Eating Disorder in a Teenage Girl (Bulimia Nervosa)

Summary:

This scenario involves a teenage girl with bulimia nervosa, a serious eating disorder characterized by binge eating followed by purging (vomiting). The patient does not recognize the severity of her condition and sees it as something normal among her peers. The goal is to identify the condition, communicate its seriousness effectively, and manage both the physical and mental health aspects.

Key Points:

1. Mental Health (Eating Disorder - Bulimia Nervosa)

• Lack of Insight: Teenagers often do not realize the harm caused by their behavior (e.g., vomiting) and may downplay it, seeing it as a common practice.

• Patient's Perspective: They may feel accused and misunderstood, believing that others do the same thing and questioning why they are being singled out.

2. Medical Risks

• Electrolyte Imbalance: Vomiting can lead to severe electrolyte disturbances (e.g., low sodium and potassium levels) which may result in life-threatening conditions like cardiac arrhythmias.

• Weight Loss: Significant weight loss (e.g., losing one stone in three months) can indicate severe health deterioration, affecting metabolism and overall health.

3. Mood and Mental Health

• Depressive Symptoms: Exploration of mood is important, including checking for signs of depression (anhedonia, low mood) and self-harm risk.

Important Considerations:

• Communicating Risks: It’s essential to communicate the life-threatening dangers of vomiting in a clear and stern way, emphasizing the disruption of normal body processes and potential cardiac risks.

• Understanding the Patient: The patient’s sense of normality around her behavior must be acknowledged, but the consequences need to be explained in terms she understands.

• Exploring Psychosocial Factors: Ask about exercise habits, weight perception, and other psychosocial aspects, including family support and any potential external pressures.

Diagnostic Approach:

1. Data Gathering:

   • SCOFF Questionnaire: Use this tool to identify eating disorders, but avoid overusing once you’ve gathered enough data (2 or more positive answers suggest a likely eating disorder).

   • Explore Other Symptoms: Investigate mood, excessive exercise, and weight loss.

   • Psychosocial History: Include questions about home life, family support, and any external stressors or abuse.

2. Physical and Medical History:

   • Focus on changes in weight, menstrual history (to check for amenorrhea), and any physical signs of malnutrition or electrolyte imbalance.

Management:

• Referral to Specialist Services:

  • Eating Disorders Unit: Immediate referral to a specialized unit for further management.

  • CAMHS (Child and Adolescent Mental Health Services): Since the patient is an adolescent, timely mental health intervention is critical.

• Call her into the hospital to do Investigations:

  • Blood tests to assess electrolyte levels, kidney function, and overall health.

  • Monitor for signs of dehydration or metabolic alkalosis due to vomiting.

• Follow-Up Plan:

  • Arrange for frequent follow-ups to monitor weight, mood, and response to treatment.

  • Ensure a multidisciplinary approach involving dieticians, psychologists, and mental health specialists.

Communication Skills:

• Building Rapport: Engage with empathy and avoid judgmental language. Teenagers often feel defensive; acknowledging their perspective before explaining the risks can improve communication.

• Breaking Bad News: Disclose the diagnosis (bulimia nervosa) in layers, starting with the physical impact (e.g., weight loss) and moving toward the mental health aspect (eating disorder).

• Clarifying the Diagnosis: Use simple, non-medical language to explain that bulimia is a psychiatric disorder and how it affects their health.

• Reassurance and Support: Highlight that treatment is available and the goal is to prevent long-term damage. Mention specific support resources like eating disorder clinics.

Ethical Considerations:

• Confidentiality: As the patient is 16, respect her confidentiality but seek consent to involve her parents, especially since they arranged the appointment.

• Safeguarding: Ensure that the patient is safe, both physically and emotionally, at home and in other environments.

• Informed Consent: For adolescents, it is crucial to obtain consent for further investigations and referrals, balancing the patient's autonomy with parental involvement.

Additional Resources:

• GMC Guidelines on Good Medical Practice: For maintaining professional standards and ensuring patient safety​.

• NHS Guidelines on Managing Eating Disorders: Evidence-based practices for referral to mental health services and eating disorder clinics.

• PLAB 2 Examiner Tips: Ensuring communication is natural and focused on the patient's needs​​.