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Factitious Hypoglycemia
Case Reports
Factitious Hypoglycemia An ll-Year Follow-Up MONIQUE Roy, M.D. ALEC Roy, M.D.
R
eviewing the literature, Kaminer and Robbins ' concluded that there are a number of fonns of insulin misuse among diabetic patients. These include attempted and completed suicide. factitious hypoglycemia. Munchausen syndrome. and the use of insulin by substance abusers. In the literature they found 18 cases of factitious hypoglycemia. 17 cases of completed suicide. and 80 cases of attempted suicide by insulin. Psychiatric diagnoses and fonnulations were not included in any of the 17 reports on factitious hypoglycemia. Depression was mentioned in the 9 of the cases of attempted suicide. but the number of these meeting diagnostic criteria for affective disorder could not be determined. Therefore. we wish to report the case of a diabetic patient who presented for investigation of factitious hypoglycemia. was evaluated by a psychiatrist. and diagnosed as having an affective disorder meeting the diagnostic criteria. We also report an II-year foIlow-up.
Case Report The patient was a 32-year-old. separated, unemployed. African-American, female bookkeeper. She Received March 26, 1993; revised April 23. 1993; accepted June 10, 1993. From the University of Medicine and Dentistry of New Jersey. Newark. Address reprint requests to Dr. Roy, University of Medicine and Dentistry, Department of Ophthalmology, DOC, 90 Bergen St., Room 6164, Newark, NJ 07103-2499. Copyright © 1995 The Academy of Psychosomatic Medicine.
64
had been diagnosed as diabetic at age 9 and had been maintained on oral hypoglycemic agents until age 29. During those years she had no episodes of ketoacidosis or hypoglycemia. At age 29 inadequate control of her diabetes led to the start of treatment with insulin. Two-and-a-half years later the insulin was stopped, and oral agents were reinstated because she had fasting hypoglycemia. She also began to have episodes of apparently spontaneous hypoglycemia. These blackouts led to hospital admissions, and she was found on occasion to have low blood glucose levels and extremely high serum insulin levels. A factitious cause for these results was suspected but she denied taking insulin. A pancreatic computed tomography scan and arteriogram did not reveal an insulinoma. She was then investigated for hypoglycemia attributable to antibodies caused by either insulin itself or to insulin receptors, with negative results. During the index admission she asked a ward orderly to go to an outside pharmacy and purchase some hair products for her. She then phoned the pharmacist and asked him to give the orderly insulin for her. The pharmacist phoned the hospital. She was confronted and turned over a vial of insulin and two used insulin syringes. During a room search an additional vial of insulin was found. Also, she later handed over razor blades and scissors. At psychiatric interview she reported that she was born out of wedlock and had been brought up by an aunt. She had discovered her mother by chance at age 14. Her mother later died at age 37 of a myocardial infarction. The patient had a diabetic aunt and 3 sisters. She revealed that she had taken a drug overdose 4 years before at the onset of marital problems with her husband. At that time she was treated with antidepressant medication. She left her husband briefly and got a grant to attend a computer course. HowPSYCHOSOMATICS
Case Reports
ever, her husband obtained the grant check and cashed it, and she had to drop out of the course. Her insulin misuse had started a year before the consultation. Her husband, who was 20 years older, became morbidly jealous, accused her of being unfaithful, opened her mail, listened to her telephone calls, and beat her. She had filed for divorce, but the judge suggested that they talk about possible reconciliation. They had in fact reconciled 6 weeks before her admission, but things had not worked out. She had decided to leave him again, get a divorce, and return to live with her adoptive parents, who had always urged her to leave her husband. Mental status examination revealed a tearful woman with depressed mood, decreased energy, concentration, and libido. It took her hours to get to sleep, then she would have disturbed sleep and was finally waking 2 hours earlier than normal. She felt that her life was going nowhere and that life was not worth living. She wished to die and revealed that suicide was "all' been thinking about for a long time, months." She stated '" feel useless" and '" want to die." She related that the insulin misuse was attempts at suicide. A diagnosis of an affective disorder was made. Arrangements were made to transfer her for psychiatric inpatient treatment to a hospital in her own state. Follow-up I I years later revealed that she spent a month in a psychiatric ward in her local hospital, where she received antidepressant medication and psychotherapy. Overthe next 5 years, she continued to receive antidepressants and psychotherapy "on and off' at her community mental health center. She obtained a divorce and learned to "deal with things better." Although divorced, her ex-husband kept bothering her, and she eventually had a second psychiatric admission, lasting 2 weeks, for anxiety, panic, and depression. Her suicidal thoughts recurred. She was treated again with antidepressant medication. Over the next 3 years she received counseling and antidepressants. Over the last 3 years she has received no psychotropic medication or counseling. She has continued to work over the last II years as a nursing assistant in a geriatric nursing home, which she has also found therapeutic by helping others. Over the last 4 years she has had a new relationship. A year ago her ex-husband died, which she found a great relief. A year ago she had a baby at age 42, which she says has changed her life. She no longer gets depressed and is living alone with her baby, albeit next door to her adoptive mother. She is considering remarriage.
VOLUME 36 • NUMBER I • JANUARY - FEBRUARY 1995
Over the last II years she had remained on insulin. Her endocrinologist confirmed that she was compliant with treatment. She remembers that with the insulin overdoses II years ago she had been "definitely trying to kill myself-my marriage messed me up."
Discussion We report a diabetic patient who presented with factitious hypoglycemia and who misused insulin with the intent to kill herself during an episode of severe depression. She was seen by a psychiatrist and diagnosed as meeting diagnostic criteria for a major depressive episode. The major stress in her life was her morbidly jealous husband. As demonstrated by our patient, factitious hypoglycemia secondary to insulin misuse can be difficult to recognize, and it may take a while for physicians to suspect that a patient might mislead them. It is of note that our patient was female, as were 16 of the 18 previous cases reported in the literature. Kaminer and Robbins 1 suggest that psychiatric evaluations be considered for patients with unexplained hypoglycemia. In particular, they emphasize using this approach because failure to identify suicidal intent, as present in our patient, may increase the chances of further episodes of insulin misuse and suicidal behavior. That psychiatric evaluation may be helpful, is exemplified in our patient who, after evaluation and the initiation of treatment, received acute treatment for her depression and stopped her acute misuse of insulin. She continued to have psychiatric morbidity over the II-year follow-up period, including a second admission with suicidal ideation. However, she continued in psychiatric contact, sought out additional help at times of exacerbation, and exhibited no further insulin misuse or other suicidal behavior.
References I. Kaminer Y, Robbins D: Insulin misuse: a review of an
overlooked psychiatric problem. Psychosomatics 1989; 30:19-24
65
Factitious Hypoglycemia An ll-Year Follow-Up MONIQUE Roy, M.D. ALEC Roy, M.D.
R
eviewing the literature, Kaminer and Robbins ' concluded that there are a number of fonns of insulin misuse among diabetic patients. These include attempted and completed suicide. factitious hypoglycemia. Munchausen syndrome. and the use of insulin by substance abusers. In the literature they found 18 cases of factitious hypoglycemia. 17 cases of completed suicide. and 80 cases of attempted suicide by insulin. Psychiatric diagnoses and fonnulations were not included in any of the 17 reports on factitious hypoglycemia. Depression was mentioned in the 9 of the cases of attempted suicide. but the number of these meeting diagnostic criteria for affective disorder could not be determined. Therefore. we wish to report the case of a diabetic patient who presented for investigation of factitious hypoglycemia. was evaluated by a psychiatrist. and diagnosed as having an affective disorder meeting the diagnostic criteria. We also report an II-year foIlow-up.
Case Report The patient was a 32-year-old. separated, unemployed. African-American, female bookkeeper. She Received March 26, 1993; revised April 23. 1993; accepted June 10, 1993. From the University of Medicine and Dentistry of New Jersey. Newark. Address reprint requests to Dr. Roy, University of Medicine and Dentistry, Department of Ophthalmology, DOC, 90 Bergen St., Room 6164, Newark, NJ 07103-2499. Copyright © 1995 The Academy of Psychosomatic Medicine.
64
had been diagnosed as diabetic at age 9 and had been maintained on oral hypoglycemic agents until age 29. During those years she had no episodes of ketoacidosis or hypoglycemia. At age 29 inadequate control of her diabetes led to the start of treatment with insulin. Two-and-a-half years later the insulin was stopped, and oral agents were reinstated because she had fasting hypoglycemia. She also began to have episodes of apparently spontaneous hypoglycemia. These blackouts led to hospital admissions, and she was found on occasion to have low blood glucose levels and extremely high serum insulin levels. A factitious cause for these results was suspected but she denied taking insulin. A pancreatic computed tomography scan and arteriogram did not reveal an insulinoma. She was then investigated for hypoglycemia attributable to antibodies caused by either insulin itself or to insulin receptors, with negative results. During the index admission she asked a ward orderly to go to an outside pharmacy and purchase some hair products for her. She then phoned the pharmacist and asked him to give the orderly insulin for her. The pharmacist phoned the hospital. She was confronted and turned over a vial of insulin and two used insulin syringes. During a room search an additional vial of insulin was found. Also, she later handed over razor blades and scissors. At psychiatric interview she reported that she was born out of wedlock and had been brought up by an aunt. She had discovered her mother by chance at age 14. Her mother later died at age 37 of a myocardial infarction. The patient had a diabetic aunt and 3 sisters. She revealed that she had taken a drug overdose 4 years before at the onset of marital problems with her husband. At that time she was treated with antidepressant medication. She left her husband briefly and got a grant to attend a computer course. HowPSYCHOSOMATICS
Case Reports
ever, her husband obtained the grant check and cashed it, and she had to drop out of the course. Her insulin misuse had started a year before the consultation. Her husband, who was 20 years older, became morbidly jealous, accused her of being unfaithful, opened her mail, listened to her telephone calls, and beat her. She had filed for divorce, but the judge suggested that they talk about possible reconciliation. They had in fact reconciled 6 weeks before her admission, but things had not worked out. She had decided to leave him again, get a divorce, and return to live with her adoptive parents, who had always urged her to leave her husband. Mental status examination revealed a tearful woman with depressed mood, decreased energy, concentration, and libido. It took her hours to get to sleep, then she would have disturbed sleep and was finally waking 2 hours earlier than normal. She felt that her life was going nowhere and that life was not worth living. She wished to die and revealed that suicide was "all' been thinking about for a long time, months." She stated '" feel useless" and '" want to die." She related that the insulin misuse was attempts at suicide. A diagnosis of an affective disorder was made. Arrangements were made to transfer her for psychiatric inpatient treatment to a hospital in her own state. Follow-up I I years later revealed that she spent a month in a psychiatric ward in her local hospital, where she received antidepressant medication and psychotherapy. Overthe next 5 years, she continued to receive antidepressants and psychotherapy "on and off' at her community mental health center. She obtained a divorce and learned to "deal with things better." Although divorced, her ex-husband kept bothering her, and she eventually had a second psychiatric admission, lasting 2 weeks, for anxiety, panic, and depression. Her suicidal thoughts recurred. She was treated again with antidepressant medication. Over the next 3 years she received counseling and antidepressants. Over the last 3 years she has received no psychotropic medication or counseling. She has continued to work over the last II years as a nursing assistant in a geriatric nursing home, which she has also found therapeutic by helping others. Over the last 4 years she has had a new relationship. A year ago her ex-husband died, which she found a great relief. A year ago she had a baby at age 42, which she says has changed her life. She no longer gets depressed and is living alone with her baby, albeit next door to her adoptive mother. She is considering remarriage.
VOLUME 36 • NUMBER I • JANUARY - FEBRUARY 1995
Over the last II years she had remained on insulin. Her endocrinologist confirmed that she was compliant with treatment. She remembers that with the insulin overdoses II years ago she had been "definitely trying to kill myself-my marriage messed me up."
Discussion We report a diabetic patient who presented with factitious hypoglycemia and who misused insulin with the intent to kill herself during an episode of severe depression. She was seen by a psychiatrist and diagnosed as meeting diagnostic criteria for a major depressive episode. The major stress in her life was her morbidly jealous husband. As demonstrated by our patient, factitious hypoglycemia secondary to insulin misuse can be difficult to recognize, and it may take a while for physicians to suspect that a patient might mislead them. It is of note that our patient was female, as were 16 of the 18 previous cases reported in the literature. Kaminer and Robbins 1 suggest that psychiatric evaluations be considered for patients with unexplained hypoglycemia. In particular, they emphasize using this approach because failure to identify suicidal intent, as present in our patient, may increase the chances of further episodes of insulin misuse and suicidal behavior. That psychiatric evaluation may be helpful, is exemplified in our patient who, after evaluation and the initiation of treatment, received acute treatment for her depression and stopped her acute misuse of insulin. She continued to have psychiatric morbidity over the II-year follow-up period, including a second admission with suicidal ideation. However, she continued in psychiatric contact, sought out additional help at times of exacerbation, and exhibited no further insulin misuse or other suicidal behavior.
References I. Kaminer Y, Robbins D: Insulin misuse: a review of an
overlooked psychiatric problem. Psychosomatics 1989; 30:19-24
65