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11/13/24, 8\:09 PM Guide | Eating disorder history

Eating disorder history

Table of contents

Introduction

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.
Con
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 o
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Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next
Summarising at regular intervals

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation\:
" O k , s o y o u’ v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u’ d l i k e t o a d d r e s s . A s t h e r e m a y n o t b e t i m e t o a d d r e s s
t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o d e a l
w i t h t o d a y . I’ l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a gr e e o n w h a t t h e f o c u s o f t o d a y’ s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
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 di

History of presenting complaint

When taking an eating disorder history, it is important to explore the patient's weight history, eating behaviours, adaptive
behaviours, physical symptoms (including asking about red

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 di
“ T a l k t o m e a b o u t y o u r w e i g h t d u r i n g y o u r c h i l d h o o d / t e e n a ge / a d u l t y e a r s”
“ W a s t h e r e a t i m e i n y o u r l i f e w h e n y o u r w e i gh t c h a n ge d d r a s t i c a l l y ?”
L – Were there any periods of weight LOSS?\:
“ H a v e y o u h a d a n y p e r i o d s o f e x c e s s i v e o r r a p i d w e i gh t l o s s ?”
“ H a v e y o u n o t i c e d a n y t r i g g e r s f o r a n y w e i gh t l o s s / g a i n i n y o u r l i f e ?”
I – What is their IDEAL weight?\:
“ T a l k t o m e a b o u t a t i m e w h e n y o u w e r e m o s t h a p p y / s a d w i t h y o u r w e i gh t ?”
“ H o w d o y o u c u r r e n t l y f e e l a b o u t y o u r w e i gh t ?”
“ W o u l d y o u l i k e t o c h a n g e y o u r c u r r e n t w e i gh t ?”
“ W h a t d o y o u t h i n k a h e a l t h y w e i g h t w o u l d b e f o r y o u ? ... M – What were their MINIMUM and MAXIMUM weights?\:
H o w w o u l d y o u f e e l i f y o u w e r e t h a t w e i g h t ?”
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“ W h a t w a s y o u r m i n i m u m / m a x i m u m w e i g h t ?”
“ H o w h a s y o u r w e i g h t c h a n g e d i n t h e l a s t o n e w e e k / m o n t h / y e a r ?”

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\:
“ W h a t w o u l d a t y p i c a l d a y’ s f o o d i n t a k e l o o k l i k e f o r y o u ?”
“ D o y o u t h i n k t h a t y o u r e a t i n g h a b i t s a r e s i m i l a r t o y o u r f r i e n d s a n d f a m i l i e s ?”
“ H a s a n y o n e e x p r e s s e d t h e y a r e c o n c e r n e d a b o u t t h e a m o u n t y o u a r e e a t i n g?”

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
e
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
is also important to exclude other dicoeliac disease.
Red
Rapid weight loss
Heart rate \<40
Signi
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\:
“ H o w d o y o u f e e l y o u r m o o d i s a t t h e m o m e n t ? D o y o u e v e r h a v e p e r i o d s o f v e r y l o w o r v e r y h i gh m o o d s ?”
“ H a v e y o u e v e r e x p e r i e n c e d a n y s y m p t o m s o f a n x i e t y o r p a n i c a t t a c k s ?”
“ D o y o u e v e r e x p e r i e n c e o b s e s s i v e o r c o m p u l s i v e t h o u g h t s ?”
“ D o y o u e v e r t h i n k a b o u t h u r t i n g y o u r s e l f o r o t h e r s ? H a v e y o u m a d e a n y p l a n s t o d o t h i s ? W h a t w o u l d s t o p y o u f r o m d o i n g
t h i s ?”
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 ideas, concerns 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.
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The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-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\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t i s i t t h a t y o u a r e m o s t c o n c e r n e d a b o u t w i t h r e ga r d t o y o u r e a t i n g a n d w e i gh t ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

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 di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A 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, re
Genitourinary\: changes to urinary frequency, changes to or absence of menstruation
Miscellaneous\: hair loss or growth, dry skin, lethargy
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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
in
Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
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
anaphylaxis).
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

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\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
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 e
“ H a v e y o u n o t i c e d a n y s i d e e

Family history

Ask the patient if there is any family history of psychiatric disease in
“ H a v e a n y o f y o u r p a r e n t s o r s i b l i n g s h a d p r o b l e m s w i t h t h e i r m e n t a l h e a l t h i n t h e p a s t ?”
“ D o y o u k n o w w h a t t y p e o f m e n t a l h e a l t h p r o b l e m s t h e y h a d ?”
It is also important to ask about a family history of gastrointestinal disease (e.g. in
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 su
disorder.
This can help you understand triggers, coping mechanisms and how they deal with stress. You should ask about stress,
alcohol, smoking, drugs, ca
taking a thorough social history allows the identisocial risk factors for suicide.
General social context
Explore the patient’s general social context including\:
“ A r e y o u f e e l i n g p a r t i c u l a r l y s t r e s s e d a t t h e m o m e n t i n a n y a r e a o f y o u r l i f e ?” ( s c h o o l , w o r k , “ H o w a r e y o u r e a t i n g h a b i t s i m p a c t i n g y o u r f a m i l y / r e l a t i o n s h i p / f r i e n d s ?”
“ H a s a n y o n e e l s e c o m m e n t e d o n y o u r m o o d o r b e h a v i o u r s r e c e n t l y ?”
“ H a v e y o u s p o k e n a b o u t y o u r c o n c e r n s t o a n y f r i e n d s / f a m i l y / p a r t n e r ?”
h o m e )
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Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Longstanding alcohol dependency can lead to malnourishment. Folate and B12 de
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\:
“ H a v e y o u n o t i c e d a n y i m p a c t o n y o u r s c h o o l w o r k / w o r k r e c e n t l y ?”
“ A r e y o u r t e a c h e r s / c o l l e a g u e s c o n c e r n e d a b o u t y o u a t a l l ?”

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

References

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