Panic and Diabetes

She was 29 and I thought she was beautiful, although nobody else did, I am sure.  No normal scales in my clinic could weigh her, but I would put her between four and five hundred pounds.  Except for someone who brought her to see me ( I think, in the back of a pickup truck, but I did not press the issue) she did not leave the house. Others did her shopping, she had some kind of public assistance.

She was on the standard medication for her depression as well as her panic attacks; paroxetine (Paxil) 40 mg, to lower their intensity and frequency, and a little bit of Xanax, which is supposed to stop such attacks in their tracks.  She used it sparingly, hardly at all — no really — she did not use it.  It did not work.  The most addictive medication doctors give for this sort of thing and she didn’t even want it because it didn’t work.   I love this woman, I loved her candor.  She told me the last  psychiatrists had renewed these medications for the last six months,  even though they didn’t work.

What was wrong???

I took a medical history.  High blood pressure, getting worse, somewhat controlled by a vasodilator.  Not a bad choice. At least a medicine for blood pressure would open her blood vessels, and would not make her more depressed, as several medicines for blood pressure would have done.

Diabetes,  Type 2 (adult onset) also getting worse.  On insulin, immense doses.  Four injections daily, she had not brought her materials and could not quote exact scales, but she was single handily, via payments by the county, keeping at least two  makers of medical insulin comercially viable.

Back to the panic attacks.  We had to look for a pattern.  Subjects or stressors that brought them on.  Anything.  To find a pattern by journaling, if she could not think of it right away, would help us to fight this.

Her answer was not typical: “I get them every day at 7 AM and 3PM  whether I take the Xanax or not.”

And that told me the answer immediately — although no other doctor had ever put such elementary pieces together — They weren’t panic attacks.  They were, by the symptoms she described, hypoglycemia.   Her schedule of insulin types and injections seemed to be screwed up.

“Why didn’t my other doctors tell me that?” she asked.  It’s a normal reaction and I hear it all the time.  It makes me want to tear my hair out. I cannot answer as to why other doctors do the things they do — and I  never did hear from her physician or even her diabetes educator. 

There is an old paradigm I still practice by — Biological, Psychological, Social theorized by psychiatrist George L. Engel at the University of Rochester, and discussed in his 1977 article in the journal “Science” — and it works.

Marvelously — if I were a comic book hero, it would be my super power.

My inability to communicate with those who care for this lady medically will most likely undermine her prognosis. They have trouble accepting  me, and I’m afraid their shame and pride will adversely affect this patient’s chances of getting better.  But I have to believe that I took one step more  than any doctor has ever done for her, and somebody along the line, somewhere in this crazy system of public health we have cobbled  together, will realize that this is her best hope.

Oh, and one more thing.  She said she kept getting fatter, and she could not follow the diet.  It turned out she did nothing — absolutely nothing — in life aside from try to follow it.

She had no other life purpose I could discern.

“Think of anything but a blue horse,” I instructed her.

Like everyone I have ever tried that on, she thought immediately of a blue horse.

“Think of anything but your diabetic diet.”

She was obsessed and stuck with it.

What had she done for pleasure?  listen to music?  draw pictures? read?  Anything???

I told her to get on the internet, for like many people who have access,  she just never thought of constructive ways to use it.  After all, how many times can you watch the video of the kitty who plays  the piano and send it to all of your friends?

I suggested she find something she liked, like a hobby.  Could she  study it?  Maybe, someday, could she make money at it?

But I often ask too many questions at once.  I only get minimal access to people and I want to give them everything I’ve got.  What could I do? This is me, I see people for a little bit and I want to fix them yesterday.

But I saw that light bulb above her head — she got the idea.  She will  work past what she used to be.  She will figure out who she will be.

I think she will somehow be all right.  I have to.  It’s the only way  I can sleep at night.