CASE 2
I need something for hay fever

Clare Davey, age 20 years

Student

PMH: constipation; anxiety; hay fever

Medication: lactulose

Clare Davey is a history student whose last two consultations were for constipation. Three months ago, one of your colleagues prescribed ispaghula husk. This did not help, so she returned to see another doctor. He noted she looked thin, and prescribed lactulose.

Today she wants something for hay fever that won’t make her drowsy during exams. She has tried loratadine and cetirizine over the counter, but they do not help much, and she finds chlorphenamine too sedating. Her main symptoms are sneezing and runny nose. You therefore hope that a prescription of a steroid nasal spray will send her on her way, leaving you to catch up on lost time.

You ask briefly about her constipation and she says, ‘I’ve got used to it.’ You’ve never seen her before but you can’t help noticing she looks thin, especially around the shoulders, even through a thick jumper. There is no record of her weight on the system.

What are your thoughts?

• She may be naturally slim.
• She may have an eating disorder, in which case it’s your duty to assess her and initiate treatment.
• She may have lost weight unintentionally, which is your duty to investigate.

What three or four initial questions could you ask to sort out these three possibilities?

• ‘How’s your general health?’
• ‘Has your weight changed over the last few months?’
• ‘What are your periods like?’ Amenorrhoea is common in anorexia nervosa, as well as bulimia even when the weight is normal.
• ‘Do you feel the cold?’ This isn’t specific to eating disorders but can help distinguish hyperthyroidism (prefers the cold) from anorexia (often feels cold).

Clare says her general health is absolutely fine, but admits she’s missed two periods. She can’t possibly be pregnant, she adds, because she broke up with her boyfriend nearly a year ago and there’s been nobody else. Her weight ‘hasn’t really changed’. She does feel the cold, but she just puts on extra layers. Today the sleeves of her jumper cover most of her hands.

You weigh her as this hasn’t been done for quite a while according to the notes. She is 47 kg. At 5’6” (about 1.68 m) tall, her BMI is 16.6, low enough for anorexia nervosa (use centile charts for patients under 18).

You consider a pregnancy test in case what she’s told you about timing is incorrect, but from Clare’s weight and her responses so far you put an eating disorder at the top of your list.

key point                

According to NICE guidance on eating disorders, GPs should take the responsibility for the person’s initial assessment and coordination of care.

Main types of eating disorders

• It’s estimated that at least 6% of the population has an eating disorder.
• Eating disorders often start in the teens and are more common in women.
• But they can occur at almost any age, e.g. children as young as six years.
• Around a quarter are men.

• Anorexia nervosa (about 0.6% population): low body weight due to preoccupation with weight and diet.
• Bulimia nervosa (two to four times as common): episodes of binge eating and weight-loss behaviour (vomiting, fasting, excessive exercise). Weight is often normal.
• Binge-eating disorder (the most common of all): recurrent persistent episodes of binge eating, at least three times a week, without compensatory weight loss behaviour. Weight may be normal or high.

The diagnosis of ‘atypical eating disorder’ is sometimes still used when features don’t fit any of the three main categories.

Of these eating disorders, anorexia seems the most likely diagnosis here.

What could you now ask to confirm this?

Your challenge is to tease out a fuller history, without losing your patient’s trust, appearing judgmental, or antagonizing her. Remember she’s likely to have already been interrogated or judged by her family and friends.

The SCOFF questionnaire can help in the diagnosis of eating disorders:

• Have you ever felt so uncomfortably full that you have had to make yourself Sick?
• Do you worry that you have ever lost Control over what you eat?
• Have you gained or lost more than One stone over a three-month period?
• Do you believe yourself to be Fat when others think you’re thin?
• Would you say that Food dominates your life?

A positive answer to two or more questions suggests anorexia or bulimia.

However, direct questioning such as this can be difficult so you may do better with a gentler start:

• ‘Tell me how things are at the moment.’ She might reveal sources of stress at home or at college.
• ‘Tell me about your weight’ and ‘What would be your ideal weight?’
• ‘Have you dieted or tried anything else to lose weight?’ followed up by ‘I realize that some people turn to various tablets…’ Find out if she eats with others (those with eating disorders often eat alone). Also ask about exercise and whether she goes to the gym.
• Ask about possible complications of eating disorders, e.g. dry skin, body hair, tiredness from anaemia, fainting spells, dental problems if vomiting.
• ‘Tell me about your mood day-to-day.’ This may reveal depression, or sources of stress, especially if you allow plenty of time for the answer.
• ‘Have there been any illnesses in the family?’ Sometimes there’s a family history of mental illness, of anorexia or gross obesity.

Clare tells you that she has always felt fat and that her mother is very slim. She doesn’t know what her ideal weight might be. She has tried laxatives but not diuretics or illicit drugs. She does not exercise regularly. All her time is taken up by her studies, and she wants to do well. She says she makes ‘lots of healthy food’ and eats mostly alone. She admits she may now have lost a bit too much weight. Her mood is ‘fine’ but she is worried about impending exams.

You now examine Clare. Apart from her weight, which you already checked, what are you looking for? Write down at least four things.

• Pulse and BP. There may be bradycardia or postural hypotension.
• Temperature. There can be hypothermia.
• Circulation. Acrocyanosis is common. Sometimes there’s oedema, and in rare cases there can be gangrenous digits.
• Test muscle power. Doing a sit-up and getting up from a squatting position are both useful tests.

Her temperature, pulse and BP are normal. Her fingers are a bit cold. She can get up from a squatting position without using her arms, except to balance.

What do you do now?

The absence of physical findings does not mean you can ignore her eating disorder. First, you could discuss your concerns about her weight, then ask if she has considered this may be anorexia. This may enable you to get agreement that she’d benefit from help before things get out of hand.

Figure 2.1 Complications of anorexia nervosa.

Meanwhile, you want to do a few simple tests, if that’s OK with her.

Clare readily agrees, mainly because, as she admits, she has less energy than she did, and can’t study half the night as she used to.

What investigations do you consider?

• FBC, U&Es and creatinine. LFTs and albumin. Glucose.
• Consider an ECG, especially if BMI is under 15, or there is bradycardia.

All Clare’s results come back normal. This is the case in most people with eating disorders. It’s mildly reassuring, because it suggests her health is not currently at high risk.

CKS/NICE has a guide to determine who is most at risk. Low BMI, postural hypotension, bradycardia, poor muscle strength and abnormal blood tests are all significant. Some people need admission.

Tip                

Remember anorexia nervosa is the most deadly of all mental health conditions.

Consider admission to hospital for any of the following

• Risk of suicide or severe self-harm (needs admission to acute psychiatry, not eating disorders unit).
• Home situation hinders recovery.
• Severe deterioration (may require admission to acute medical ward).
• Very low body weight (refer urgently if BMI <15).
• Medical complications (e.g. severe electrolyte disturbance, hypoglycaemia or severe intercurrent infection).

If considering compulsory admission (whatever your patient’s age), get specialist advice.

See Resources for details.

For everyone else, referral to the Community Mental Health Team...