Abstract
You have been asked to meet with Mrs Jane Belfield, the mother of 18-year-old Ruby. You recently assessed Ruby in the outpatient clinic following a GP referral for a possible eating disorder.
Practice Stations
Station 11.1: Anorexia Nervosa Explanation
Station 11.2: Anorexia Nervosa
Station 11.3: Re-feeding Syndrome
Station 11.4: Bulimia Nervosa
Station 11.1 (4 Minutes)
Candidate Instructions
You have been asked to meet with Mrs Jane Belfield, the mother of 18-year-old Ruby. You recently assessed Ruby in the outpatient clinic following a GP referral for a possible eating disorder.
At the initial assessment, you learnt that Ruby had been a very active adolescent. She played hockey regularly for a local team and also enjoyed cycling and swimming. However, during the first few months of university, she spent a lot of time socialising and eating takeaway meals with her new friends. Consequently, she noticed she had started putting on weight.
Ruby had always thought of herself as slim, and the sudden weight gain made her feel very uncomfortable. As a result, she started to monitor her diet and began counting calories. She acknowledged that this had become more of a preoccupation over the last few months and agreed that she had lost a considerable amount of weight.
Ruby admits that she has also started exercising again, but not for enjoyment – rather, for fear of putting on weight again.
Ruby denied any self-induced vomiting or the use of either laxatives or diet pills.
Ruby currently lives at home with her parents. She has taken time off her university course with the agreement of her academic tutor, who was concerned about the amount of weight she had lost.
Pertinent Investigations
ECG – Nil acute pathology detected
Blood tests – All within normal range except white cell count (WCC) of 3.2×109/L [ref range: 4 – 11.0]
Blood pressure – 95/70 mmHg, Heart rate – 60 bpm
BMI – 15 kg/m2
You have diagnosed Ruby with anorexia nervosa. She recognises she has a problem with her eating; however, she is apprehensive about treatment and the prospect of gaining weight.
Ruby has consented for you to share information from her initial assessment with her mother.
Discuss Ruby’s diagnosis with her mother and answer any questions she may have.
Actor Instructions
You are Mrs Jane Belfield, the mother of 18-year-old Ruby. Ruby has returned home early from her first year at university after some concerns about stress and weight loss. When you came to pick her up a few weeks ago, you were shocked to see how much weight she had lost.
Since returning home, Ruby has told you about her recent diagnosis of anorexia. You have heard a little about this diagnosis but would like more information. You are frightened she will not get better, as you know that anorexia can cause death.
If the candidate explains things in a non-judgemental way and appears understanding, you explain that you are concerned that your own adolescent issues with eating may have somehow been passed on to your daughter, even though you have always been careful not to discuss weight or diet with her.
Ruby is your only child, and you want to help Ruby in any way possible.
The specific questions you’d like answered are as follows:
What is anorexia?
Why do people develop anorexia?
What treatment is available?
Can people fully recover?
How can the family best support Ruby?
Feedback Domains
Knowledge
The candidate explains that those suffering from anorexia nervosa, or anorexia, have a very low body weight that is caused by abnormal eating behaviours outside of social or cultural norms.
The candidate demonstrates a clear understanding of the diagnostic criteria for anorexia nervosa and uses this to explain why Ruby has been diagnosed with anorexia:
BMI lower than 18.5 kg/m² (classified as underweight)
Deliberate weight loss, induced by the patient (e.g. not caused by a health problem or scarcity of food)
Weight gain prevented by various means (e.g. vomiting, purging, restricting, exercise)
Increased preoccupation with weight and shape, or overestimation of weight
The candidate demonstrates an awareness of the biological, psychological, and social risk factors and uses this to explain why Ruby may have developed anorexia:
Young age
Genetics (multiple genes involved)
Female gender
Family history of eating disorder, substance misuse, or other mental health disorder
Social pressures
Adverse life experiences (e.g. childhood abuse)
Personality traits (e.g. perfectionism)
Co-morbid mental illness
Management
The candidate carefully outlines the physical health complications of anorexia (e.g. osteoporosis, cardiac arrhythmias, amenorrhoea, and electrolyte imbalances) and how these are of primary concern.
They highlight that Ruby will require a variety of regular investigations, including ECGs, vital signs, blood tests, and frequent weight checks. The candidate explains that Ruby’s tests so far have indicated a slightly low WCC and blood pressure, which is consistent with her low BMI.
The candidate lays out an appropriate treatment strategy, with a focus on dietician support (including a prescriptive meal plan) and psychological therapies (e.g. modified CBT for eating disorders).
There is an appreciation that there is not usually a role for medication in the treatment of anorexia, although it may be required for co-morbid psychiatric conditions.
The candidate explains that treatment is normally provided in the community; however, if there is a significant concern about a patient’s physical health, then treatment in the hospital is sometimes necessary.
The candidate offers reassurance that the prognosis is better if treatment is started earlier on in the illness. They explain that approximately 50% of those with anorexia nervosa make a full recovery.1
The candidate may highlight that the prognosis is likely to be better with good family involvement. They may also mention that there are carer’s groups that Ruby’s mother could attend for support.
Communication
The candidate should use layman’s terms and pause to check understanding before the end of each explanation. Additionally, if the mother talks about her own childhood difficulties with eating, they are sensitive to this and highlight the multifactorial cause of anorexia. Lastly, the candidate remembers to offer written information on anorexia nervosa.
Author’s Note
As with many psychiatric conditions, having a good support network is incredibly important in recovery, and this is especially true with eating disorders. The eating disorders charity Beat (beateatingdisorders.org.uk) outlines advice for family members and carers of those with eating disorders.
Interestingly, ICD-11 has removed ‘fear of fatness’ as a requirement for diagnosis. Anorexia nervosa is now ‘typically associated’ with a fear of weight gain, a subtle but important distinction. Furthermore, ICD-11 requires a patient either to consider low body weight as central to their self-identity or to inaccurately perceive their weight as normal or excessive.2
With regard to medication options, there is some evidence to support the unlicensed use of olanzapine;3 however, many patients are aware of the particularly unwanted side effects (e.g. weight gain), and therefore careful discussions should be had before initiating these.
Station 11.2 (90 Seconds)
Candidate Instructions
You are working with a liaison psychiatry team. You have been asked to assess Ms Annie Jones, a 19-year-old woman on a medical ward. The referral states that the patient was admitted to the hospital with abdominal pain and a BMI of 14.
Other than low serum potassium, which has now been corrected, the medical team reports that all physical investigations have come back as unremarkable.
Take a history from Ms Jones and complete a risk assessment.
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