Severe Hypoglycaemia Mistaken for Conversion Disorder

A 2025 case report in Clinical Case Reports describes a 17-year-old girl with type 1 diabetes who developed episodes of abnormal behaviour and unusual movements. She was initially given a preliminary diagnosis of conversion disorder. Severe hypoglycaemia was later found during the episodes, and the conversion diagnosis was dropped.

She had been diagnosed with type 1 diabetes about five months earlier and was using regular insulin and NPH insulin. Ten days before presenting to psychiatry, she began having episodes in the early morning involving agitation, shouting and what the authors described as bizarre motor activity. They lasted several minutes, without loss of consciousness or convulsions, and tended to improve after breakfast.

Systemic and neurological examinations were unremarkable. Renal, liver and thyroid function tests were also within normal limits. During psychiatric assessment, depressive symptoms were identified. She was struggling with her recent diabetes diagnosis, and her parents were having marital difficulties.

The authors describe how this background influenced the diagnosis:

“Given the stress of managing her diabetes and the recent marital issues involving her parents, she was given a preliminary diagnosis of conversion disorder for her new onset bizarre behavior.”

She was also diagnosed with major depressive disorder and started on fluoxetine 20 mg daily, with psychotherapy planned. The episodes then increased from about one or two per week to almost daily.

Glucose during the attacks

Her caregivers eventually checked her blood glucose during an episode. It was 36 mg/dL. They gave her sugar and honey, and the symptoms rapidly improved as her glucose rose.

A few days later she had another episode. Her glucose was 24 mg/dL. Again, the abnormal behaviour improved after the hypoglycaemia was corrected.

The diabetes clinic attributed the episodes to hypoglycaemia and reduced her insulin dose by 15%. Her caregivers were instructed to give rapidly absorbed carbohydrate if another episode occurred.

Psychiatry then withdrew the conversion diagnosis:

“At the psychiatry clinic, the diagnosis of conversion disorder was dropped...”

Fluoxetine was also stopped. The original report discusses the possibility that fluoxetine contributed to the increase in hypoglycaemic episodes, although this was not established.

What the authors concluded

The case report is explicit about the eventual explanation:

“Hypoglycemia was the cause of the bizarre behaviors.”

There was more than a single low glucose reading. Values of 36 mg/dL and 24 mg/dL were recorded during separate attacks, and the symptoms improved when the hypoglycaemia was treated. During more than a year of follow-up without further hypoglycaemia, the reported psychiatric symptoms did not recur.

Why wasn't hypoglycaemia considered earlier?

The patient already had type 1 diabetes and was taking insulin. Her episodes occurred in the early morning and improved after breakfast. However, glucose had not initially been measured during the attacks. The report also notes limited access to glucose test strips.

The authors themselves address why the symptoms were initially interpreted differently:

“At the psychiatry clinic, hypoglycemia was not considered as the cause of the psychiatric symptoms because of the presence of multiple stressors that could explain her symptoms, which were initially attributed to conversion disorder.”

Once glucose was checked during the episodes, severe hypoglycaemia was documented twice. Treating it improved the symptoms, the insulin regimen was adjusted and the conversion diagnosis was withdrawn.

A 2026 response: anchoring and premature closure

The case prompted a published response in Clinical Case Reports in 2026. Chukwuka Elendu and Excel Victor-Anozie focused specifically on the diagnostic process and raised the possibility that the patient's recent diabetes diagnosis and family circumstances had contributed to diagnostic anchoring and premature closure.

“factors such as recent diagnosis and family stress may have contributed to diagnostic anchoring and premature closure”

They questioned why hypoglycaemia had not initially been considered in a patient with known type 1 diabetes and argued for point-of-care glucose testing when patients with diabetes present with acute behavioural or neuropsychiatric changes.

The letter also points to practical factors surrounding the case: limited glucose monitoring, fragmented care, delayed insulin adjustment and the use of NPH insulin, which carries a risk of nocturnal hypoglycaemia.

On fluoxetine, the letter is more cautious than the original report. The increase in episodes followed the start of fluoxetine, but timing alone could not establish that the drug caused the worsening hypoglycaemia.

The eventual explanation was metabolic

There was no later diagnosis of epilepsy, multiple sclerosis, Parkinson's disease or another neurological disorder. The episodes were attributed to severe hypoglycaemia in a patient receiving insulin for type 1 diabetes.

That makes this case different from many of the diagnostic cases covered here. The alternative to conversion disorder was not another neurological disease. A metabolic abnormality was producing behavioural and movement symptoms, and it was demonstrated by checking glucose while the symptoms were happening.

A separate case involving severe hypoglycaemia

We have covered another, unrelated case in which severe hypoglycaemia was discovered after an FND diagnosis. Mikayla Perks: When an FND Diagnosis Preceded the Discovery of Severe Hypoglycaemia concerns an Australian teenager whose seizure-like episodes had been diagnosed as FND before severe hypoglycaemia was subsequently identified.

The two cases come from different sources and should be read separately. What they share is straightforward: severe hypoglycaemia was identified only after symptoms had already been interpreted as functional. In the 2025 case, glucose was measured during two attacks, the symptoms improved after glucose correction, and the treating team explicitly withdrew the conversion diagnosis.

Sources

Shibeshi MS, Tolcha AG, Zerihun T. Psychiatric Manifestations of Hypoglycemia in an Adolescent: A Case Report. Clinical Case Reports. 2025.
Elendu C, Victor-Anozie E. Response to the case report. Clinical Case Reports. 2026.