Department of Family Medicine
Problem Areas in Diabetes
Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, Schwartz CE (1995)
Background and Development:
The PAID is a measure of diabetes-specific emotional distress that was developed by the Joslin Diabetes Center, Boston. It was written originally in US English, but has later been translated into Spanish, Japanese, Dutch, German, Chinese, Croatian, Danish, and Portuguese. This self-administered questionnaire consists of 20 items that cover a range of emotional problems frequently reported in type 1 and type 2 diabetes. Each item is scored 0 to 4 ("Not a problem" to "Serious Problem"). The sum of the 20 items is multiplied by 1.25 to yield a final score 0-100.
Psychometric reports to date on the PAID have shown it to: (i) have consistently high internal
reliability (i.e. a = 0.90); (ii) have sound ( r = 0.83) 2-month test–retest reliability using a sample of stable patients; (iii) to correlate strongly with a wide range of theoretically related constructs such as general emotional distress, depression, diabetes self-care behaviours, diabetes coping, and health beliefs;
and (iv) to be a statistically significant predictor of glycaemic control in a study that tracked a managed care population control for 1 year. In cross-sectional studies, the PAID has been found to be weakly related to HbA1c, and unrelated to duration of diabetes, education, ethnicity, and gender when adjusted for age (Welch et al. 1997, Polonsky et al. 1995).
Assessment of the Measure in Elderly Populations
In cross-sectional studies, the PAID has been found to be negatively correlated to age (Welch et al. 2003).
Assessment of the Measure in Minority Populations
In cross-sectional studies, the PAID has been found to be unrelated to duration of diabetes, education, ethnicity, and gender when adjusted for age (Welch et al. 2003).
Numerous studies have used the PAID. See the list of additional references below.
Design Strengths and Weaknesses:
To determine the responsiveness of the instrument Welch et al. (1997) reviewed 7 published reports of diabetes treatment interventions that used the PAID in longitudinal studies. PAID emotional distress scores declined significantly in all 7 studies.
Garry Welch, PhD
Director, Behavioral Medicine Research
Baystate Medical Center
140 High Street Room 239
Springfield, Ma 01199
Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, Schwartz CE: Assessment of diabetes-related distress. Diabetes Care 1995;18:754-60.
Snoek FJ, Pouwer F, Welch GW, Polonsky WH: Diabetes-related emotional distress in Dutch and U.S. diabetic patients: cross-cultural validity of the problem areas in diabetes scale. Diabetes Care 2000;23:1305-1309.
Welch GW, Jacobson AM, Polonsky WH: The Problem Areas in Diabetes Scale: An evaluation of its clinical utility. Diabetes Care 20:760-766, 1997.
Welch GW, Weinger K, Anderson, B, Polonsky WH. Responsiveness of the Problem Areas In Diabetes (PAID) questionnaire. Diabetic Medicine. 2003: 20;69-72.
van der Ven N, Weinger K, Yi Joyce, Pouwer F, Ader H, van der Ploeg HM, Snoek FJ. The confidence in diabetes self care scale: Psychometric properties of a new measure of diabetes-specific self-efficacy in Dutch and US patients with type 1 diabetes. Diabetes Care 2003 26(3): 713-718.
Additional References Provided by the Authors:
Updated November 8, 2004
A. Published papers
1. Akimoto M, Fukunishi I, Shinoe Y, Yamaguchi C, Yano A, Kawasaki Y, Oyamada T, Hirozane S, Kanno K, Yamazaki T. Content analysis of group work sessions in the context of an educational program for inpatient diabetes patients. Psychological Reports 89(3): 641-649, 2001
2. Al-Arabi AM, Rahim SI, Al-Bar AA, AbuMadiny MS, KarimAA. Validity of self-reporting questionnaire and Rahim Anxiety Depression Scale. Saudi Medical Journal, 20(9): 711-716, 1999.
3. Anderson RT, Skovlund SE, Marrero D, Levine D, Meadows K, Brod M, Balkrishnan. Development and validation of the insulin treatment satisfaction questionnaire. Clinical Therapeutics 26(4): 565-578, 2004
4. Becker DJ, Ryan CM. Intensive diabetes therapy in childhood: Is it achievable? Is it desirable? Is it safe? Journal of Pediatrics 134(4): 392-394, 1999
5. Bradley C, Gamsu DS. Diabetes: psychosocial issues in adolescents and adults. Current Opinion in Psychiatry 8(6): 400-406, 1995
6. Clark CM, Snyder JW, Meek RL, Stutz LM, Parkin CG. A systematic approach to risk stratification within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care 24: 1079-1086, 2001
7. DeVries JH, Eskes SA, Snoek FJ, Pouwer F, Van Ballegooie E, Spijker AJ, Kostense PJ, Seubert M, Heine RJ. Continuous intraperitoneal insulin infusion in patients with ‘brittle’ diabetes: favourable effects on glycaemic control and hospital stay. Diabetic Medicine 19: 496-501, 2002
8. DeVries JH, Snoek FJ, Kostense PJ, Heine RJ. Improved glycaemic control in type 1 diabetes patients following participation per se in a clinical tria – mechanisms and implications. Diabetes/Metabolism Research and Reviews 19(5): 357-362, 2003
9. Fitchett G, Murphy PE, Kim J, Gibbons JL, Cameron JR, Davis JA. Religious struggle: prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. International Journal of Psychiatry in Medicine 34(2): 179-196, 2004
10. Glasgow RE, Toobert DJ, Gillette CD. Psychosocial barriers to diabetes self-management and quality of life. Diabetes Spectrum 14(1): 33-41, 2001
11. Glasgow RE. Outcomes of and for diabetes education research. Diabetes Educator 25(6, Suppl. S): 74-88, 1999
12. Gonder-Frederick LA, Cox DJ, Ritterband LM. Diabetes and behavioral medicine: the second deacde. Journal of Consulting and Clinical Psychology 70(3): 611-625, 2002
13. Grant RW, Devita NG, Singer DE, Meigs JB. Improving adherence and reducing medication discrepancies in patients with diabetes. Annals of Pharmacotherapy 37(7): 962-969, 2003
14. Izquierdo RE, Knudson PE, Meyer S, Kearns J, Ploutz-Snyder R, Weinstock RS. A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care 26: 1002-1007, 2003
15. Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. Current Concepts 333(19): 1249-1253, 1996
16. Karlsen B, Idsoe T, Dirdal I, Hanestad BR, Bru E. Effects of a group-based counseling programme on diabetes-related stress, coping, psychological well-being and metabolic control in adults with type 1 or type 2 diabetes. Patient Education and Counseling 53 (3): 299-308, 2004
17. Karlsen B, Idsoe T, Hanestad BR, Murberg T, Bru E. Perceptions of support, diabetes-related coping and psychological well-being in adults with type 1 and type 2 diabetes. Psychology, Health & Medicine 9(1): 53-70, 2004
18. Klepac MP. Integrative diabetes education: expansion and evaluation of a holistic program using quantitative and qualitative methodology. Dissertation Abstracts International A 61/04: 1313, 2000. UMI ProQuest Digital Dissertations Publication Number AAT 99966834.
19. Lerman-Garber I, Barron-Uribe C, Calzada-Leon R, Mercado-Atri M, Vidal-Tarnayo R, Quintana S, Hernandez ME, Ruiz-Reyes MdlL, Tamez-Gutierrez LE, Nishimura-Meguro E, Villa AR. Emotional dysfunction associated with diabetes in Mexican adolescents and young adults with type-1 diabetes. Salud Publica Mex 45: 13-18, 2003
20. Meadows KA, Abrams C, Sandbaek. Adaptation of the Diabetes Health Profile (DHP-1) for use with patients with type 2 diabetes mellitus: psychometric evaluation and cross-cultural comparisons. Diabetic Medicine 17(8): 572-580, 2000
21. Melkus GD, Spollett G, Jefferson V, Chyun D, Tuohy B, Robinson T, Kaisen A. A culturally competent intervention of education and care for black women with type 2 diabetes. Appied Nursing Research 17: 10-20, 2004
22. Mollema ED, Snoek FJ, Ader HJ, Heine RJ, Van Der Ploeg HM. Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: psychological comorbidity and general well-being. Journal of Psychosomatic Research 51: 665-672, 2001
23. Mollema ED, Snoek FJ, Pouwer F, Heine RJ, Van Der Ploeg HM. Diabetes Fear of Injecting and Self-Testing Questionnaire: a psychometric evaluation. Diabetes Care 23: 765-769, 2000
24. Mulcahy K, Maryniuk M, Peeples M, Peyrot M, Tomky D, Weaver T, Yarborough P. Technical review: Diabetes self-management education core outcomes. Diabetes Educator 29(5): 768, 770, 773-784, 787-788, 790-792, 794-796, 798, 800-803, 2003
25. Newlin K, Melkus GD, Chyun D, Jefferson V. The relationship of spirituality and health outcomes in black women with type 2 diabetes. Ethnicity & Disease 13: 61-68, 2003
26. Nichols GA, Hillier TA, Javor K, Brown JB. Predictors of glycemic control in insulin-using adults with type 2 diabetes. Diabetes Care 23: 273-277, 2000
27. Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, Schwartz CE. Assessment of diabetes-related distress. Diabetes Care 18: 754-60, 1995
28. Polonsky WH, Welch G. Listening to our patients' concerns: understanding and addressing diabetes-specific emotional distress. Diabetes Spectrum 9: 8-10, 1996
29. Polonsky WH. Understanding and assessing diabetes-specific quality of life. Diabetes Spectrum 13: 36-41, 2000
30. Pouwer F, Snoek FJ, Van Der Ploeg HM, Ader HJ, Heine RJ. Monitoring of psychological well-being in outpatients with diabetes: effects on mood, HbA1c, and the patient’s evaluation of the quality of diabetes care: a randomized controlled trial. Diabetes Care 24: 1929-35, 2002
31. Pouwer F, Snoek FJ. Patients’ evaluation of the quality of diabetes care (PEQD): development and validation of a new instrument. Quality and Safety in Health Care 11: 131-136, 2002
32. Pouwer F, Van Der Ploeg HM, Ader HJ, Heine RJ, Snoek FJ. The 12-item Well-Being Questionnaire: an evaluation of its validity and reliability in Dutch people with diabetes. Diabetes Care 22: 2004-2010, 1999
33. Quattrini C, Tesfaye S. Understanding the impact of painful diabetic neuropathy. Diabetes/Metabolism Research and Reviews 19(Suppl. 1): S2-S8, 2003
34. Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. Journal of Clinical Psychology 57(4): 457-478, 2001
35. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes/Metabolism Research and Reviews 15(3): 205-218, 1999
36. Sato E, Miyashita M, Suzukamo Y, Kazuma K. Development of a diabetes diet-related quality-of-life scale. Diabetes Care 27(6): 1271-1275, 2004
37. Shea S, Starren J, Weinstock RS, Knudson PE, Teresi J, Holmes D, Palmas W, Field L, Goland R, Tuck C, Hripcsak G, Capps L, Liss D. Columbia University’s informatics for diabetes education and telemedicine (IDEATel) project: rationale and design. Journal of the American Medical Informatics Association 9: 49-62, 2002
38. Snoek FJ, Pouwer F, Welch GW, Polonsky WH. Diabetes-related emotional distress in Dutch and U.S. diabetic patients: cross-cultural validity of the Problem Areas in Diabetes Scale. Diabetes Care 23: 1305-1309, 2000
39. Snoek FJ, Van Der Ven NCW, Lubach C. Cognitive behavioral group training for poorly controlled type 1 patients: a psychoeducational approach. Diabetes Spectrum 12: 147-152, 1999
40. Snoek FJ, Van Der Ven NCW, Lubach CHC, Chatrou M, Ader HJ, Heine RJ, Jacobson AM. Effects of cognitive behavioural group training (CBGT) in adult patients with poorly controlled insulin-dependent (type 1) diabetes: a pilot study. Patient Education and Counseling 45: 143-148, 2001
41. Snoek FJ. Breaking the barriers to optimal glycaemic control - what physicians need to know from patients’ perspectives. International Journal of Clinical Practice Suppl. 129: 80-84, 2002
42. Steed L, Cooke D, Newman S. A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus. Patient Education and Counseling 51(1): 5-15, 2003
43. Sultan S, Heurtier-Hartemann A, Grimaldi A. Comprendre les patients pour promouvoir l’autorégulation dans le diabète de type 2: vivre avec une maladie évolutive qui commence avant son début. Diabetes Metabolism 29(2 Pt 3): 3S21-3S30, 2003. [Understanding patients to promote self-regulation in type 2 diabetes: how to live with an illness beginning before its onset.]
44. Sultan S, Heurtier-Hartemann A. Coping and distress as predictors of glycemic control in diabetes. Journal of Health Psychology 6: 731-739, 2001
45. Sultan S, Jebrane A, Heurtier-Hartemann A. Rorschach variables related to blood glucose control in insulin-dependent diabetes patients. Journal ofPersonality Assessment79(1): 122-141, 2002
46. Temple AJS. The effects of diabetes self-management education on diabetes self-care, diabetes self-efficacy, and psychological adjustment to diabetes. Dissertation Abstract International, B 64/04: 1689, 2003. UMI ProQuest Digital Dissertations, Publication Number AAT 3087164.
47. Tkacs NC. Hypoglycemia unawareness: your patients with diabetes won’t always know when their blood sugar is low. AJN American Journal of Nursing 102(2): 34-41, 2002
48. Trief PM, Himes CL, Orendorff R, Weinstock RS. The marital relationship and psychosocial adaptation and glycemic control of individuals with diabetes. Diabetes Care 24: 1384-1389, 2001
49. Trief PM, Wade MJ, Britton KD, Weinstock RS. A prospective analysis of marital relationship factors and quality of life in diabetes. Diabetes Care 25: 1154-1158, 2002
50. Trief PM, Wade MJ, Pine D, Weinstock RS. A comparison of health-related quality of life of elderly and younger insulin-treated adults with diabetes. Age Ageing 32: 613-618, 2003
51. Trozzolino L, Thompson PS, Tansman MS, Azen SP. Effects of a psychoeducational group on mood and glycemic control in adults with diabetes and visual impairments. Journal of Visual Impairment & Blindness 97(4): 230-239, 2003
52. Turan B, Osar Z, Turan JM, Damci T, Ilkova H. The role of coping with disease in adherence to treatment regimen and disease control in type 1 and insulin treated type 2 diabetes mellitus. Diabetes Metabolism 28(3): 186-193, 2002
53. Turan B, Osar Z, Turan JM, Ilkova H, Damci T. Dismissing attachment and outcome in diabetes: the mediating role of coping. Journal of Social and Clinical Psychology 22(6): 607-626, 2003
54. Upton LR, Bush BA, Taylor RE. Stress, coping and adjustment of adventitiously blind male veterans with and without diabetes mellitus. Journal of Visual Impairment & Blindness 92(9): 656-665, 1998
55. Van Der Ven NCW, Lubach CHC, Hogenelst MHE, Van Iperen A, Tromp-Wever AME, Vriend A, Van Der Ploeg HM, Heine RJ, Snoek FJ. Cognitive behavioural group training (CBGT) for patients with type 1 diabetes in persistent poor glycaemic control: who do we reach? Patient Education and Counseling, in press
56. Van Der Ven NCW, Weinger K, Yi J, Pouwer F, Ader H, Van Der Ploeg HM, Snoek FJ. The Confidence in Diabetes Self-Care Scale: psychometric properties of a new measure of diabetes-specific self-efficacy in Dutch and US patients with type 1 diabetes. Diabetes Care 26: 713-718, 2003
57. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes/Metabolism Research and Reviews 17(4): 246-249, 2001
58. Vileikyte L. Psychological aspects of diabetic peripheral neuropathy. Diabetic Reviews 7(4): 387-394, 1999
59. Von Goeler DS, Rosal MC, Ockene JK, Scavron, De Torrijos F. Self-management of type 2 diabetes: a survey of low-income urban Pueerto Ricans. Diabetes Educator 29(4): 663-672, 2003
60. Wandell PE, Brorsson B, Aberg H. Psychic and socioeconomic consequences with diabetes compared to other chronic conditions. Scandianavian Journal of Social Medicine 25(1): 39-43, 1997
61. Weinger K, Butler HA, Welch GW, La Greca AM. Measuring diabetes self-care: a psychometric analysis of the Self-Care Inventory with adults. in press.
62. Weinger K, Jacobson AM. Psychosocial and quality of life correlates of glycemic control during intensive treatment of type 1 diabetes. Patient Education and Counseling 42: 123-131, 2001
63. Welch G, Guthrie DW. Supporting lifestyle change with a computerized psychosocial assessment tool. Diabetes Spectrum 15: 203-207, 2002
64. Welch G, Weinger K, Anderson B, Polonsky WH. Responsiveness of the Problem Areas In Diabetes (PAID) questionnaire. Diabetic Medicine 20: 69-72, 2003
65. Welch GW, Jacobson AM, Polonsky WH. The Problem Areas in Diabetes Scale: an evaluation of its clinical utility. Diabetes Care 20: 760-766, 1997
66. Welch GW, Weinger K, Jacobson AM. Psychosocial issues and type 2 diabetes. In Textbook of Type 2 Diabetes. Goldstein BJ, Muller-Wieland D, Eds. London: Martin Dunitz, 2003, p. 65-76
67. West C, McDowell J. The distress experienced by people with type 2 diabetes. British Journal of Community Nursing 7: 606-613, 2002
68. Whittemore R, Melkus GD, Grey M. Self-report of depressed mood and depression in women with type 2 diabetes. Issues in Mental Health Nursing 25(3): 243-260, 2004
69. Wolpert HA, Anderson BJ. Young adults with diabetes: need for a new treatment paradigm. Diabetes Care 24 (9): 1513-1514, 2001
B. Published Conference Presentations
70. Affenito SG, McAvoy K, Greaves J, Bussolini D, Welch GW. Evaluating the emotional burden of diabetes using the Problem Areas In Diabetes survey. Journal of the American Dietetic Association 100(9, Suppl. 1): S, 2000. Abstract.
71. Anderson RT, Slovlund SE, Marrero D, Brod M. ITSQ Study Group. Development and validation of the insulin treatment satisfaction questionnaire (ITSQ). Value In Health 5(6): page, 2002. Abstract PDB9, 548?.
72. Antisdel JE, Laffel LMB, Anderson BJ. Improved detection of eating problems in women with type 1 diabetes using a newly developed survey. Diabetes 50(Suppl. 2): A47, 2001. Abstract 190-OR.
73. Champagne N, Edelman S. Long term improvement in attitude, exercise routine, and maintenance of glucose control in Type 1 diabetes following attendance in an intensive educational and motivational program. Diabetes 48(Suppl. 1): A38, 1999. Abstract 0160.
74. de Groot M, Welch G, Chipkin S. Patient readiness to improve diabetes self care is associated with a high level of diabetes-related emotional distress in an inner city diabetes clinic population. Diabetes 52(Suppl. 1): A411, 2003. Abstract 1783-P.
75. Earley MA, Puczynski S, Nagel RW. Problem Areas In Diabetes scale: differences by treatment regiment in type 2 primary care patients. Diabetes 49(Suppl. 1): A324, 2000. Abstract 1354-P.
76. Franko D, Weinger K, Goebel-Fabbri A, Rodriguez M, Fikkan J, Pearson K, Anderson B. Insulin omission in women with type 1 diabetes: validity of the Eating Disorder Inventory. Diabetes 52(Suppl. 1): A412-A413, 2003. Abstract 1789-P.
77. Goebel-Fabbri A, Rodriguez M, Weinger K, Franko D, Fikkan J, Pearson K, Anderson B. Who omits insulin? A model of eating disorders in type 1 diabetes. Diabetes 52(Suppl.1): A414, 2003. Abstract 1795-P.
78. Gross CC, Scain SF, Scheffel RF, Gross JL, Hutz CS. Brazilian version of the Problem Areas In Diabetes scale: validation and identification of high risk individuals for emotional distress. Diabetes 53(Suppl. 2): A439, 2004. Abstract 1839-P.
79. Inoue-Shibata M, Kosaki A, Baba T, Kawata K, Sato S, Hasegawa T, Nishikawa M, Iwasaka T. Personality predictors of glycemic control in patients with type 2 diabetes. Diabetes 53(Suppl. 2): A441, 2004. Abstract 1847-P.
80. Ishii H, Welch GW, Jacobson A, Goto M, Okazaki K, Yamamoto T, Tsujii S. The Japanese version of the Problem Area In Diabetes scale: a clinical and research tool for the assessment of emotional functioning among diabetic patients. Diabetes 48(Suppl. 1): A319, 1999. Abstract 1397.
81. Izquierdo R, Knudson P, Meyer S, Kearns J, Weinstock RS. A comparison of diabetes education administered through telemedicine versus in person. Diabetes 49(Suppl. 1): A344, 2000. Abstract 1441-PO.
82. Jackson RA, Ovalle K, Quickel K. Diabetes immersion: the Joslin Diabetes Outpatient Intensive Treatment (DOIT) program. Diabetes 48(Suppl. 1): A422, 1999. Abstract 1866.
83. Kanbara S, Danawati W, Yajima Y, Yamamoto H, Nakazono N, Kira S, Taniguchi H. Emotional distress and health perceptions of diabetics in Yogyakarta, Indonesia. Diabetes 53(Suppl. 2): A609-A610, 2004. Abstract 2577-PO.
84. Kulzer B, Hermanns N, Scholze A, Kubiak T, Haak T. Concerns about insulin therapy in patients with type 2 diabetes. Diabetes 53(Suppl. 2): A438-A439, 2004. Abstract 1837-P.