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Multidisciplinary Treatment and ED-DMT1: Recovery from Diabulimia

The mental health disorder known to doctors and therapists as ED-DMT1 (Eating Disorder-Diabetes Mellitus Type 1), and to most laypeople as “diabulimia,” is a severe form of eating/weight disorder that affects people with Type 1 diabetes. Because it can only affect those who require insulin to control their diabetes, it’s not as common as other eating disorders like Anorexia Nervosa or Binge Eating Disorder. However, the medical and psychiatric outcomes are every bit if not more severe than more frequently occurring disorders. ED-DMT1 is treatable, but it requires a highly specialized plan and a multidisciplinary team to do so.

What Is Diabetes Type 1?

Most people know someone with diabetes mellitus type 1; it’s a relatively common disease. Unlike type 2 diabetes which tends to begin later in life, and does not require insulin to manage, type 1 diabetes is normally present from a young age (and often in the same pre-teen and adolescent years when eating disorders begin. With this disease, the pancreas does not make sufficient insulin on its own. Insulin helps the body process the glucose found in food. Without insulin to help the cells absorb this sugar from foods, the sugar remains in the blood, and many serious health complications can arise.

In the long term, without managing food and insulin levels, people with diabetes type 1 face many chronic symptoms. Per the Mayo Clinic, these include:

  • Increased thirst
  • Frequent urination
  • Extreme hunger
  • Unexplained weight loss
  • Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there’s not enough available insulin)
  • Fatigue
  • Irritability
  • Blurred vision
  • Slow-healing sores
  • Frequent infections, such as gums or skin infections and vaginal infections

As regards ED-DMT1, the key symptom is “unexplained weight loss,” which we’ll come back to when we contextualize insulin use and eating disorders. However, if a person with diabetes type 1 doesn’t take insulin can experience an episode of diabetic ketoacidosis, in which the body, without enough blood sugar in the cells, begins to burn body fat. This makes the blood acidic and can put a person into a coma or cause death. People with ED-DMT1 find themselves at much higher risk of this complication.

What Is Bulimia Nervosa?

According to the DSM-V, bulimia nervosa consists of:

  1. Recurrent episodes of binge eating, as characterized by both:

    Eating, within any 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances.

    A feeling that one cannot stop eating or control what or how much one is eating.

  2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.

In slightly less clinical terms, bulimia nervosa is a mental health condition in which a person forces themselves to purge calories after binge eating episodes or meals. Most commonly, this is done through vomiting, but other methods of purging might be used. Bulimia nervosa is caused by a variety of factors, including genetic, biological, and environmental aspects that affect a person’s relationship with food and body weight. People with bulimia can range from severely underweight to overweight (or obese), but they tend to have body image distortions and/or body dysmorphic disorder.

This means that they tend to be preoccupied or obsessed with their appearance, checking the mirror compulsively, and worry about how others perceive them. Normally, there is a perceived flaw in their appearance that isn’t noticeable to others or is overblown in the person’s self-perception. Body dysmorphic disorder can drive people to take steps to “fix” their perceived flaw, whether through cosmetic procedures, makeovers and changing styles, or by using disordered eating behaviors to lose weight or prevent weight gain.

What Is ED-DMT1, or “Diabulimia?”

The term “diabulimia” is a somewhat controversial one. While ED-DMT1 is a recognized eating disorder, its acronym doesn’t really resonate with people outside the medical/psychiatric profession. Using a recognizable name for the disorder such as “diabulimia” helps raise awareness and understanding that this disorder is a thing that many people have to deal with, and is more than some kind of obscure psychiatric term. On the other hand, using “diabulimia” to describe this disorder can be misleading, especially for a person who has the disorder but is looking for ways to deny that there is a problem. By calling it “bulimia,” a person who skips insulin to lose weight might tell themselves, “Well, I don’t binge and purge, so I must not have an eating disorder.” No matter what it’s called, the disorder is extraordinarily dangerous and difficult to treat.

In cases of ED-DMT1, a person who has both type 1 diabetes and body dysmorphic disorder will skip insulin doses or reduce them in order to raise their blood sugar levels and prevent the absorption of glucose in the cells. As mentioned earlier, one of the consequences of insulin deficiency is sudden, unexplained weight loss. A person with diabulimia takes advantage of this to lose weight or prevent weight gain. Without insulin, they also binge eat without gaining weight because the food is not properly absorbed into the cells. Repeated restriction of insulin can result in all the negative physical consequences of diabetes such as vision problems, neuropathy, infections, menstrual disturbances, and especially DKA (diabetic ketoacidosis), which can result in diabetic coma or death.

ED-DMT1 does not affect people with type 2 diabetes, since that condition does not require artificial insulin, instead being treated through a nutrition and exercise regimen. However, type 2 diabetes can be caused or triggered by obesity, which can happen in people with binging-type eating disorders. Whether a person has diabetes and an eating disorder or ED-DMT1, though, treatment is complex and difficult.

Multidisciplinary Treatment Is a Must

With most eating disorders, such as anorexia nervosa or binge eating disorders, there is both a psychological and a medical component to treatment. Eating disorder treatment professionals seek to identify and remove disordered eating behaviors while at the same time restore nutritional balance and restore weight to a healthy level. However, after medically stabilizing the client, the treatment team generally focuses on psychiatric and behavioral treatments (albeit with an eye on long-term nutritional planning and rehabilitation).

With ED-DMT1, a multidisciplinary approach to treatment is necessary both in the immediate time after admitting to treatment and in the long term. In comparison to other disorders like anorexia nervosa, where weight restoration and nutritional rebalancing can alleviate most of the physical symptoms of the disorder, a person with diabulimia will continue to have type 1 diabetes and require insulin even after the disordered behaviors have been successfully eliminated.  For this reason, long after their time in a residential treatment center, ED-DMT1 patients will need a combined medical and psychiatric presence in their lives. Outpatient treatment following residential is quite common; it helps keep regular tabs on the patient’s physical condition as well as their mental state.

Many treatment programs for eating disorders condition their clients to avoid thinking about food in terms of calories (which can become objects of obsession for those compelled to lose weight), and instead ask them to think of food as nourishment or a means to satiety. Unfortunately, people with diabetes type 1 must think about caloric intake; they must closely monitor their caloric intake to maintain their blood sugar levels. This makes the common principle in eating disorder treatment of “intuitive eating” without regard for weight gain or loss impracticable in people with ED-DMT1. Instead, the psychological treatment methods used to promote intuitive eating in other cases are more likely to address a client’s emotional response to insulin rather than food. Combined with cognitive retraining techniques like CBT and DBT that help address body image disorders, long-term recovery is possible.

Get Help As Soon As You Can

Diabulimia can cause sudden, irreversible damage in the form of ketoacidosis, and the long-term effects can be just as dangerous. Early intervention is a key part of a successful recovery – many studies have shown that it’s easier to change disordered eating behaviors before they’ve become regular habits. If you or a loved one is showing signs of ED-DMT1, reach out today to a specialized program like Rosewoods that can provide multidisciplinary treatment for diabulimia.

Melissa Spann, PhD, LMHC, CEDS-S

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.
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