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Diabulimia — MRCPsych Paper B MCQ

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HardChild & Adolescent PsychiatryDiabulimiaMRCPsych Paper B

A 14-year-old girl with type 1 diabetes has recurrent marked hyperglycaemia and two admissions with diabetic ketoacidosis. Her HbA1c is 98 mmol/mol and her BMI is on the 52nd centile. She reports intense fear of weight gain and intermittently restricts carbohydrates, but her dominant weight-control behaviour is deliberately withholding mealtime insulin to induce glycosuria. She reports no objective binge-eating episodes, no self-induced vomiting or laxative use, and no sensory aversion to food. Which is the most precise formulation of the principal disordered-eating pattern?

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Reveal the answer and explanation

Correct answer: D — Insulin-omission type 1 diabetes with disordered eating (“diabulimia”)

Explanation lettering: E = shown as B · B = shown as C · C = shown as D · D = shown as E

The answer is C. Deliberate restriction or omission of required insulin to lose weight through glycosuria — colloquially “diabulimia”, increasingly termed type 1 diabetes with disordered eating (T1DE) — is the defining pattern here, signalled by extreme hyperglycaemia (HbA1c 98 mmol/mol) and recurrent ketoacidosis despite a normal-centile BMI. It is a descriptive clinical phenotype, not a standalone ICD-11 or DSM-5-TR category. Anorexia nervosa (A) is excluded by the absence of significantly low body weight; bulimia nervosa (B) and binge-eating disorder (D) both require recurrent objective binge episodes, which are explicitly absent; ARFID (E) is defined by intake restriction without weight/shape concern, whereas her behaviour is driven by fear of weight gain. NICE NG69 mandates addressing insulin misuse within psychological treatment, ketone monitoring for DKA risk, and joint working between the eating disorder and diabetes teams; in this age group that means integrated paediatric diabetes and CAMHS eating-disorder care.

Reference: NICE NG69, Eating disorders: recognition and treatment — Recommendations, section 1.8 (physical/mental comorbidities: diabetes), 2017 (current edition). https://www.nice.org.uk/guidance/ng69/chapter/Recommendations