Trapped by the Arrows: Avoidant/Restrictive Food Intake Disorder and the Illusion of Control in Type 1 Diabetes Mellitus

Abstract

We present the case of a 25-year-old female patient with a 20-year history of type 1 diabetes mellitus (T1DM), who experienced recurrent episodes of shakiness, diaphoresis, and dizziness, despite normal blood glucose levels. These symptoms were attributed to changes in the direction of the arrows displayed on her continuous glucose monitoring (CGM) device. Further investigations, including capillary and venous blood glucose measurements, ruled out biochemical hypoglycemia. Psychiatric evaluation using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria excluded anorexia nervosa, bulimia nervosa, diabulimia, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and autism spectrum disorder (ASD). Upon analysis of her CGM data and clinical history, it became apparent that her restrictive eating behavior was driven by a fear of glycemic fluctuations, both hypoglycemia and hyperglycemia, rather than body image concerns. She was ultimately diagnosed with avoidant/restrictive food intake disorder (ARFID), primarily driven by worry about blood glucose instability. This case highlights the importance of distinguishing between psychological and physiological causes of glycemic fluctuations in T1DM and underscores the need for early intervention in patients with restrictive eating patterns.