20 CHILD/ADOLESCENT PSYCHIATRY NOVEMBER 2010 • CLINICAL PSYCHIATRY NEWS How to Distinguish Depression and Diabulimia BY BRUCE JANCIN tients weigh themselves often. Very of- “It’s scary, isn’t it? But don’t try to use an endocrinologist or nurse practitioner, ten. They may take issue with the accu- this information to scare the teenagers. a dietician experienced in treating pa- EXPERT ANALYSIS FROM A CONFERENCE ON THE MANAGEMENT OF DIABETES IN racy of the clinic scale, according to Ms. I’ve tried. It didn’t work,” she said. “In- tients with eating disorders, and a psy- YOUTH Shih, a registered dietician at Packard side a teenager’s mind, it’s as easy as chotherapist skilled in treating diabu- Children’s Hospital at Stanford (Calif.) 1+1=2. Insulin equals weight gain, there- limic patients. KEYSTONE, COLO. – Two common Medical Center with a practice consist- fore insulin shots equal fat shots. And no Finding such a team can be difficult. comorbidities in type 1 diabetic adoles- ing primarily of type 1 diabetic children insulin equals weight loss.” Ms. Shih has three private practice clin- cents are depression and the eating dis- and adolescents with eating disorders. Clinicians with a special interest in ics throughout the San Francisco Bay order popularly known as diabulimia. The second question to ask is, “What ED-DMT1 have adapted the DSM-IV Area, so she knows most local psy- Both feature high and upwardly trending do you think you should weigh?” The de- chotherapists. Many are comfortable hemoglobin A1c levels, often accompa- pressed patient may answer, “I don’t Diabulimic treating eating disorders. Few are com- nied by weight loss. But a couple of sim- know – whatever.” But not so with the patients weigh fortable in situations where type 1 dia- ple questions can help a clinician readily patient with diabulimia. themselves often betes is integral to the psychopathology. distinguish between the two. “The patients with eating disorders and may take Exactly the opposite is true among di- These questions probe for distortions in will always say something less than their issue with the eticians: Many are highly skilled at dia- body image and eating behavior, two current weight. They could be thin as a accuracy of the betes management but don’t have the core features of bulimia as described in rail, but they see themselves as fat,” she clinic scale. passion or background to take on youths the DSM-IV. These also are central to di- continued. with comorbid eating disorders. abulimia, but diabulimia isn’t a DSM-IV Diabulimic teens also are somewhat MS. SHIH On her Web site (www.gracenutri- diagnosis and thus does not have formal obsessive and compulsive about their tion.org), Ms. Shih is compiling a list of diagnostic criteria, Grace Shih explained eating behavior. They restrict fats and criteria for bulimia, which center on practitioners who treat diabulimia. She is at the conference, sponsored by the Uni- sweets, go on frequent diets, and often binge eating and “inappropriate com- eager to receive more recommendations versity of Colorado, Denver, and the Chil- feel guilty after eating. And they’re ex- pensatory behavior” on at least two oc- for additions to the list. dren’s Diabetes Foundation at Denver. ceptionally good at calorie counting. Ask casions per week for 3 months. This Her own treatment approach involves A couple of years ago, international a simple question like, “How many calo- compensatory behavior might be purg- taking the time to get to know the dia- experts met in Minneapolis and declared ries are there in an apple?” and the re- ing, misuse of laxatives, or excessive ex- bulimic patient and figuring out that in- the preferred term for diabulimia is “eat- sponse might be, “How big is the diam- ercise, but in diabulimic patients it takes dividual’s potential motivator for ing disorder in diabetes mellitus type 1,” eter of the apple?” the form of a greater than 25% reduction change. To the young person who is an abbreviated ED-DMT1. However, “dia- Depressed diabetic teens, on the oth- in insulin dose for more than 3 months academic overachiever eager to get into bulimia” has caught on with patients, er hand, will often eat anything, but in for the purpose of weight loss. a top university, Ms. Shih might point out families, and the mass media, and Ms. very small quantities. “A bite of chips, a If a patient’s blood glucose is in excess that taking her insulin as directed would Shih generally stuck with that term in bite of hamburger, a bite of chocolate – of 250 mg/dL, the weight loss can be sig- bring more energy, a better attention her presentation. Also, because the that’s how they eat,” Ms. Shih said. nificant, since the renal threshold for span, fewer headaches – and better male:female ratio in diabulimia is 1:10, Roughly 25% of adolescents with type glucose is 160-180 mg/dL. grades. For the athlete, the appeal might the same as in patients with DSM-IV eat- 1 diabetes have comorbid depression. Ms. Shih cautioned that teens often be the prospect of loss of lean body ing disorders, Ms. Shih often used “she” The prevalence of ED-DMT1 is 11%- cheat on their blood glucose records to mass because of uncontrolled diabetes. in referring to diabulimic teens. 30%, depending on the study. hide the fact that they’re not taking in- To the patient with blurred vision The first question to ask a type 1 dia- Diabulimia has serious health conse- sulin. They may provide recordings of di- caused by swelling of the lens because of betic adolescent to learn whether she has quences. Japanese investigators reported lute orange juice or dog’s blood, but the osmotic changes induced by very high a distorted body image is, “How much that a cohort of type 1 diabetic patients most common way to cheat is to poke a blood glucose levels, it might be the ar- do you weigh?” The clinician already took an average of 11.5 and 15.9 years to finger and take a blood sample while gument that her eyesight changes, unlike knows the answer, of course: It’s right develop simple and advanced retinopa- running the finger under the faucet. retinopathy, are reversible with improved there in the front of the chart. The ques- thy, compared with 3.4 and 7.6 years, re- “This is not a group of bad kids,” she diabetes control. tion’s real purpose is to gain insight into spectively, in diabulimic patients. Time to stressed. “This is a group of very smart kids. “Most of these patients don’t take in- the patient’s perception of her weight. diagnosis of nephropathy averaged 15.1 They are just too smart for their own good.” sulin at all, so set small goals and start A depressed diabetic teen will often an- years in type 1 diabetic patients without Once a clinician suspects a patient has slow,” the dietician advised. swer, “I don’t know my weight, and I diabulimia vs. 6.6 years in those with the diabulimia, it’s time to get skilled pro- Ms. Shih disclosed having no conflicts don’t care.” In contrast, diabulimic pa- eating disorder. fessional help from a team consisting of of interest. ■ Regular Bedtimes Linked to Better Developmental Outcomes BY BRUCE JANCIN tion, and emotional development at age 4 years, along Major Finding: Earlier bedtime predicted signifi- with parental phone interviews conducted when the FROM THE ANNUAL MEETING OF THE ASSOCIATED cantly higher scores at age 4 years on receptive PROFESSIONAL SLEEP SOCIETIES children were aged 9 months and again at 4 years. language, literacy, phonologic awareness, and Among the key findings: early math, but not expressive language. SAN ANTONIO – Parental emphasis on a consistent Ǡ Three-quarters of children went to bed between 8 VITALS bedtime emerged as the strongest predictor of favor- Data Source: An analysis of 8,000 children from and 10 p.m., 22% had a bedtime of 10 p.m. or later, and able developmental outcomes at 4 years of age in an the landmark Department of Education–spon- 3% regularly hit the sack before 8 p.m. sored Early Childhood Longitudinal Study–Birth Ǡ 8,000-child study. Cohort. Sixty percent of children woke up between 7 and 9 “Getting parents to set bedtime routines can be an a.m. Thirty-two percent regularly awakened before 7 important way to make a significant impact on chil- Disclosures: Dr. Gaylor reported having no finan- a.m. cial conflicts in connection with the study. dren’s emergent literacy and language skills. Pediatri- Ǡ Children from higher socioeconomic status house- cians can easily promote regular bedtimes with parents holds went to bed significantly earlier and were 36% and children, behaviors which in turn lead to healthy Of note, the average nighttime sleep duration of the more likely to have a rule about bedtime. sleep,” Erika E. Gaylor, Ph.D., said at the meeting. preschoolers included in this analysis from the land- Ǡ African American children went to bed an average Preschoolers who averaged fewer than the 11-12 mark Department of Education–sponsored Early Child- of a quarter hour later than did white children and slept hours of total sleep per 24-hour cycle, recommended hood Longitudinal Study–Birth Cohort was 10.5 hours. significantly less during the night. in guidelines by the American Academy of Sleep And since other studies have shown only one-quarter Ǡ Earlier bedtime predicted significantly higher scores Medicine and other major groups, had significantly of 4-year-olds still take a daytime nap, that means at age 4 years on receptive language, literacy, phono- lower test scores on language, early math, and litera- most U.S.