Secret Insulin-Injection Syndrome among Adolescents with Type 1 Diabetes
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《新英格兰医药杂志》
To the Editor: Despite improvements in the management of type 1 diabetes mellitus, severe hypoglycemia is not rare among young patients. The incidence of severe hypoglycemia ranges from 0.02 to 0.07 case per patient–month, including episodic recurrence in approximately 20 percent of patients.1,2,3 Since 1990, we have identified 16 patients (15 girls and 1 boy) who had more than three comas within three months, all of whom admitted, generally years later, that they had secretly self-administered large doses of regular insulin. The mean (±SD) age of the patients was 12.9±0.5 years, the mean duration of diabetes was 6.2±0.7 years, and the mean level of glycosylated hemoglobin was 8.1±0.3 percent.
Patients secretly administering injections to themselves had a high frequency of familial dysfunction (8 of 16 patients), and they claimed that the official insulin dose was below 0.5 unit per kilogram per day (9 of 16 patients). An inexperienced pediatric diabetologist diagnosed Munchausen syndrome by proxy in one of the patients, and the error was echoed by the justice system, with serious consequences for the family. Child psychiatrists considered 15 of the 16 patients to be normal and 1 to be psychotic. Seven patients, judged to have marked psychological dysfunction in their families, deliberately used secret injections to induce coma; they said that they did so to get the attention of the medical staff with the aim of obtaining help. Five other patients used secret injections to normalize their blood glucose levels, in response to parents' extreme fear of complications. Four other patients used secret injections to mask poor metabolic control (indicated by weight loss, hyperglycemia, or ketosis) when they felt they had gone too far in omitting insulin doses.
We found no specific feature that reliably identified those with secret insulin-injection syndrome among the many adolescents treated with insulin who had repeated hypoglycemic coma. We would suggest that all children who have more than two comas within a three-month period should be hospitalized to allow them and their parents to have in-depth discussions with physicians, nurses, and psychiatrists. The medical team must explain the risks associated with repeated coma. The pediatric diabetologist should make clear that secret insulin-injection syndrome is suspected as the cause of coma. Faced with denial and arguments, the diabetologist should not struggle with the patient to obtain "the truth." The adolescent involved is usually very anxious and needs both medical and psychiatric help. A firm and comprehensive diagnosis seems to be the key to preventing recurrence. Secret insulin-injection syndrome is a serious condition that may lead to medical and judicial errors, complications, or even death.
Pierre Bougnères, M.D., Ph.D.
Pascal Boileau, M.D., Ph.D.
Brigitte Aboumrad
H?pital Saint-Vincent-de-Paul
75014 Paris, France
pierre.bougneres@paris5.inserm.fr
References
Mortensen HB, Hougaard P. Comparison of metabolic control in a cross-sectional study of 2,873 children and adolescents with IDDM from 18 countries: the Hvidore Study Group on Childhood Diabetes. Diabetes Care 1997;20:714-720.
Rosilio M, Cotton JB, Wieliczko MC, et al. Factors associated with glycemic control: a cross-sectional nationwide study in 2,579 French children with type 1 diabetes. Diabetes Care 1998;21:1146-1153.
Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA 2002;287:2511-8.
Patients secretly administering injections to themselves had a high frequency of familial dysfunction (8 of 16 patients), and they claimed that the official insulin dose was below 0.5 unit per kilogram per day (9 of 16 patients). An inexperienced pediatric diabetologist diagnosed Munchausen syndrome by proxy in one of the patients, and the error was echoed by the justice system, with serious consequences for the family. Child psychiatrists considered 15 of the 16 patients to be normal and 1 to be psychotic. Seven patients, judged to have marked psychological dysfunction in their families, deliberately used secret injections to induce coma; they said that they did so to get the attention of the medical staff with the aim of obtaining help. Five other patients used secret injections to normalize their blood glucose levels, in response to parents' extreme fear of complications. Four other patients used secret injections to mask poor metabolic control (indicated by weight loss, hyperglycemia, or ketosis) when they felt they had gone too far in omitting insulin doses.
We found no specific feature that reliably identified those with secret insulin-injection syndrome among the many adolescents treated with insulin who had repeated hypoglycemic coma. We would suggest that all children who have more than two comas within a three-month period should be hospitalized to allow them and their parents to have in-depth discussions with physicians, nurses, and psychiatrists. The medical team must explain the risks associated with repeated coma. The pediatric diabetologist should make clear that secret insulin-injection syndrome is suspected as the cause of coma. Faced with denial and arguments, the diabetologist should not struggle with the patient to obtain "the truth." The adolescent involved is usually very anxious and needs both medical and psychiatric help. A firm and comprehensive diagnosis seems to be the key to preventing recurrence. Secret insulin-injection syndrome is a serious condition that may lead to medical and judicial errors, complications, or even death.
Pierre Bougnères, M.D., Ph.D.
Pascal Boileau, M.D., Ph.D.
Brigitte Aboumrad
H?pital Saint-Vincent-de-Paul
75014 Paris, France
pierre.bougneres@paris5.inserm.fr
References
Mortensen HB, Hougaard P. Comparison of metabolic control in a cross-sectional study of 2,873 children and adolescents with IDDM from 18 countries: the Hvidore Study Group on Childhood Diabetes. Diabetes Care 1997;20:714-720.
Rosilio M, Cotton JB, Wieliczko MC, et al. Factors associated with glycemic control: a cross-sectional nationwide study in 2,579 French children with type 1 diabetes. Diabetes Care 1998;21:1146-1153.
Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA 2002;287:2511-8.