Psychosomatic Medicine 1:527-552 (1939)
© 1939 American Psychosomatic Society

Present Trends in the Evaluation of Psychic Factors in Diabetes Mellitus

A Critical Review of Experimental, General Medical and Psychiatric Literature of the Last Five Years

¹ Departments of Psychiatry and Medicine, Columbia University, New York, New York

In this attempt to report present trends in the evaluation of the psychic factor in diabetes mellitus, the experimental, general medical and psychiatric literature of the last five years has been combed. A considerable amount of space has been given to the experimental field because at the present time it appears to hold out the best prospect of ultimately furnishing the key to the psychosomatic problem presented. Impetus was furnished to all branches of research in metabolism by the discovery of Houssay and Biasotti in 1931 that diabetes of depancreatized animals could be attenuated and their lives prolonged by extirpation of the anterior pituitary gland.

Houssay's work and its consequences have revolutionized theories of the mechanism of diabetes and have led to the relinquishment of the simpler insulinogenic concept. This has broadened the base for the understanding of the influence of emotional factors.

Numerous extracts of the anterior pituitary affecting metabolism have been described. One of the most important extracts is made from crude gland which has a diabetogenic effect on the normal animal. Young, by a series of brilliant experiments, has shown that repeated injections of such extracts result in a permanent diabetic condition after treatment is discontinued.

Many modifications of the original Houssay experiment have been tried to test the diabetogenic influence of other participants. Long believes that the adrenal cortex is essential. A modification of the diabetic condition similar to that effected by Houssay and Biasotti has been obtained by bilateral injury to the hypothalamus. Other evidence of implication of the hypothalamus in disturbed sugar metabolism, its importance as a center for the involuntary nervous system and its participation in automatic emotional discharge make it a focal point in attempts to understand degrees of emotional participation in diabetes.

Studies in the hereditary factor in diabetes show quite conclusively the importance of a diabetic anlage and there is some evidence that this may be passed on as a recessive Mendelian trait. In evaluating the emotional factor in the etiology of the disease the constitutional predisposition should be taken into account. It seems unwarranted, however, to dismiss the importance of the psychic factor either on account of hereditary predisposition or on the evidence of the World War that shell-shock is not an important etiological factor. Recent general medical literature, except in arguments along these lines, is silent on the subject.

Recent psychiatric contributions to the subject, though scattered, show an awakened interest with a new approach afforded by psychoanalytic insight. Emphasis is away from settling the whole question of psychogenesis in diabetes on the frequency of traumatic diabetes but is laid rather on the presence of anxiety, concealed or overt, which is unable to discharge through the conscious voluntary system and is forced through regressive changes to discharge at more primitive autonomic levels. It is well established that emotional changes can affect the blood sugar level. Up to the present time it has not been definitely proved whether or not it is possible to precipitate a diabetes by such influences. Cases in which emotional disturbances seem of importance in the causation of diabetes are cited including the first report of a case of diabetes to be psychoanalytically investigated.

A review of psychotherapy in diabetes is made. The importance of attention to personality factors in the uncooperative case, as well as in those cases which react to emotional conflict with increased sugar, is stressed. An outline of an attempt to deal systematically with emotional tension in diabetes is reported.

Note:

I should like to express my appreciation to Dr. Earl T. Engle who has kindly read the section on the experimental field and made valuable suggestions, to Dr. Edward S. Tauber for valuable assistance in compiling the bibliography, to the National Committee on Maternal Health through the Sex Biology Gift for loaning his services and rendering other assistance in the preparation of the manuscript and to PSYCHOSOMATIC MEDICINE for its initial suggestion of the need for this review and its encouragement in the undertaking.