Stress Fractures

By Marc Siegel|Wednesday, May 01, 1996
RELATED TAGS: DIABETES
When I first met Sandra Peterson, she was wearing thick glasses and a nondescript yellow skirt and blouse. She was slight, just over five feet tall, and so reserved that she seemed timid. Sandra had come to see me about her diabetes. She had brought her blood glucose meter, the handheld machine that measures blood sugar levels. She pricked her finger with the tiny metal lancet and squeezed out the single drop of blood necessary for an accurate reading, nothing more. By that measure, her glucose level--the amount of sugar in her blood--was within the normal range.

Sandra didn’t complain of tingling feet, thirst, or blurry vision--the common symptoms of a poorly managed diabetic condition.

Strangely, given her knowledge about her condition, she denied having had regular visits to another internist before seeing me. She said she could take care of her diabetes herself and added that she had been injecting a single shot of insulin a day. When I asked Sandra where she had obtained the insulin, she said a doctor had prescribed it for her at the hospital where she worked. Sandra explained that she was a registered nurse at a nearby community hospital.

Patients with diabetes lack the ability to absorb glucose from the blood into their cells--either because they don’t secrete enough insulin, a hormone made by the pancreas, or because they don’t respond to the insulin they do make. In either case, prolonged exposure to high blood sugar levels can cause circulatory problems and nerve damage. These circulatory problems, in turn, often cause sluggish blood flow in the legs and abnormalities in the retina. My examination, however, turned up none of the telltale signs of diabetes. Sandra’s pulse and retinas were normal, and the soles of her feet were sensitive to the prick of a pin.

I told myself that Sandra lacked the typical signs of diabetes- related damage because, at 39, she was relatively young. But her single- shot insulin regimen was a bad idea for a young diabetic. Patients who develop diabetes before middle age generally lack the ability to produce enough insulin. They therefore tend to need insulin several times a day to keep their blood sugar stable.

After I drew Sandra’s blood, I wrote out a prescription for a regimen of two shots of insulin a day. I said I would increase the complexity and frequency of her shots when I was sure she could manage them. Sandra promised to check her glucose level throughout the day and give me a list of the results. She scheduled an appointment for the following week.

When Sandra didn’t show up for that appointment, my secretary, Lois, called her. They made an appointment, but Sandra skipped that one too.

Who referred this patient? I asked Lois.

No one, she replied. She walked in off the street.

I was reluctant to call the hospital where Sandra said she worked, though I had no other way to check on the truth of her story. I decided to wait. Her first blood tests had come back normal.

The next time I saw Sandra, she arrived without an appointment. And she was so changed that I didn’t recognize her. She was wearing shorts, a ripped T-shirt, and a red fedora, and her face was streaked with makeup. She cursed at Lois, who recognized her and asked me what to do. I suggested we do a screening for drugs. Under the bright lights of the examining room, Sandra suddenly became polite and cordial. The drug screen was normal, but her glucose level was 250 milligrams per deciliter of blood. Depending on when a person last ate, the normal glucose level can range from about 70 to 140.

I suspected that Sandra--despite her nurse’s training--wasn’t complying with my instructions for controlling her blood sugar. And her careless dress and attention-seeking behavior hinted that she had lost control of more than her diabetes. Nevertheless, Sandra insisted that she could handle a complex daily treatment regimen consisting of several insulin injections of varying amounts. I reluctantly designed one for her.

The following day I tried to call Sandra at her hospital. I didn’t reach her, but to my relief her supervisor confirmed that Sandra did indeed work there. She said that although Sandra was a little strange, she was a good nurse. She also confirmed that Sandra was a diabetic, but she was surprised to hear that she got her insulin from one of the hospital’s doctors.

A week after showing up in the fedora, Sandra called. She insisted that she was following my orders closely, and she said her blood sugar levels were normal.

At the time of Sandra’s next appointment, a patient appeared at the front desk dressed in a mannish blue suit. Although Lois recognized the patient as Sandra, Sandra insisted on filling out a new patient information form. Lois brought me the completed form with a puzzled look. The address, phone number, and other information were exactly the same as Sandra’s, except that the patient listed his name as Donald, his age as 22, and his diagnosis as unknown.

In the examining room, I asked Sandra if she was taking her insulin.

My name is Donald, she replied, and I am not a diabetic.

I asked Donald if he felt stressed. When he nodded, I gently asked if he would consider seeing a psychiatrist. Donald said he didn’t think he needed to see one. I explained that he might find it helpful to talk about what was making him feel so stressed. After I gave him my reasons, he agreed to go. He didn’t seem to need much convincing.

At this point I suspected that Sandra was suffering from multiple personality disorder, a condition that--despite its media popularity--is actually quite rare. After evaluating Sandra, the psychiatrist agreed. Although this disorder is poorly understood, some psychiatrists believe it is caused by a trauma so overwhelming that the patient forges new personalities to escape the pain. Other psychiatrists see the flowering of the personalities simply as a dramatic cry for help.

I explained to the psychiatrist that I thought Sandra’s disorder was interfering with her management of her diabetes. Her blood sugar levels seemed to vary depending on the personality she was manifesting. I suspected that one personality would comply with the regimen and keep her blood sugar levels stable. But another personality would disregard the regimen, and her levels would swing out of control.

Well, you’ll have a chance to test your theory, the psychiatrist said. I’m admitting her to the hospital.

There, however, my theory was proved wrong. Nurses on the psychiatric ward watched Sandra carefully. Her blood glucose levels and food intake were checked around the clock. Under such conditions, there is little chance for noncompliance. Nevertheless, Sandra’s glucose level frequently rose out of control. Then another idea occurred to me. A few studies have found metabolic differences between the personalities in a patient with multiple personality disorder. Blood pressure, heart rate, and even the EEGs that measure electrical activity in the brain vary from one personality to the next. What about blood sugar?

The amount of sugar in our blood is determined by a complex interaction of several hormones, and that interaction changes when we are frightened or upset. In a stressful situation, the adrenal glands--small glands that sit on top of the kidneys--release hormones that prepare the body to react. This fight-or-flight reaction enables us to break down sugar we have stored in our tissue. The sugar floods into the bloodstream, giving us the energy we need to respond quickly to a threat. At the same time, more insulin is produced by the pancreas, enabling us to use the sugar or store it, if necessary. A diabetic like Sandra, however, can’t make the insulin she needs to take advantage of the rise in blood sugar. The result is an abnormal elevation in blood sugar. Although the blood is flooded with sugar, the muscles are starving for fuel.

Sandra was now undergoing intensive psychotherapy, and as she cycled from one personality to the next, the psychiatric nurses noted significant swings in her glucose levels. One of Sandra’s personalities was Sylvia, a placid 60-year-old former schoolteacher who was supposedly very sensitive to insulin. On one particular day, Sylvia’s glucose level was 52. Forty minutes later, Sylvia claimed to be Sandra. Sandra, who tended to be moody, had a glucose level of 185. The personality named Tamara, who behaved like the ill-mannered young woman I had encountered wearing the fedora, had a glucose level of 212. But the personality named Rachel, a 12- year-old girl who liked wearing flowery dresses and loathed taking any kind of medicine, had a glucose level that never exceeded 100. Most of the time, in fact, Rachel refused to take her insulin, and the nurses had to wait for another personality to emerge before giving it to her.

During the two months Sandra was in the hospital, the psychiatric nurses documented over 40 personalities--all with distinctive voices, postures, and temperaments. Donald, who had the cracking tenor of an adolescent boy, was calm and stood very straight. Tamara, a nervous chain- smoker, had a shrill voice. Rachel’s voice was soft and sweet; she never smoked and was never upset.

I was unable to prove that the fluctuations in Sandra’s blood sugar were directly caused by changes of personality, but they were difficult to explain any other way. There was a clear link between how upset the patient was and her blood sugar level, which strongly hinted that the level was associated with the hormonal response. In addition, none of the personalities that claimed to be diabetes-free were ever found to have a glucose level higher than 200, whereas the personalities of Sandra, Tamara, and Shirley--a self-described jazz singer who walked with a pronounced limp--often did.

Sandra’s psychiatrist never pinpointed the exact onset of her psychiatric problems, but he suspected that she had had multiple personality disorder for many years in a form so mild that no one had noticed. Ultimately, he settled on Sandra as the core personality, and the staff began to work on helping her integrate the other personalities. For medical reasons, I was disappointed, but I held my tongue. Simply put, Sandra was not the personality with the best glucose levels. As a nurse, she should have been capable of handling her diabetes, but she was easily upset and her glucose levels often varied.

The personality of Sandra also seemed, to me, not to be the best choice from a psychiatric point of view. At one point in her hospitalization, Sandra ordered Donald to kill himself and threatened to send a gun to him. But that murderous intent eventually dissolved, and Sandra’s psychiatrist thought she was ready to go home. The nurses disagreed; they thought she was too unstable. The psychiatrist discharged Sandra anyway: he felt she was out of danger. She had clearly improved, and her personality shifts were much less frequent.

Apparently he was right. Since leaving the hospital, Sandra has done surprisingly well. She follows a complex treatment regimen of five insulin injections a day and keeps her appointments with her psychiatrist and me. She has managed to hold on to her job as a nurse. Her employer decided not to pursue the matter of how she had obtained her insulin before coming to me.

I will never know the origins of Sandra’s psychiatric problems. What I do know is that she is a diabetic. But the condition of her other personalities raises a question I can’t answer. Could Donald--who claimed to be diabetes-free--have remained healthy without receiving any insulin? Could Sylvia? I don’t really think so, but sometimes I do wonder.
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