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In this paper we describe the psychoanalytic treatment of a patient with so-called ‘brittle diabetes’, a form of insulin-dependent diabetes characterized by extreme and chronic failure to maintain blood glucose control. We have now treated 20 such patients and we feel able to offer a preliminary formulation in respect of the common unconscious determinants of this syndrome. This paper is intended primarily to be a clinical presentation. A fuller description of the statistical basis of our model may be found in Moran (1987) and the summary of the outcome of our work is in Moran et al (1990) and Fonagy and Moran (1990).
As part of our study of a series of brittle diabetic patients, we carried out formal assessments of the dynamic nature of the psychopathology of these individuals. In this process we delineated two pathways of psychological causation of the brittle diabetic state, the first relating to pathological biochemical functioning and the second to psychopathological functioning.
It is claimed that the metabolic imbalance found in diabetic patients weakens the homeostatic capacity of the neuroendocrine system of some patients who then respond to even mild psychosocial stress by excessive release of Cortisol and other stress hormones. These in turn serve to counteract the normoglycaemic influence of insulin. This aspect of the problem has been extensively investigated, but by no means resolved, by other workers (eg Cox et al., 1984; and Barglow et al., 1986) and we have no additional data to cast light upon this controversial issue.
The second pathway concerns the conscious or unconscious acts of transgression of the treatment regimen. In all the cases of brittle diabetes we have treated psychotherapeutically we have found major instances of non-adherence to the regimen which could in and of themselves have accounted for the volatile blood glucose level. We recognize that this is by no means a compelling explanation for the aetiology of brittle diabetes, as major t