

44
Table 11: Mean and standard deviation of State anxiety and Trait
anxiety with respect to sex of the diabetic patient
Anxiety Sex of the
respondents
N Mean Std.Deviation
State anxiety Male
53 58.38 4.683
Female
18 59.72 4.456
Trait anxiety Male
53 54.72 3.243
Female 18 55.33 3.498
From the table, state anxiety level of male respondents (M= 58.38) is less than the
mean value of female respondents (M=59.72).
Also the trait anxiety level of male respondents (M=54.72) is less than that of the
mean value of female respondents (M=55.33).
anxiety with respect to prevalence of other disease of the diabetic
patient
Anxiety Disease status N Mean Std.Deviation
State anxiety
Have other
disease
63 58.49 4.697
Have no other
diseases
8 60.50 3.891
Trait anxiety
Have other
disease
63 54.68 3.257
Have no other
diseases
8 56.38 3.420

45
From the table, state anxiety level of the respondents having other disease (M= 58.49)
is less than the mean value of the respondents who are having no other diseases
(M=60.50).
Also the trait anxiety level the respondents having other disease (M=54.68) is less than
that of the mean value of the respondents who are having no other diseases
(M=56.38).
anxiety with respect to food control of the diabetic patient
Anxiety Food Control N Mean Std.Deviation
State anxiety
Have food
control
46 58.87 4.956
No food control
25 58.44 4.053
Trait anxiety
Have food
control
46 54.91 3.352
No food control
25 54.80 3.253
From the table, state anxiety level of the respondents having food control (M= 58.87)
is higher than the mean value of the respondents who are having no food control
(M=58.44).
Also the trait anxiety level the respondents having food control (M=54.91) is higher
than that of the mean value of the respondents who are having no food control
(M=56.38).

46
Table 14: Mean and standard deviation of State anxiety with respect
to type of treatment of the diabetic patient
Anxiety Type of
treatment
N Mean Std.Deviation
State anxiety
Insulin 59 58.90 4.686
Tablet 12 57.83 4.448
The table shows that, state anxiety level of the respondents having insulin treatment
(M= 58.90) is higher than the mean value of the respondents who are having tablets
(M=57.83).
Table 15: Mean and standard deviation of State anxiety with respect
to discussion with peer of the diabetic patients.
Anxiety Discussion N Mean Std.Deviation
State anxiety
Having
discussion
43 58.33 4.545
No discussion
28 59.32 4.785
From the table, state anxiety level of the diabetic patients having discussion with their
peer (M= 58.33) is lower than the mean value of the diabetic patients who do not have
discussion with peer (M=59.32).

47
Table16: Mean and standard deviation of State anxiety with respect
to educational qualification of the diabetic patient
Edu.qualification N Mean Std. Deviation
State Anxiety
SSLC & below 47 58.40 4.302
Plus two 23 59.30 5.380
degree & above
1 58.00 .
Total
71 58.72 4.633
Trait Anxiety
SSLC& below
47 54.87 3.373
Plus two
23 54.96 3.254
degree & above
1 53.00 .
Total
71 54.87 3.295
From the table it is observed that, state anxiety level of diabetic patients having
educational qualification SSLC and below is 58.4, plus two is (54.9) and degree &
above is 58.
From the table it is observed that, trait anxiety level of diabetic patients having
educational qualification SSLC and below is 58.8, plus two is 54.9 and degree &
above is 53

48
Table 17: Mean and standard deviation of diabetic patients with
respect to family members having diabetes
Familymember N Mean Std. Deviation
State Anxiety
wife
7 57.57 3.952
husband
2 59.00 .000
nobody 61 58.82 4.825
In-laws
1 58.11 .
Total
71 58.72 4.633
From the table it is observed that, state anxiety level of patient whose wife have
diabetes is 57.5, whose husband have diabetes is 59, whose in laws have diabetes is
58.11 and nobody have diabetes is 58.8

49
respect to family members having diabetes
Frequency of
consultation
N Mean Std. Deviation
State Anxiety
weekly 9 58.11 4.567
twice a month 3 60.00 8.660
once a month 41 58.68 5.027
once in three
months
17 58.88 3.219
once in six
months
1 59.00 .
Total 71 58.72 4.633
The table shows that, the state anxiety level of diabetic patients who consults doctor
weekly is 58.11; twice a month is 60, once a month is 58.6, once in three months is
58.8, and once in six months is 59.
respect to means of getting knowledge about the disease.
N Mean Std. Deviation
State Anxiety
television 3 54.33 3.055
health clubs
1 57.00 .
Doctors, nurses 67 58.94 4.638
Total
71 58.72 4.633

50
From the table, it shows that state anxiety level of diabetic patients who gets more
knowledge about the disease from television is 54.33, from health clubs is 57 and from
doctors/nurses is 58.94.
Hypothesis
1. There is no significant effect of ‘sex’ on state anxiety of the diabetic patients
2. There is no significant effect of ‘Prevalence of other diseases’on state anxiety of
diabetic patients.
3. There is no significant effect of ‘Food control’ on state anxiety of diabetic
patients
4. There is no significant effect of type of their treatment on state anxiety of
diabetic patients.
5. There is no significant effect of ‘discussion about disease with their peer’ on
state anxiety of diabetic patients.
6. There is no significant effect of ‘educational qualifications’ on state anxiety of
the diabetic patients.
7. There is no significant effect of ‘diabetic patients whose family members have
diabetes’ on state anxiety.
8. There is no significant effect of ‘frequency of consultation for treatment’ on
state anxiety of the diabetic patients.
9. There is no significant effect of ‘means of getting knowledge about the disease’
on state anxiety of diabetic patients.
10. There is no significant relation between trait anxiety and state anxiety.

51
Table: 20 ‘t’ value of state anxiety with respect to sex of the diabetic patient
Anxiety Sex of the
respondents
N Mean Std.Deviation t Sig. (2
tailed)
State
anxiety Male
53 58.38 4.683
-1.065 0.291
Female 18 59.72 4.456
The hypothesis stated (hypothesis 1) is tested with independent sample t- test. The‘t’
value (-1.065) indicates that there is no significant difference in state anxiety with
respect to the sex of the respondents at p=0.291.That implies that state anxiety is
independent of sex of the Diabetic patients.
Table 21:‘t’ value of State anxiety and Trait anxiety with respect to
prevalence of other disease of the diabetic patient
Anxiety Disease
status
tailed)
State
anxiety
Have other
disease
63 58.49 4.697
-1.158 0.251
Have no
other
diseases
8 60.50 3.891
The hypothesis stated (Hypothesis 2) tested with independent sample t- test. The‘t’

52
respect to the respondents having other disease at p=0.251.That implies that state
anxiety is independent of prevalence of other diseases of the Diabetic patients.
Table 22: ‘t’ value of State anxiety and Trait anxiety with respect to
food control of the diabetic patient
Anxiety Food
Control
tailed)
State
anxiety
Have food
control
46 58.87 4.956
0.371 0.712
No food
control
25 58.44 4.053
The hypothesis stated (Hypothesis 3) is tested with independent sample t- test. The‘t’
value (0.371) indicates that there is no significant difference in state anxiety with
respect to the respondents having food control at p=0.712.That implies that state
anxiety is independent of food control of the Diabetic patients.
type of treatment of the diabetic patient
Anxiety Type of
treatment
tailed)
State
anxiety
Insulin 59 58.90 4.686
0.723 0.472Tablet 12 57.83 4.448

53
value (0.723) indicates that there is no significant difference in state anxiety with
anxiety is independent of type of treatment of the Diabetic patients
discussion with peer of the diabetic patients.
Anxiety Discussion N Mean Std.Deviation t Sig. (2
tailed)
State
anxiety
Having
discussion
43 58.33 4.545
-0.884 0.380No
discussion
28 59.32 4.785
anxiety is independent of type of discussion with peer of the Diabetic patients

54
Table 25: One way ANOVA score of State anxiety with respect to
educational qualification of the diabetic patients
From the table, it is observed that, the F value 0.32 is not significant at p=0.72. Hence
there is no significance in state anxiety with respect to educational qualification of the
diabetic patients in Thiruvananthapuram district.
Even though it is not showing any significant difference, (Hypothesis 6)the high mean
value of the patients who held plus two educational qualification (59.30) shows that,
this category have high level of state anxiety.
family members having diabetes of the diabetic patients
anxiety Sum of
Squares
df Mean
Square
F Sig.
State
anxiety
Between
Groups
14.177 2 7.089
.324 .724Within
Groups
1488.189 68 21.885
Total 1502.366 70
anxiety Sum of
Squares
df Mean
Square
F Sig.
State
anxiety
Between
Groups
11.636 3 3.879
.174 .913
Within
Groups
1490.731 67 22.250
Total 1502.366 70

55
The table shows that the the F value 0.17 is not significant at p=0.91. Hence there is
no significance in state anxiety with respect to family members having diabetes of the
value of the patients whose husbands having diabetes (59.00) shows that, this category
have high level of state anxiety.
frequency of consultation of the diabetic patients
From the table, it is observed that, the F value 0.09 is not significant at p=0.98. Hence
there is no significance in state anxiety with respect to frequency of consultation of the
value of the patients who consults doctor twice a month (60.00) shows that, this
category have high level of state anxiety.
anxiety Sum of
Squares
df Mean
Square
F Sig.
State
anxiety
Between
Groups
8.835 4 2.209
.098 .983
Within
Groups
1493.532 66 22.629
Total
1502.366 70

56
means of getting knowledge about the disease of diabetic patients.
From the table it is observed that, the F value 1.51 is not significant at p=0.22. Hence
there is no significance in state anxiety with respect to means of getting knowledge
about the disease of the diabetic patients in Thiruvananthapuram district.
value of the patients who gets knowledge about the disease from doctors and nurses
(58.9) shows that, this category have high level of state anxiety.
anxiety Sum of
Squares
df Mean
Square
F Sig.
State
anxiety
Between
Groups
63.938 2 31.969
1.511 .228
Within
Groups
1438.428 68 21.153
Total
1502.366 70

57
Table 29: Correlation value of Strait anxiety and Trait anxiety of
diabetic patients in Trivandrum
Trait Anxiety State Anxiety
Trait Anxiety
Pearson Correlation 1 .618**
Sig. (2-tailed)
.000
N 71 71
State Anxiety Pearson Correlation
.618**
1
Sig. (2-tailed) .000
N 71 71
**. Correlation is significant at the 0.01 level (2-tailed).
From the table it is observed that r = 0.61 which is highly significant at p<0.01which
means that, there is a perfect positive correlation between Trait anxiety and State
anxiety. I.e. State anxiety increases with increase of trait anxiety.
So the null hypothesis is rejected.( Hypothesis10).

58
Chapter v
SUMMARY, FINDINGS, SUGGESTIONS
AND CONCLUSIONS

59
Summary
Developed countries have made significant strides to control infectious diseases which
have resulted in increasing the lifespan of individuals, however non-infectious diseases have
not received the same attention. Diabetes is one of those diseases which have now become a
major global health problem. It is both progressive and life threatening with potentially
devastating consequences for health (Suresh, 2006). The International Diabetes Federation
(IDF) estimated at least 285 million people worldwide are suffering from diabetes disease
(about 6.4% of adults), however it is predicted to reach approximately 435 million by 2030
(IDF, 2010). Asia is one of the regions that have a high prevalence rate of diabetes. The
presence of anxiety among diabetes patients is associated with multiple behaviors that have
a negative impact on disease management. These include increased smoking, alcohol or
other drug abuse; poorer eating and appetite dysregulation; and poorer self-managed
metabolic control.
The aim of present research was to investigate the ‘Prevalence of State anxiety and Trait
anxiety among diabetic patients’. Further, the research was to examine the relation between
trait anxiety and state anxiety of diabetic patients. The sample consisted of 71 adults
diagnosed with Type 2 diabetes visiting the 4 PHC’s of Trivandrum district. Their age
ranged from 35 to 75 years old.
The demographic data sheet and selected tools were administered on all the identified
diabetic patients. All the respondents voluntarily participated in this research. They were
notified that their personal information provided in the study would be kept strictly
confidential and used for research purpose only. The sample for the study was selected
based on the inclusion criteria. Demographic details of the subjects were also obtained from

60
patient interviews and from their medical records in order to ensure the suitability of the
sample.
The data obtained after the interview sessions were subjected to statistical analyses.
Tests were done to examine the objectives and hypothesis. Mean and standard deviation
were calculated of all independent and dependent samples. After that, one way ANOVA and
Correlation were carried out test the hypothesis. One way ANOVA and independent‘t’test
showed that there is no significance of sex, educational qualification, frequency of
consultation, discussion with peer on state anxiety of the diabetic patient. The correlation
test showed that there is a highly significant relation between Trait anxiety and State anxiety
of the diabetic patients. i.e.; State anxiety increases with respect to trait anxiety of the
diabetic patients.
Findings
The aim of present research was to investigate the ‘Prevalence of State anxiety and Trait
anxiety among diabetic patients’. Further, the research was to examine the relation between
trait anxiety and state anxiety of diabetic patients. The sample consisted of 71 adults
diagnosed with Type 2 diabetes visiting the 4 PHC’s of Trivandrum district. Their age
ranged from 35 to 75 years old.
The demographic data sheet and selected tools were administered on all the identified
diabetic patients. All the respondents voluntarily participated in this research. They were
notified that their personal information provided in the study would be kept strictly
confidential and used for research purpose only. The sample for the study was selected
based on the inclusion criteria. Demographic details of the subjects were also obtained from
patient interviews and from their medical records in order to ensure the suitability of the
sample. The data obtained after the interview sessions were subjected to statistical analyses.

61
Tests were done to examine the objectives and hypothesis. Following are the findings of the
study;
1) There is no significant difference between the mean scores of males and females
on the examination of state anxiety. It means that there is no significant effect of
gender on the state anxiety of diabetic patients.
2) Majority of the respondents have SSLC & below, 32.4% have plus two and only
1.4% have degree & above educational qualification.
3) Majority of the diabetic patients in Thiruvananthapuram district have other related
diseases and 11.3% do not have any other related diseases.
4) Majority of the diabetic patients in Thiruvananthapuram district have food control
and 35.2% don’t have any food control.
5) Majority of the diabetic patients in Thiruvananthapuram district are having Insulin
treatment and 16.9% are having tablets.
6) Better part of the diabetic patients in Thiruvananthapuram district once a month,
23.9% once in three months, 12.7% weekly, 4.2% twice a month and 1.4% once in
a month makes consultation to doctor.
7) Majority of the diabetic patients in Thiruvananthapuram district discuss about the
disease with their peer, while 39.4% do not.
8) Better part of the diabetic patients in Thiruvananthapuram district have low level
of trait anxiety and 14.1% have medium level of trait anxiety and only 1.4% has
high level of trait anxiety
9) Majority of the diabetic patients in Thiruvananthapuram district have high level of
state anxiety and 11.3% have medium level state anxiety and 85.9% have low level
state anxiety.

62
10) State anxiety level of the respondents having food control is higher than the mean
value of the respondents who are having no food control.
11) State anxiety level of the respondents having insulin treatment is higher than the
mean value of the respondents who are having tablets.
12) State anxiety level of the diabetic patients having discussion with their peer is
lower than the mean value of the diabetic patients who do not have discussion with
peer.
13) State anxiety level of diabetic patients having educational qualification SSLC is
higher than other categories.
14) State anxiety level of diabetic patients who consults doctor weekly is higher than
those who consult twice a month, once a month, once in three months and once in
six months.
15) ‘Prevalence of other diseases’ has no significant effect on state anxiety of the
Diabetic patients.
16) ‘Food control’ has no significant effect on the state anxiety of the Diabetic patients
in Thiruvananthapuram district.
17) ‘Type of treatment’ has no significant effect on state anxiety of the Diabetic
patients in Thiruvananthapuram district.
18) ‘Discussion with peer about the disease’ has no significant effect on state anxiety
of the Diabetic patients in Thiruvananthapuram district.
19) ‘Educational qualification’ has no significant effect in state anxiety of the diabetic
patients in Thiruvananthapuram district.
20) The diabetic patients whose family members also has the disease has no significant
effect on the state anxiety of them.

63
21) ‘Frequency of consultation for treatment’ has no significant effect on the state
anxiety of the diabetic patients in Thiruvananthapuram district.
22) Means of getting knowledge about the disease has no significance effect on the
state anxiety of the diabetic patients in Thiruvananthapuram district.
23) There is a highly positive correlation between Trait anxiety and State anxiety. I.e.
State anxiety increases with increase of trait anxiety of the diabetic patients in
Trivandrum district.
Suggestions
1) Diabetic education should form part of the PHC’s and other sub centres for
health so that diabetic patients will get knowledge about the disease by way of
which they will try to either control or prevent of the same.
2) Provide counseling services through PHC’s and health centres for those who
have high level of diabetic anxiety.
3) Issue of diet sheet to every patient should become mandatory and ensure it is
not very much different from the family's diet.
4) Initiate diabetes health care centre in every rural areas with full facilities so
that all critical cases can be managed.
5) Importance of yoga should be inculcated in the mind of the patients. Teach
Yoga such as Pranayama, Halasana, Dhaurasana, Arthamal, Sendrassana,
Pachimatarasana, Vajrasana, and Dhanurasana as it is more effective in
controlling diabetes and anxiety.

64
6) Diabetes education and anxiety management camps to be conducted in
different area once or twice in a month with social organisation like Rotary
club or Lion club etc.
7) Media can be used to propagate the information about control of diabetic
anxiety to public.
8) Folk songs, street plays can be initiated to spread the evil effects of the disease.
9) Government voluntary organisation should come forward to provide medicines
especially insulin in concession rate.
10) Diabetes health care costs may be reduced using a variety of cost contained
strategy.
11) Recommendation for prevention of Diabetes and occurrence of diabetes related
complications
Conclusion
Being diagnosed and living with diabetes can affect people in very different ways.
While some may find coping with diabetes has very little impact on day-to-day life, others
may find that it has turned their lives upside down. From the data analyses, it can be
concluded that state anxiety of diabetic patients have a significant relation with their trait
anxiety. Diabetic patients who have high level of trait anxiety are more prone to have high
level of state anxiety. Also the level of state anxiety is almost same for both males and
females, even though women’s have slightly higher level of state anxiety. The trait anxiety
influence the state anxiety of diabetic patients and other health factors, and diseases
conditions will also leads to anxiety.

65
Limitation of the present study
Some of the limitations of this study which can exist in the researches under the similar
theme have been presented below:
1) The presented samples in this study were limited to the population of diabetes
patients of Trivandrum district though the samples were from diverse
demographic areas. It is worth mentioning that other studies may be necessary in
order to generalize the findings to the entire Kerala and Indian diabetes
population.
2) All of the diabetes patients in the study sample were diagnosed with Type 2
diabetes; therefore the results may not generalize to all type of diabetes.
Avenues of future research
Suggestions for future study are as follows:
1) A similar study can be conducted on the other types of diabetes in order to
draw further generalizations.
2) A longitudinal study may be conducted across various developmental stages to
find out whether the state anxiety of diabetic patients remains the same or
changes in future.
3) Another area for further work could be to gain a better understanding of the
effects of a stressful life in developing diabetes.

67
References
1) Alberta, K.G., Zimmet, P.Z. (1998). Definition, diagnosis and classification of
diabetes mellitus and its complications. Part 1: diagnosis and classification of
diabetes mellitus provisional report of a WHO consultation. Diabetes. Med; 15:
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2) American Psychological Association, (APA, 2002). Ethical principles of
psychologists. American Psychological Association, Chicago.
3) Anderson, R.J., Grigsby, A.B., Freedland, K.E., de Groot, M., Mc Gill, J.B.,
Clouse, R.E., & Lustman, P.J. ( 2002). Anxiety and poor glaycemic control: A
meta analytic review of literature. International journal of psychiatry in medicine,
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4) Australian Institute of Health and Welfare (AIHW) (2002). Chronic diseases and
associated risk factors in Australia, 2001. Australian Institute of Health and
Welfare (AIHW), Canberra.
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No. 8.
6) Khowaja LA, Khuwaja AK, Cosgrove P: Cost of diabetes care in out-patient
clinics of Karachi, Pakistan. BMC Health Serv Res 2007, 21:189.
7) Engum, A. The role of depression and anxiety in onset of diabetes in a large
population-based study. J Psychosom Res. 2007;62:31–38.
8) DeCoster, V.A. Challenges of type 2 diabetes and role of health care social work: a
neglected area of practice. Health & Social Work. 2001;26:26–37.

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9) Farvid, M., Qi, L., Hu, F., Kawachi, I., Okereke, O.I., Kubzansky, L.D., Willett,
W.C. Phobic anxiety symptom scores and incidence of type 2 diabetes in US men
and women. Brain, Behavior, and Immunity. 2014;36:176–182
10) Grigsby, A., Anderson, R., Freedland, K., Clouse, R., Lustman, P. Prevalence of
anxiety in adults with diabetes: a systematic review.
11) Lin EH, Rutter CM, Katon W, Heckbert SR, Ciechanowski P, Oliver MM, et al:
Depression and advanced complications of diabetes: a prospective cohort study.
Diabetes Care 2010, 33:264-269.
12) Ali S, Stone M, Skinner TC, Robertson N, Davies M, Khunti K: The association between
depression and health-related quality of life in people with type 2 diabetes: a systematic
literature review. Diabetes Metab Res Rev 2010, 26:75-89.
13) Nichols l, Barton PL, Glazner J, McCollum M: Diabetes, minor depression and health
care utilization and expenditures: a retrospective database study. Cost Eff Resour Alloc
2007, 5:4.
14) Shaban, M.C., Fosbury, J., Kerr, D., Cavan, D.A. The prevalence of depression and
anxiety in adults with Type 1 diabetes. Diabet Med. 2006;23:1381–1384.
15) Smith, K.J., Beland, M., Clyde, M., Gariepy, G., Page, V., Badawi, G. et al, Association
of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res.
2013;74:89–99.
16) Jalenques, I, Tauveron, I, Albuisson, E, Lonjaret, D, Thieblot, P, Coudert, AJ. Prevalence
of anxiety and depressive symptoms in patients with type 1 and 2 diabetes. Rev Med
Suisse Romande. 1993;113:639–646.
17) Hasan, S.S., Clavarino, A.M., Mamun, A.A., Dingle, K., Kairuz, T. The validity of
personality disturbance scale (DSSI/sAD) in women with diabetes; using longitudinal
study. Pers Individ Dif. 2015;72:182–188.

69
18) Berlin, I, Bisserbe, JC, Eiber, R, Balssa, N, Sachon, C, Bosquet, F, Grimaldi, A. Phobic,
anxiety symptoms, particularly the fear of blood and injury, are associated with poor
glycemic control in type 1 diabetic adults. Diabetes Care. 1997;20:176–178.
19) Hermanns, N., Kulzer, B., Krichbaum, M., Kubiak, T., Haak, T. Affective and anxiety
disorders in a German sample of diabetic patients: prevalence, comorbidity and risk
factors. Diabet Med. 2005;22:293–300.
20) Bowden, D., Cox, A., Freedman, B., Hugenschimdt, C., Wagenknecht, L., Herrington, D.
Carr, J. Review of the Diabetes Heart Study (DHS) family of studies: a comprehensively
examined sample for genetic and epidemiological studies of type 2 diabetes and its
complications. The Review of Diabetic Studies: RDS. 2010;7:188–201
21) Bouwman V, Adriaanse MC, van ‘t Riet E, Snoek FJ, Dekker JM, Nijpels G: Depression,
anxiety and glucose metabolism in the general Dutch population: the new Hoorn study.
PloS One 2010, 5:e9971. 8. Pouwer F: Should we screen for emotional distress in type 2
diabetes mellitus? Nat Rev Endocrinol 2009, 5:665-71
Journals
1. High levels of anxiety and depression in diabetic patients with Charcot foot Zahra
Chapman, Charles Matthew James Shuttleworth and Jörg Wolfgang Huber.
2. Association of glycaemia with macro vascular and micro vascular complications of
Type 2 diabetes: prospective observational study. British Medical Journal 2000; 321:
405-412.
3. Diabetes UK and South Asian Health Foundation recommendations on diabetes
research priorities for British South Asians - Diabetes UK, published June 2009.
Website References
1. https://www.idf.org/membership/sea/india
2. www.diabetesfoundationindia.org/

70
3. www.diabetes.co.uk › Diabetes and Emotions
4. www.diabetes.org › Research & Practice › Patient Access to Research
5. www.diabetesselfmanagement.com › Blog › Joe Nelson
6. https://diabetessisters.org/article/tips-managing-diabetes-and-anxiety
7. www.diabeticlifestyle.com › Live Well › Everyday Life
8. www.calmclinic.com/anxiety/causes/hypoglycemia
9. www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central
10. www.diabeticconnect.com/diabetes.../154-stress-or-anxiety
11. forums.webmd.com/3/diabetes-exchange/forum/6209

71
I. Socio Demographic Profile
1. hbÊv :
2. enwKw : ]pcpj³ / kv{Xo
3. tPmen :
4. Øew:
5. hnZym`ymkw : 1. SSLC & below
2. +2
3. Degree & above
6. n§Ä¡v F{X mfmbn {]talwD-v ?
7. {]tals¯ XpSÀ¶vaäptcmK§ÄDt-m ? 1. D-v 2. CÃ
Ds-¦nÂþþþþþþþþþþþþ :
8. {]tals¯ XpSÀ¶v `£W {IaoIcWw / nb{´Ww S¯p¶pt-m ?
1. D-v 2. CÃ
9. IpSpw_¯nÂaämÀs¡ms¡ {]talwD-v ?
`mcy `À¯mhv aI³ / aIÄ acpa¡Ä
BÀ¡panÃ
10. GXpXcwNnInÕmcoXnbmWv n§Ä S¯p¶Xv þ
1. C³kpen³ 2.KpfnI
11. {]talNnInÕbv¡mbntUmIvSsd / tlmkv]näenÂFt¸msgms¡
t]mImdp-v ?

72
1. Bgv¨tXmdpw 2. amk¯nÂc-pXhW 3.amk¯nÂHcn¡Â
4. aq¶pamk¯nÂHcn¡Â 5. Bdpamk¯nÂHcn¡Â
12. Xmsg ]dbp¶hbnÂ n¶pw {]tals¯¸änbpÅ IqSpXÂhnhc§Ä
n§Ä F{Xt¯mfwIn«p¶p-v
H«panÃ Ipd¨v
hfscb[nIw
1. CâÀsäv
2. ]{Xw
3. Sn.hn
4. slÂ¯v ¢mkv
5. tUmIvSÀ / gvkv
6. kplr¯p¡Ä
13. {]talapÅka{]mb¡mcpambn {]tals¯¸än NÀ¨ sN¿mdpt-m ?
1. D-v 2. CÃ

73
Trait Anxiety scale
1. Rm³ kt´mjhmmbncp¶p.
2. amknI ]ncnapdp¡waqew Fn¡v
XfÀ¨ tXm¶mdp-mbncp¶p.
3. nkmcImcy§Ä¡vhsc Rm³
hnjan¡mdp-mbncp¶p.
4. Fn¡vBßhnizmkw
tXm¶mdp-mbncp¶p.
4. FsâPohnXwkam[m]cambncp¶
p
6. A{][m Imcy§Ä¡v Rm³
{]m[myw
sImSp¡mdp-mbncp¶p.
7. `mhnsb]än Rm³
DÂ¡WvTmIpemWv
8. {]XnkÔnIfpw, _p²nap«pIfpw
Rm³ Hgnhm¡m³
{ian¡pambncp¶p.
9. NqtSdnb {Kq¸vNÀ¨Ifnepw Rm³
im´mbv Ccn¡pambncp¶p.
10. kw`hn¡mhp¶
nÀ`mKy§sfHmÀ¯v
Rm³ hnjan¡mdp-mbncp¶p.
11. hey {]m[mywCÃm¯ Imcy§sf
HmÀ¯vhsc Rm³
hnjan¡mdp-mbncp¶p.
12. _p²nap«pÅ {]iv§sf tcnSm³
Rm³ B{Kln¡pambncp¶p.
13. ncmiIÄ¡v aÊnÂ n¶v I fbm³
]äm¯ hn[w Rm³ {]m[myw
sImSp¡mdp-mbncp¶p.
14. aäpÅhsc t]mse `mKyapÅhÀ
Bsb¦nÂF¶v Rm³
B{Kln¡mdp-mbncp¶p.
Ft¸mgpw hÃt¸mgpw Hcn¡epanÃ

74
15. th-hn[w hnntbmKn¡m³
Ignbm¯XnmÂ, Rm³ Ahkc§sf
jvSs¸Sp¯mdp-mbncp¶p.
16. Fn¡vXmXv]cyanÃm¯
kµÀ`§fnÂ/Npäp]mSpIfnÂ Rm³
hymIpes¸Smdp-mbncp¶p.
17. s]mXpP kwkmc§sf Rm³
amn¡mdnÃmbncp¶p.
18. PohnXwITnamsW¶pw, Ahsb
BÀ¡pwXcWw sN¿m³ IgnbnÃm¶v
Fn¡vtXm¶mdp-mbncp¶p
19. Rm³ ZrVnÝbw DÅ
hyànbmbncp¶p
20. ho«nÂ Rm³ kzØpw
im´pambncp¶p
21. Fn¡vt_mdSn¡mdnÃmbncp¶p.
22. Fn¡vA{IaWkz`map-mbncp¶p.
23. Fn¡vaSnbmbncp¶p.
24. Rm³
A{IamkàmImdp-mbncp¶p.
25. Fn¡vsshakyw
tXm¶mdp-mbncp¶p.
26. Fn¡vA`ncpNnCÃm¯ tPmenIÄ
Fn¡vsNt¿-nhcmdp-mbncp¶p.
27. Fn¡vIp{]NmcWs¯
t]Snbmbncp¶p.
28. Fn¡vhnaÀi§sf t]Snbmbncp¶p.
29. Fn¡vkzØambn Dd§m³
km[n¡mdnÃmbncp¶p.
30. Häbv¡pÅbm{XIÄ Fn¡v
t]Snbmbncp¶p.

75
State Anxiety Scale
1. Fn¡v sS³j³ tXm¶mdp-v
2. Fn¡v ]ÝmXm]w tXm¶mdp-v
3. Fn¡vkzØXD-v
4. Fn¡vhnjawtXm¶mdp-v
5. ht¶¡mhp¶ ]cmPb§sf
]änRm³ZpJn¡mdp-v
6. Fn¡pNn´m¡pg¸whcmdp-v
7. Fn¡pDXvIWvTD-mImdp-v
8. Fn¡pBizmkwtXm¶mdp-v
9. Fn¡pBßhnizmkwtXm¶mdp-v
10. Fn¡phnImchnhiXD-mImdp-v
11. Fn¡p `bwD-mImdp-v
12. Fn¡pBµw Ap`hs¸Smdp-v
13. Fn¡pim´X Ap`hs¸Smdp-v
14. Fn¡pkwXr]vXntXm¶mdp-v
15. Rm³ Bthi`cnX³ BImdp-v

76
16. Fn¡p mWt¡SptXm¶mdp-v
17. Fn¡p aÈm´ntXm¶mdp-v
18. Fn¡pkpc£nXXzwAp`hs¸Smdp-v
19. Fs¶s¡m-vH¶npw
sImÅnse¶tXm¶ep-v
20. Fn¡vXfÀ¨ tXm¶mdp-v
21. Rm³ kt´mjhmmWv
22. Rm³ kq£aXbpÅhmWv
23. Fn¡pXeNpäÂAp`hs¸Smdp-v
24. Rm³ A{IamkàmImdp-v
25. Rm³ hnj®mImdp-v
26. Fn¡phncàntXm¶mdp-v
27. Fn¡pamknI ]ncnapdp¡w
tXm¶mdp-v
28. Fn¡pGIm´X Ap`hs¸Smdp-v
29. Rm³ D]{ZhImcnBImdp-v
30. Fn¡phnaqIXtXm¶mdp-v

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