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Taking an Eating Disorder History – OSCE Guide

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The ability to take a history from a patient presenting with a suspected eating disorder is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking an eating disorder history in an OSCE setting.


Background

Eating disorders are mental health conditions in which the person uses the control of food to cope with feelings and/or other situations. This usually involves eating too little or too much, purging behaviours or worrying excessively about body weight or shape.

The three most common eating disorders are:

  • Anorexia nervosa: an eating disorder characterised by weight loss, inability to maintain appropriate body weight for age/height and often associated with distorted body image. It generally involves the restricting of calories and sometimes also involves excessive (and compulsive) exercise and purging.
  • Bulimia: often involves bingeing and then purging. People with bulimia often make themselves sick or take medications such as laxatives or diuretics to help them get rid of calories.
  • Binge eating disorder: involves eating excessive amounts of food in a short period and then having feelings of guilt and upset.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal
  • Active listening: through body language and your verbal responses to what the patient has said
  • An appropriate level of eye contact throughout the consultation
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
  • Making sure not to interrupt the patient throughout the consultation
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat)
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next
  • Summarising at regular intervals
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”
  • “Can you explain what that pain was like?”

Once the patient has finished speaking, it is helpful to check if there are any other issues. If the patient has multiple presenting complaints, work with them to establish a shared agenda for the rest of the consultation:

  • “Ok, so you’ve mentioned that you have three problems today that you’d like to address. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

When taking an eating disorder history, it is important to explore the patient’s weight historyeating behavioursadaptive behavioursphysical symptoms (including asking about red flags) and psychological symptoms

Weight history

It is important to establish a history of any weight changes. The SLIM mnemonic can be used to structure these questions.

S – What was their weight at different STAGES of life?:

  • “Talk to me about your weight during your childhood/teenage/adult years”
  • “Was there a time in your life when your weight changed drastically?”

L – Were there any periods of weight LOSS?:

  • “Have you had any periods of excessive or rapid weight loss?”
  • “Have you noticed any triggers for any weight loss/gain in your life?”

I – What is their IDEAL weight?:

  • “Talk to me about a time when you were most happy/sad with your weight?”
  • “How do you currently feel about your weight?”
  • “Would you like to change your current weight?”
  • “What do you think a healthy weight would be for you?… How would you feel if you were that weight?”

M – What were their MINIMUM and MAXIMUM weights?:

  • “What was your minimum/maximum weight?”
  • “How has your weight changed in the last one week/month/year?”

Eating behaviours

Establish what would be a normal day for them and what their beliefs around eating are. It is also helpful to understand if they believe they have a problem:

  • “What would a typical day’s food intake look like for you?”
  • “Do you think that your eating habits are similar to your friends and families?”
  • “Has anyone expressed they are concerned about the amount you are eating?”

Adaptive behaviours

Ask about any adaptive behaviours such as excessive exercise or purging related to their eating habits:

  • Exercise: establish how much exercise and what kind of exercise they are doing. Explore their motivation for exercise and its effect on their calorie intake.
  • Purging: establish if they are undertaking any purging rituals such as vomiting or medication use. It is important here to consider the misuse of insulin if they are diabetic.
  • Binge eating: establish if they binge eat, if they have triggers for this and how it makes them feel afterwards.

Physical symptoms

Asking about physical symptoms will help you establish if there are red flags indicating hospital admission may be required. It is also important to exclude other differential diagnoses for weight loss such as inflammatory bowel disease or coeliac disease.

Red flag features
  • Rapid weight loss 
  • Heart rate <40
  • Significant orthostatic changes in systolic BP (>20 mmHg) 
  • History of recurrent syncope
  • ECG abnormalities (prolonged QTc, arrhythmias, signs of electrolyte abnormalities)
  • Fluid refusal or signs of severe dehydration (reduced urine output, tachypnoea, tachycardia, reduced skin turgor, sunken eyes)
  • Low temperature (hypothermia)
  • Signs of electrolyte disturbance
  • Unable to stand up from squatting or sit up from laying (SUSS test)

Psychological symptoms

Mood disorders and social withdrawal are commonly associated with eating disorders. Approximately 20% of deaths in people with anorexia nervosa are due to suicide. It is important to assess this risk as part of your history taking:

  • “How do you feel your mood is at the moment? Do you ever have periods of very low or very high moods?”
  • “Have you ever experienced any symptoms of anxiety or panic attacks?”
  • “Do you ever experience obsessive or compulsive thoughts?”
  • “Do you ever think about hurting yourself or others? Have you made any plans to do this? What would stop you from doing this?”

For more information, see the Geeky Medics guide to suicide risk assessment.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideasconcerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. 

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more naturalpatient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • What is it that you are most concerned about with regard to your eating and weight?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far“Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next“Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Neurological: memory, concentration, numbness or weakness in limbs, dizziness on sitting to standing
  • Respiratory: shortness of breath particularly on exercise
  • Cardiovascular: palpitations or chest pain
  • Gastrointestinal: changes to bowel habits, abdominal pain, reflux, bloating
  • Genitourinary: changes to urinary frequency, changes to or absence of menstruation
  • Miscellaneous: hair loss or growth, dry skin, lethargy

Past medical history

It is important to know if the patient has been previously admitted to hospital or engaged with an eating disorder service previously. Similarly, you should ask about other health conditions that may be contributing to weight loss (such as inflammatory bowel disease or coeliac disease), as well as allergies that could affect their eating.

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


Drug history

It is important to establish if they are taking any laxatives, weight loss pills or diuretics either over the counter or sourced elsewhere. 

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Family history

Ask the patient if there is any family history of psychiatric disease in first-degree relatives:

  • “Have any of your parents or siblings had problems with their mental health in the past?”
  • “Do you know what type of mental health problems they had?”

It is also important to ask about a family history of gastrointestinal disease (e.g. inflammatory bowel disease, coeliac disease) when considering other causes of weight loss. 

It may be useful to draw a genogram displaying this information.


Social history

Taking a comprehensive social history is particularly important in the context of a person suffering from a suspected eating disorder.

This can help you understand triggers, coping mechanisms and how they deal with stress. You should ask about stress, alcohol, smoking, drugs, caffeine use and support networks. Assess the impact of their eating habits on their life. In addition, taking a thorough social history allows the identification of social risk factors for suicide.

General social context

Explore the patient’s general social context including:

  • “Are you feeling particularly stressed at the moment in any area of your life?” (school, work, home)
  • “How are your eating habits impacting your family/relationship/friends?”
  • “Has anyone else commented on your mood or behaviours recently?”
  • “Have you spoken about your concerns to any friends/family/partner?”

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

Longstanding alcohol dependency can lead to malnourishment. Folate and B12 deficiency may consequently develop. 

See our alcohol history taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

Occupation

Assess the impact of the patient’s symptoms on their ability to attend work or school:

  • “Have you noticed any impact on your school work/work recently?”
  • “Are your teachers/colleagues concerned about you at all?”

Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr I Rodd

Paediatric Consultant

Royal Hampshire County Hospital


Editor

Dr Chris Jefferies


References

  • NICE Clinical Knowledge Summary. Eating Disorders. Available from: [LINK]
  • Royal College of Psychiatrists. Medical Emergencies in Eating Disorders (MEED). Available from: [LINK]

 

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