Deliberate Insulin Underdosing and Omission Should Be Included in DSM-V Criteria for Bulimia Nervosa

Abstract

An endocrinologist referred a22-year-old woman with IDDM toour psychiatry clinic because of herbulimia, anxiety, and depression. Shestarted bingeing four to five times aweek during her sophomore year ofcollege. She felt out of control anddecided to disconnect her insulinpump overnight after bingeing. Shereasoned that omitting insulin wouldcause the same weight loss she expe-rienced in high school before shewas diagnosed with IDDM. Unhook-ing her pump partially reduced heranxiety about gaining weight, buther hemoglobin A1c climbed from7% to 16%, and guilty and embar-rassed by her behavior, she avoidedher family and her endocrinologist.We diagnosed her with bulimianervosa, with disconnection of herinsulin pump counted as the “inap-propriate compensatory behavior”needed for this diagnosis. We pre-scribed both low dose clonazepam tohelp with her anxiety and poor sleepand weekly psychotherapy forbulimia and depression. Sheresponded to graduated exposuretechniques to decrease her postbingeanxiety and the frequency of discon-necting her insulin pump. Shelearned to challenge cognitive distor-tions (e.g., that bingeing was areward and that her life was betterwhen she was thinner). During ther-apy, she practiced telling her familyand friends about her disorder, andher guilt, isolation, and anxietydeclined quickly after she shared her“secret” with them. She stopped dis-connecting her insulin pumpalthough she still has occasionalthoughts of restarting her diabulimicbehavior. Her mood was stable andeuthymic at her 3- and 6-month fol-low-up appointments. She has kepther regular appointments with usand with her endocrinologist, andher hemoglobin A1c has steadilyimproved.