Recurrent diabetic ketoacidosis | Diabetes Psychiatry

Recurrent DKA

Recurrent DKA should prompt a psychological and psychiatric question

Diabetic ketoacidosis is an acute medical emergency caused by insulin deficiency. An individual episode may have a readily identifiable precipitant: infection, interruption of insulin delivery, difficulty with sick-day management, or insulin omission.

When DKA becomes recurrent, however, the clinical question changes.

A person may already have received repeated diabetes education, insulin adjustment, sick-day advice and access to modern diabetes technology. Yet DKA continues to happen.

At this point it is useful to move from asking:

“What caused this episode of DKA?”

to asking:

“Why does DKA keep happening to this particular person?”

Recurrent DKA can itself be a case-finding signal for psychological, psychiatric and social difficulty.

What do we mean by recurrent DKA?

There is no single universally accepted definition.

For clinical case finding, a pragmatic threshold is:

≥2 episodes of DKA within 2 years

The purpose of the threshold is not to define a new diagnosis. It is to identify a population whose pattern of acute diabetes outcomes justifies a different kind of assessment.

Services may reasonably choose different thresholds according to their population and resources.

The important change is conceptual:

recurrence itself becomes clinically meaningful.

Why think about mental health?

Mental-health and social difficulties are disproportionately represented among people experiencing recurrent DKA.

Studies have identified associations with depression, diabetes distress, eating disorders, substance misuse, socioeconomic adversity and other psychiatric difficulties. Research specifically comparing people with and without recurrent DKA has also found greater anxiety, difficulty regulating emotion and personality dysfunction among the recurrent DKA population.

This does not mean that every episode of recurrent DKA is caused by mental illness.

It means that repeated DKA should increase our curiosity about psychological and psychiatric factors rather than decrease it.

The international consensus report on hyperglycaemic crises identifies mental-health conditions and social determinants of health among the strongest factors associated with recurrent DKA and recommends mental-health screening following hyperglycaemic crises.

UK DKA guidance similarly recognises that recurrent admissions often have psychological components and may benefit from formal mental-health involvement.

The argument for mental-health assessment after recurrent DKA is therefore no longer simply theoretical.

DKA as a case-finding signal

Conventional mental-health pathways usually begin with symptoms.

A person reports depression, anxiety, psychosis or suicidal thoughts. A clinician recognises a possible mental-health disorder. A referral is made.

High-risk diabetes creates another possibility.

Start with the outcome.

Repeated DKA

↓

Could psychological or psychiatric factors be contributing?

↓

Offer assessment

This matters because some of the people at greatest risk will never spontaneously present to mental-health services.

They may not describe themselves as depressed.

They may repeatedly fail to attend appointments.

They may decline conventional psychological therapy.

They may have had difficult previous relationships with healthcare.

Or the principal manifestation of their psychological difficulty may be occurring through their diabetes.

The diabetes outcome therefore becomes one way of finding the person.

Do not assume that recurrent DKA means deliberate self-harm

Insulin omission is an important proximate cause of DKA.

But knowing that insulin was omitted does not tell us why it was omitted.

The same observable behaviour can arise through very different psychological processes.

Insulin may be omitted because of:

depression and loss of self-care
hopelessness
diabetes distress or burnout
avoidance
fear of weight gain
an eating disorder
executive dysfunction
substance use
chaotic living circumstances
cognitive difficulties
difficulties obtaining or organising insulin
interpersonal crises
impulsivity
difficulty tolerating thoughts or feelings associated with diabetes
suicidal intent.

These are not interchangeable.

In particular:

Insulin omission is not synonymous with suicidal behaviour.

A person may understand intellectually that omission can eventually result in DKA while having no conscious wish to die.

Equally, the absence of stated suicidal intent does not make repeated life-threatening DKA psychologically unimportant.

The task is to understand the function of the behaviour rather than infer intent from the medical consequence alone.

What should the assessment contain?

A diabetes psychiatry assessment of recurrent DKA should examine the person, their diabetes and the relationship between them.

1. Reconstruct the DKA

Begin with what actually happens.

When was insulin last taken?

Which insulin was omitted?

Was basal insulin continuing?

Was glucose being monitored?

Were ketones checked?

Was CGM connected?

Did the person recognise that they were becoming unwell?

When did they realise they needed help?

What happened next?

Who contacted emergency services?

Was there a period during which the person knew they were deteriorating but could not act?

This reconstruction is often more informative than asking simply why somebody “didn't take their insulin.”

2. Look at the pattern, not only the latest episode

Plot previous DKA episodes.

Consider:

frequency
clustering
precipitating events
relationship breakdown
changes in housing
alcohol or drug use
eating-disordered behaviour
psychiatric deterioration
disengagement from services
insulin or pump difficulties
periods of improved diabetes care.

The pattern may reveal more than any individual admission.

Ask:

What is different when DKA is not happening?

Periods of relative stability can provide important information about what protects the person.

3. Understand the diabetes

The psychiatric clinician needs sufficient diabetes knowledge to understand the behaviour being assessed.

This may include:

diabetes duration
insulin regimen
basal insulin
mealtime insulin
pump use
CGM
HbA1c trajectory
glucose patterns
previous DKA
severe hypoglycaemia
renal function
albuminuria
retinopathy
neuropathy
other complications.

This is not simply medical background.

It can change the psychiatric formulation.

Someone intermittently forgetting mealtime insulin but reliably taking basal insulin presents a different psychological and physical-risk problem from someone who repeatedly stops all insulin for several days.

4. Assess mental health broadly

Do not restrict the assessment to depression.

Consider:

Mood
Depression, hopelessness, anhedonia, loss of future orientation.

Anxiety and diabetes distress
What emotions are generated by thinking about diabetes?

Eating disorder
Is insulin being restricted because of weight or eating concerns?

Personality functioning
How does the person manage affect, relationships, crises and help-seeking?

Trauma and attachment
How are dependency, trust and care experienced?

Neurodevelopment
Could ADHD, autism or executive-function difficulties be affecting diabetes care?

Substances
Alcohol and illicit drugs may directly and indirectly increase DKA risk.

Cognition
Can the person plan, remember, organise and respond appropriately when physically unwell?

Suicide and self-harm
Assess directly rather than inferring intent from DKA.

5. Ask about the relationship with diabetes

For some people, repeated DKA cannot be understood solely through symptoms or diagnoses.

Ask:

Who or what is diabetes to you?

Where does diabetes live in your life?

How often do you think about it?

What happens when you do?

What does taking insulin mean to you?

Diabetes may be experienced as intrusive, punitive, frightening, demanding, shameful or hated.

For others it is kept largely outside awareness.

A person may spend long periods effectively not knowing that they have diabetes, psychologically if not factually.

Glucose is not checked. Insulin becomes intermittent. Appointments are avoided.

Only when physical deterioration becomes impossible to ignore does diabetes abruptly return to mind.

Understanding this oscillation between avoidance and crisis may be more clinically useful than describing the person as simply “non-adherent.”

From assessment to formulation

The formulation should connect psychological processes with diabetes behaviour and the resulting physical outcome.

For example:

Depression

↓

Reduced future orientation and self-care

↓

Basal insulin becomes inconsistent

↓

DKA

Or:

Diabetes evokes intense shame and fear

↓

Thinking about glucose becomes difficult

↓

CGM and appointments are avoided

↓

Insulin decisions become increasingly disconnected from glucose

↓

DKA

Or:

Interpersonal crisis + difficulty regulating affect

↓

Diabetes care rapidly disappears from mind

↓

Insulin omitted

↓

Physical deterioration

↓

Emergency care becomes the point at which help is finally received

The formulation asks:

What function does the current pattern serve, and what keeps it going?

That question creates possibilities for treatment.

Treatment: look for the lever

The first goal does not have to be excellent glycaemic control.

For someone experiencing repeated DKA, the initial goal may simply be:

How can we make the next DKA less likely?

The answer will differ between people.

It might involve:

making basal insulin more reliable
changing an insulin regimen
responding earlier to ketones
maintaining CGM use
treating depression
treating an eating disorder
reducing substance use
helping somebody seek help earlier
stabilising housing
involving family or carers
changing the healthcare response to crisis
establishing one reliable clinical relationship.

The most effective intervention may not be the most obvious one.

The task is to identify the lever capable of producing an appreciable change in risk.

Why psychotherapy?

Psychotherapy here does not necessarily mean offering a separate weekly course of psychotherapy.

It means approaching the clinical encounter psychotherapeutically.

What is happening emotionally?

What is happening in the relationship?

What makes help difficult to receive?

What does the clinician represent to the patient?

What happens when diabetes is discussed?

What feelings are being regulated through avoidance?

Can the clinician and patient remain curious about a dangerous behaviour without immediately turning the encounter into instruction, criticism or persuasion?

For some people, thinking about diabetes produces considerable emotional heat.

The appointment can gradually become a place where diabetes is thinkable without becoming overwhelming.

That may be a prerequisite for behavioural change.

Why continuity matters

Repeated DKA often occurs in people whose healthcare is itself fragmented.

Emergency department.

Acute medical ward.

Diabetes review.

Discharge.

Another crisis.

Another admission.

Another assessment.

A longitudinal diabetes psychiatry relationship offers something different.

The same clinician can see the person when things are going well and when they are going badly.

Patterns become visible.

Setbacks do not automatically end treatment.

The formulation can evolve.

Small changes can accumulate.

For some people, monthly contact maintained over a substantial period may achieve more than a short episode of intensive treatment that they cannot sustain.

Risk

Recurrent DKA can involve substantial risk even when suicidal intent is absent.

Assessment should consider:

current DKA risk
suicidal intent
insulin overdose
intentional insulin omission
eating-disordered behaviour
substance use
capacity
ability to seek help
previous ICU admission
speed of previous deterioration
social support
safeguarding.

Occasionally, psychiatric disorder may be sufficiently severe that mental-health legislation or capacity-based intervention needs consideration.

These decisions require individual assessment and should follow local statutory, emergency and safeguarding procedures.

What should clinicians do tomorrow?

If you work in a diabetes service and want to begin identifying this population:

1. Find out who has recurrent DKA.
Use admission data rather than relying only on referrals.

2. Start with a pragmatic threshold.
For example, identify adults with ≥2 DKA episodes within 2 years.

3. Review the pattern.
Who is returning repeatedly? How concentrated are admissions within a smaller group?

4. Offer mental-health assessment because of the DKA pattern.
Do not require the diabetes team first to prove that the problem is psychiatric.

5. Assess diabetes and mental health together.

6. Formulate the pathway into DKA.
What repeatedly happens between relative stability and admission?

7. Identify one appreciable change.
What is the smallest realistic intervention that could materially reduce risk?

8. Stay involved long enough to find out whether the formulation was right.

The central question

Recurrent DKA is a physical-health outcome.

It is also information.

It tells us that something in the current system of diabetes care is repeatedly failing.

Sometimes that failure is technical or educational.

Sometimes it is social.

Sometimes it is psychiatric.

Frequently these factors coexist.

Diabetes psychiatry treats the recurrence itself as a reason to become curious about the whole person.

Not simply: “Why did this DKA happen?”

but: