Bulimia Nervosa: Vomiting Presentation (NEW)

MLACases

[Psychiatry > Eating Disorders]

Bulimia Nervosa: Vomiting Presentation (NEW)


Task


Where you are: 

FY2 doctor in the GP surgery. 

Who the patient is: 

Emily Stratford is a 16-year-old who has been vomiting. Her mother, Liz Stratford has made a telephone / video appointment for you to speak to the daughter. The mother has some concerns.

Other information you have about the patient:

None.

What you must do:

Talk to the patient and discuss management.  


Patient Information


  • You are Emily Stratford, 16 years old. 
  • You have been vomiting for 8 months. Your mother saw you vomiting this morning, which prompted her to make a telephone / video appointment for you to speak to the doctor. 
  • When asked why you vomit, you explain that you make yourself vomit using your fingers because you think you are fat. You usually do this after losing control of how much you eat. You have been binging and inducing vomiting at least two or three times per week for the past 8 months. You only volunteer this information if the doctor makes you feel comfortable and approaches the topic sensitively.
  • You eat salad for breakfast, lunch and dinner. But sometimes when hungry you lose self-control and eat very large amounts of junk food.
  • When asked about role models, you describe a female friend at school who gets all the attention from boys because she is the thinnest in the class. 
  • You avoid going to the gym to exercise because you feel self-conscious about your weight.
  • When asked, you do not consider it a problem that a healthcare professional can help you with and you do not think you have an eating disorder.

Data Gathering


  • GRIPS 2
    • I understand that your mother had some concerns... Can you take me through what’s been happening recently?
  • Open Questions
    • Tell me more about this vomiting...
    • Take me through what happens exactly...

Note:

A non-judgemental tone is important when trying to extract sensitive information from a patient. Remember that you are talking to a vulnerable young person so do make sure your vocal tone reflects this. Be friendly, gentle and non-intimidating. This is particularly important for male doctors.


  • Explore Vomiting (briefly)
    • When did it start?
    • FODIPARA – remember to ask precipitating factor: Is there anything you can think of that might be causing you to vomit? 
  • Differential Diagnosis (just a few)
    • Gastroenteritis - fever, diarrhoea, tummy pain
    • Pregnancy - exclude by asking LMP (later)
    • Migraine - headache, aura, shyness to light and sound
    • DKA - excessive thirst and urination, weight loss, tummy pain
    • Bulimia Nervosa - ask sensitively by depersonalising the question and then bringing it back to the patient, for example:
      • Sometimes... after having a large meal, some people can feel uncomfortably full or have feelings of guilt or shame, which can lead them to make themselves sick to get rid of that uncomfortable feeling. I was wondering if by any chance you’ve ever experienced anything similar to this?

Note:

From here you can transition into completing the rest of the SCOFF screening questionnaire. 


  • SCOFF Questionnaire - Two or more positive answers to the following questions are suggestive of anorexia nervosa or bulimia nervosa and so proceed with full Eating Disorder History.
    • Sick - Ever make yourself Sick because you feel uncomfortably full or because of feelings of guilt or shame (if not already asked)
    • Control - Ever lost Control of how much you eat?
    • One Stone - Have you recently lost more than One stone in a 3-month period? (1 stone = 6.35kg)
    • Fat Do you believe you are Fat when others think you are thin?
    • Food - Would you say that Food dominates your life?

Note:

A binge is defined as consuming an excessive amount of food in a discreet time period accompanied by a sense of loss of control and overeating at that time.

Compensatory behaviours include vomiting, purging, fasting, excessive exercise, laxative, diuretic, diet pill use or insulin use in diabetic patients. 

In bulimia nervosa both binge eating and compensatory behaviours occur each on average at least once a week for 3 months.

Unlike anorexia nervosa, bulimics may have weight within normal limits or above weight range for age and so may be kept secret for many years.


  • Eating Disorder History :-  
    • Weight – How do you feel about your weight? Do you know how much you weigh at the moment? How often do you weigh yourself? What’s your ideal bodyweight?
    • Diet & Exercise Talk me through your diet (breakfast, lunch, dinner), are you physically active? How often? 
    • Body image / dysmorphiaWhat do you see when you look in the mirror? Do you like what you see?
    • Role models for body weight and shape Is there anyone that you aspire to look like or consider to have the perfect body?
    • Bulimia specific:-
        • Binge eating (“binges”)since when? how many times per week? alone or groups?
        • Compensatory mechanisms (“purges”)
          • Self-induced vomitinghow many times per week?
          • Others – e.g. laxatives, over-exercising – how many times per week?
    • Psychological features :-
      • Guilt, fear of gaining weight, anxiety/depression.
      • Red flags 🚩 (requiring emergency psychiatric admission):-
        • Suicidal thoughts / attempts
        • Deliberate Self-harm – often by cutting or scratching. 
    • Physical features :-
      • Fatigue, constipation, reflux, hair loss, and amenorrhoea.
      • Red flags 🚩 (requiring emergency medical admission):-
        • Syncope (“faints”), pre-syncope (“feeling faint / blackouts / dizziness / funny turns”), palpitations (“heart racing”), or severe abdominal pain.

Note:

Screen for some co-existing mental health problems, as these are often associated with eating disorders. For example:

  • Obsessive-compulsive disorder – do you wash or clean a lot? do you check things a lot? Do your daily activities take a long time to finish?
  • Social phobia - fear of social scrutiny or embarrassment, avoidance behaviours.
  • Panic disorder - acute attacks of shortness of breath, palpitations, nausea, dizziness, and fear of impending doom.
  • Depression – low mood, anhedonia. 
  • Self-harm – often by cutting or scratching. 

  • General Health
    • 3 P's – periods, pills (contraception), partners. (NB: only ask the relevant P’s) 
      • Assess for amenorrhea (which may be clouded by use of contraceptives).
      • Assess if she has a partner / is sexually active.
    • FAMISH
      • FFamily (home, partner, children) | Friends (spoken to anyone, support network) | Finances (Work, financial difficulties or debt) | Forensics
        • Stressors at school, work or home (including the internet and social media)
      • A - Alcohol & recreational drugs
      • MMedical & psychiatric history | Drug history + Allergies | Family history
        • Medical & Psychiatric History – include screen for co-existing mental health problems.
        • Drug history - including over-the-counter. 
        • Family history - of eating disorders, depression, or substance abuse.
      • IInsight / Impact (ADLs, work).
        • Insight - In terms of help, do you think there is anything that can be done by a medical professional to help you with your situation?
        • Impact - on school performance, tiredness.
      • SStress / Sleep / Social History (independence for ADLs, Diet, Exercise)
      • H - Hallucinations & Delusions

Note:

Consider the possibility of bullying and abuse.


  • ICE – should be covered by insight.

Management


  • Provisional Diagnosis - Suspected Bulimia Nervosa 
    • Offer explanation - Is Bulimia something you’ve heard of before? Would you like me to explain it further?
      • Bulimia Nervosa (often just called Bulimia) is an eating disorder. 
      • People with bulimia nervosa have episodes of binges (uncontrolled eating) followed by purges (measures to counteract the excessive food intake such as making themselves sick, excessive exercise, deliberately fasting, or using laxatives).
      • Bulimics have a distorted view of their body and are obsessed with losing weight. It affects their ability to have a 'normal' eating pattern.
      • Bulimia is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia nervosa, you are most likely to be normal weight or overweight. If you have anorexia you tend to eat less than you need to but if you have bulimia you have times when you 'binge eat'. This is followed by times when you try to counteract the over-eating.
      • Some methods of purging such as vomiting and laxative use if prolonged can cause a chemical imbalance in the body. For example, a low potassium level may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low potassium levels can affect the heart and be life threatening.
      • Treatments include family therapies, self-help measures and psychological therapies. Many people with bulimia get better with treatment.
  • Management Plan
Key Themes (Overview):
  • Refer immediately to Children and Young People’s Mental Health (CYPMH) services (Under 18)
    • For specialist assessment and management.
  • F2F Follow-up
    • While awaiting specialist assessment (physical examination, blood tests including U&Es).
  • Advice
    • Food diary; self-help books; advice to avoid dental erosion and sexual health advice (if applicable).
  • Aftercare (FSL)
    • Regular follow ups (children should be reviewed weekly); Safety netting for physical and psychological red flags symptoms; Leaflets that are age appropriate.

Note:

  • Suspected eating disorder in Adults:
    • Specialist Eating Disorder Unit (or Community Mental Health Team (CMHT)) – depending on locality
  • Suspected eating disorder in Under 18 years:
    • Children and Young People’s Mental Health (CYPMH) services (or to a Children’s Health Team in hospital (paediatrics)).

  • Refer immediately to Children and Young People’s Mental Health (CYPMH) services (Under 18) - For specialist assessment and management.
    • What specialist will do:
      • May offer Bulimia-Nervosa-focused Family Therapy (FT-BN) - 1st line
        • People under 18 years of age will usually be offered family therapy. This involves you and your family talking to a therapist, exploring how bulimia has affected you and how your family can support you to get better. This may be offered through your local children and young people's mental health services. If family therapy is not suitable, you may be offered CBT, which will be similar to the CBT offered to adults.

Note:

Severe malnutrition and purging behaviours can lead to life-threatening complications such as cardiovascular instability or severe electrolyte disturbance (e.g. hypokalaemia).


  • F2F Follow-up - While awaiting specialist assessment (physical examination, blood tests including U&Es).
      • Physical Examination
        • Basic Observations  
          • BP (hypotension or orthostatic hypotension are red flags)
          • Pulse (bradycardia, postural tachycardia)
          • Temperature (hypothermia is a red flag)
          • Weight, Height / BMI – may be falsified. Use centile charts for persons less than 18 years of age.
        • General Physical Examination - including hands, face, mouth, heart, abdomen and Sit up–Squat–Stand (SUSS) test.
          • Possible positive findings: Russel’s sign: calluses on the knuckles where they have scraped against the teeth, teeth erosion, swollen salivary glands, mouth ulcers. SUSS score <2. 
        • Bedside tests
          • ECG and urine dipstick
      • Blood tests 
        • FBC, U&Es, LFT, glucose, calcium, magnesium, phosphate.

Note:

Those with vomiting as a compensatory behaviour should be given advice on the importance of regular dental and medical review.


  • Advice - Food diary; self-help books; advice to avoid dental erosion and sexual health advice (if applicable).
    • Food diary
    • Self-help books
    • Advice to avoid dental erosion:
      • Advise on the importance of regular dental and medical review.
      • To avoid brushing teeth immediately after vomiting as this can brush acid on to the teeth causing further damage.
      • Rinse with water or a non-acidic mouthwash after vomiting.
      • Reduce the acidity of the oral environment (for example by avoiding acidic foods and drinks). 
    • Sexual health advice
      • If sexually active, advise of the risk of unplanned pregnancy and the need for effective contraception even if they have amenorrhoea. 

Note:

Arrange regular review (frequency dependant on the clinical situation [for example, children should be reviewed weekly]). This is to monitor levels of physical and mental health risk and consider the need for urgent admission, further investigations, or increasing the urgency of the referral.

Always screen for the possibility of complications, which can be life threatening in those with eating disorders.

Ensure both the patient and family/carers have access to information and support.


  • Aftercare (FSL) - Regular follow ups (children should be reviewed weekly); Safety netting for physical and psychological red flags symptoms; Leaflets that are age appropriate.
    • Follow up – in 1 week while awaiting specialist assessment. 
    • Safety netting – for red flag symptoms (physical, psychological) - seek urgent medical attention if
      • Physical - Syncope (“faints”), pre-syncope (“feeling faint / blackouts / dizziness / funny turns”), palpitations (“heart racing”), or severe abdominal pain.
      • Psychological - thoughts of suicide or self harm.
    • Leaflet / Reading information - there are many organisations that support people with bulimia. I will leave you some reading information for you to have a read through. There are also some leaflets here targeted to close friends and family should you wish to get them involved – which of course I would encourage you to do:

Note: (NICE Clinical Knowledge Summaries)

  • Consider emergency admission for anyone at risk of serious physical or psychological complications such as:
    • Biological - Severely compromised physical health including:
      • BMI or body weight below a safe range — degree of dietary restriction and rate of weight loss is important, for example more than 1kg per week indicates high risk.
      • Cardiovascular instability for example bradycardia of 40 beats or less per minute), tachycardia on standing, prolonged QT interval on ECG, or hypotension (including postural).
      • Hypothermia.
      • Reduced muscle power on the Sit up–Squat–Stand (SUSS) test.
      • Concurrent infection.
      • Overall ill health or rapid deterioration.
      • Abnormal blood tests such as electrolyte imbalance or hypoglycaemia.
      • Risk of refeeding syndrome:
        • Risk is increased by rapid weight loss, fasting for over five days, BMI less than 16kg/m2, compensatory behaviours (such as laxative misuse or vomiting), dehydration, use of diet pills or diuretics, water loading or excessive exercise.
    • Psychological - Acute mental health risk (such as risk of suicide attempt or serious self-harm):
      • Consider psychiatric crisis care or psychiatric inpatient care – discuss with a specialist if unsure whether admission to medical/paediatric ward is more appropriate.
    • Social - Lack of support at home:
      • Consider admission if the person may not be kept from significant harm at home or where the home environment impedes recovery.


Lesson Summary

Task

16-year-old who has been vomiting for 8 months. Her mother made a video appointment for her to speak to the doctor. Emily induces vomiting once or twice a week using her fingers because she thinks she is fat. She feels self-conscious about her weight. She does not consider it a problem a healthcare professional can help with.

Approach

  1. History of vomiting
  2. DDs of vomiting, including eating disorder screening (SCOFF)
  3. Eating disorder history (weight, diet/exercise, body image, role models, Bulimia specific questions)
  4. Screening for co-existing mental health problems e.g. OCD
  5. General health & psychosocial history
    1. Women's health
    2. FAMISH (School, Bullying, Alcohol & Drugs, PMAF, Impact, Insight)
    3. ICE
  6. Provisional diagnosis
    1. Bulimia nervosa
    2. Offer explanation
  7. Management
    1. Simultaneous referral to the Eating Disorder Unit and Child and Adolescent Mental Health Services (CAMHS)
    2. Face-to-face follow-up while waiting for a specialist assessment.
      1. Clinical examination (BP, Weight & BMI, GPE, SUSS)
      2. Blood tests
    3. Specialist: Bulimia-nervosa-focused family therapy (FT-BN) 1st line
    4. Advice
      1. Food diary
      2. Self-help books
      3. Dental care.
      4. Sexual health advice (if applicable)
    5. Aftercare
      1. F2F Follow-up in 2 weeks
      2. Safety netting for red flag symptoms.
      3. Leaflet

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