Acute but transitory mental symptoms occasionally associated with a deficiency of blood sugar There is no single psychological pattern, but rather a wide variety of reactions in different cases. The most frequent are apathy, irritability, anxiety, restlessness, and negativism. In severe cases confusion, disorientation, fugue states, delirium, and stupor may occur. Disturbed speech, hallucinations, and delusions have also been observed. See BRAIN DISORDERS. During a hypoglycemic attack the patient complains of weakness, hunger, and perspiration. He may also suffer from tremor, unsteady gait, double vision (diplopia), and convulsions. The symptoms disappear soon after the administration of sugar and there is no recollection of the attack. Hypoglycemic states are sometimes experienced by diabetics who have taken too much insulin. The majority of cases, however, are due to spontaneous overproduction of insulin caused by islet cell tumors of the pancreas. A small number appear to be functional or psychosomatic in origin, although the mechanism is obscure. An occasional case is due to self-administration of insulin in an attempt to solve emotional problems.Illustrative Case: HYPOGLYCEMIC STATE A hospital nurse suffered from severe hypoglycemic attacks. She was thoroughly examined, but the doctor could not find any organic basis for this reaction. He therefore called in a psychiatric consultant. During a preliminary interview the psychiatrist began to suspect that she had been taking insulin by herself. A search of her room revealed that this was so. When she could not give an adequate explanation of her behavior, he continued his investigation The psychiatrist found that a number of causative factors were probably operating, some on a conscious, some on an unconscious level. He discovered that the doctor who had conducted the blood-sugar examination had previously performed a hysterectomy on the nurse, and had at that time informed her of the existence of a pancreatic tumor. He also found that her mother had been a diabetic, that she herself had often administered the drug to patients in the hospital, and that her father had been given insulin to relieve depression shortly before he died of cancer. All these factors had combined to make her particularly aware of hypoglycemia.But why was she administering insulin to herself The answer was twofold. First, questioning revealed that not long before her attacks she had gone to a doctor to obtain dispensation from a religious fast. (She had always been a heavy eater and suffered intensely when she fasted.) He said he would grant the dispensation only if she were found to be suffering from hypoglycemia. She therefore took insulin before the examination and naturally the hypoglycemia was found. In taking it she discovered that it made her feel particularly well.All these reactions were brought into the open in the course of discussions with the psychiatrist, and the result was a complete cessation of the attacks. (Adapted from Noyes and Kolb, 1963)