Adam Haycock and G B Ajayi describe an alarming new syndrome that affects mainly students

Definition

Educational diabetes (ED) is a syndrome of unknown aetiology characterised by deranged metabolism, altered behaviour, and the clinical features of diabetes. It is predominantly associated with any type of compulsory intellectual functioning.

Classification

ED is best described as a spectrum of disease, but it is convenient to divide it into two types, with clinical cases ranging between them.

Type 1 (non-specific ED): insidious onset in early adulthood, male>female, characterised by lethargy, somnolescence, polydipsia (particularly for caffeine or alcohol containing drinks), and polyuria (possibly secondary to increased intake).

Type 2 (exam associated ED): widely prevalent, with seasonal variation particularly in the early summer months. Female>male. Notable by florid symptoms, altered behaviour, and emotional state.

Pathogenesis

Although this disease has an as yet unknown aetiology, several predisposing factors are known. These include the following.

• Progression to further education
• Long periods of immobility, especially at or near office furniture
• Forced exposure to educational material - for example, textbooks or journals
• Abnormal attention to normally disregarded activities such as washing up

Presentation and clinical features

Presentation may be acute or chronic.

Acute presentation is unusual without previous symptoms, but may occur in type 2 in close association with impending exams. Symptoms are as for chronic ED, but they are more florid and associated with nausea, vomiting, palpitations, sweating, tremor, ataxia, and acute confusional state.

People with chronic ED commonly present by their absence from normal activities (sports, clubbing, drinking binges, etc). Pathetic excuses to avoid these--for example, "I can't come clubbing because I have to do some work"--are usually blatantly obvious, and suspicion should be raised.

Chronic ED is characterised by insidious onset of the following.

• Hyperphagia, along with increased appetite, particularly for foods with a high sugar content (chocolate, ice cream), and thirst, as for type 1. This often results in weight gain and acne vulgaris.
• Urinary symptoms are common and include polyuria, frequency, and urgency.
• Abnormal sleep patterns; these may include hypersomnia or hyposomnia, generalised somnolescence. Less common manifestations include postprandial narcolepsy and altered circadian rhythms.
• Emotional lability, with periodic episodes of depression, mania, or hysteria. Impending "feelings of doom" are often pronounced, along with perceptual abnormalities and suicidal intention.
• Compulsive mindless television watching, often degenerating into addiction. Poor prognosis is indicated by a pathological dependence on Australian soap operas.

History

A good history should be taken although particular care should be taken when inquiring about weight gain in females.

Examination

The following signs should be sought.

• General aspect: overweight with acne
• Hands: ink stained fingers, bitten nails
• "Caffeine tremor" (25 Hz)
• Face: hyperpigmentation of lower orbital epithelium
• Weakness in levator palpebrae superioris (distinguish from ptosis by bilateral involvement and reversibility on caffeine infusion)
• Cardiovascular symptom: tachycardia
• Respiratory symptom: tachypnoea
• Abdominal symptoms: decreased muscle tone, distended abdomen, masses of lard
• Central nervous system: grossly abnormal
• Mental state examination: NAD (not actually done).

Investigations

• Playstation ability: 80% sensitive, but only 30% specific (rated on levels successfully completed).
• Alcohol tolerance test: gold standard. Inverse of the time taken to neck one pint (secs ^-1)xtotal No of pints consumed in one evening.
• score 0-5.0 - diagnostic.
• score 5.1-7.0 - impaired alcohol tolerance. Repeat test in four weeks' time.
• score>7.1 - normal.
• score<3 - need to place patient on an alcohol sliding scale.

Treatment

Acute: this is a medical emergency. Immediate management should follow "ABC"

• A - Avoid mentioning work or exams
• B - Buy patient a drink
• C - Calm patient down

Then treat as chronic.

Chronic: assemble a multidisciplinary team. This should include psychologists, among them chocolate and caffeine addiction specialists, and social services for rehabilitation into normal every day life.

This condition is normally completely reversible on removal of precipitating factors such as books or exams. An effective treatment regimen entails intermittent treatment with ultraviolet light (eg resting by a pool) and light entertainment (eg 1 hour Tomb Raider). In females, retail therapy has been proved to be highly effective. Treatment should be continued until asymptomatic, usually two to three months, and then tailed off slowly over six months to prevent relapse.

If complete respite is not possible, the aim of treatment is to prevent any further deterioration. Close support should be given from educational services in the form of prepared revision notes and preferably model answers for any upcoming examination questions. Social services can assist by providing helpers to perform daily chores that may tax the patient--for example, cooking and cleaning.

Complications

The most commn complications are:

• Acopia: extreme emotional lability resulting in excess lacrimation, with associated postnasal drip, or catatonic withdrawal (may result in acute CA--see below)
• Amicopenia aka Norman no-mates syndrome: inevitable progression occurs if untreated.
• Acute career arrest (CA):this is a medical emergency--remove to suitable area for ultrarapid tox and follow up career rehabilitation programme.

Prognosis

Poor relapsing and remitting course until private practice attained.