Medical Assessment – Eating Disorders including ARFID

Medical History

• General medical history including bowels

• Previous eating disorder treatment

• Allergies, including food allergies

• Medications

• Development

• Teams involved i.e. GP, paediatrician, allied health, specialists

Menstrual History

• Age of menarche

• Regularity, length

• Absence of menstrual periods

• Date of last menstrual period

• Use of contraception (pill, IUD)

HEADDS Assessment / Risk Assessment

• Suicidal ideation

• Deliberate self-harm

• Past suicidal behaviours and self-harm events

• Agitation

• Risk of harm to others

• Previous violent behaviour towards others

• Is the person the sole / shared caregiver of a child < 18 years If yes, first name, age, do they live with the client full or part time?

Presence of Comorbid Psychiatric Illnesses

• Mood disorders

• Anxiety disorders

• Obsessive compulsive disorders

• Psychotic disorders

• Drug and alcohol use

Psychiatric history (neglect, trauma, depression, self-harm, suicidal thoughts, bullying)

Effect of Eating Disorder on Life

• Effects of eating disorder (physically, emotionally, occupationally, socially, cognitively)

• Impact of eating disorder on family or significant other

• Amount of time spent thinking about eating, weight, and shape (per hour or per day)

• Broken sleep, wake up thinking about the eating disorder

• Individual’s view on what maintains the eating difficulties

• Individual’s beliefs about what needs to change in order for them to get better

• Denial or acknowledgment of illness severity

• Insight into illness

• Motivation to change (importance of change and confidence to execute change)

Cognitive Changes, Mood, & Personality

• Changes in mood (irritability, rigid, low mood)

• Evidence of starvation syndrome (cognitive impairment, personality changes, preoccupation with food)

• Impaired concentration and alertness

• Agitation

• Increased / decreased need for sleep

• Impaired ability to make decisions, rigid and inflexible thinking

• Personality traits (perfectionism, obsessiveness, impulsivity)

Neurodevelopmental history

• Autism

• Sensory Difficulties

Developmental history pertaining to food / growth / appetite

Social & Family History

• Living situation, family / carer support, school, work

• Family history of mental health / physical health

Assessment of Eating Disorder

It is important to assess the presence of eating disorder behaviours using a nonjudgemental, person-centred approach. Many of these behaviours carry significant shame and guilt, and the individual will need to feel a sense of rapport with you before opening up.

Nutrition Intake

• Onset of concerning eating behaviour

• Time course of beliefs around food (timed with onset of eating disorder)

• When food / body concerns became problematic

• Any association with an aversive experience (e.g. choking, vomiting, or abdominal pain)

• Dietary changes and dieting history (type, amount, skipping meals, bingeing, food refusal)

• Interest in shopping, cooking, calorie counting

• Current food intake, including portion size (breakfast, snack, lunch, snack, dinner, snack)

• Appetite drive reduced

• Foods eaten and foods not currently eaten, e.g. cutting out ‘unhealthy foods’

• Avoidance or aversion of specific sensory experiences (taste, smell, texture, temperature, appearance)

• Anxiety regarding consequences of eating (e.g. fear of gastrointestinal consequences)

• Restricted or narrow range of food choices not related to caloric content

• Negative response (e.g. anxiety or disgust) associated with food intake

• Fluid intake (overall intake, specific types of drinks including diet and energy drinks)\

• Food allergies/intolerances (what food, what happens, formal or self- diagnosed)

• Food preferences (vegetarian, vegan, organic, no preservatives)

• Religious and cultural beliefs

• Rituals around eating (eating alone, in secret, heavy use of spices and condiments, time taken to eat, hoarding, cutting into small pieces, weighing and measuring food, cooking for others but refusing to eat)

• Excuses for not eating, denying hunger

Purging

• Self-induced vomiting (how often, method, precipitants)

• Blood vomited (how often, how much)

• Use of laxatives, enemas, suppositories, diuretics, diet pills, misuse of insulin, steroids, self-phlebotomy, self-lavage (what, how much, when)

Binge Eating

• Usual binge episode (type of food, quantity, frequency, duration)

• Feelings before, during and after

• Feeling of loss of control

• Binge environment (where, when)

• Perceived triggers

• Uncontrolled grazing outside of binges

• Behavioural consequences following binge eating (restricting / fasting, self-harm, isolation)

• Stealing of food / money for a binge episode

• Disappearing to bathroom during or after meal

Other Behaviours

Establish a baseline level of frequency and intensity of the following behaviours:

• Chewing and spitting

• Rumination (regurgitation of food, then re-chewed, re-swallowed or spat out)

• Night eating

• Medication, vitamins, and complementary medicines

• Illicit drug taking

• Cigarette smoking

• Alcohol intake

• Chewing gum

• Baggy or layered clothing

Exercise

• Current pattern of exercise and changes

• Types of exercising (aerobic / anaerobic, gym, class, social based)

• Most extreme exercise

• Incidental activity (walking, standing)

• Duration of exercise per 24 hours

• Calorie goals per session

• Motivation to exercise

• Compulsive exercise

• Effects of missing a day of exercise

• Is weight and shape controlled with exercise?

• Exercise despite illness or injury

Assessment of Weight

For someone with an eating disorder, being weighed can be very distressing. This needs to be done with sensitivity and empathy. Try to refrain from making comments about the number on the scales.

Weight History

• Weight history through child / adolescence / adult years

• Premorbid weight

• Highest and lowest weight

• Current weight

• Current trend / rate of change in the past 6 months

• Desired vs healthiest weight

• Current height and BMI

• Healthy BMI range or BMI percentile for children and adolescents

• Body weight and shape within family

Attitudes Towards Weight & Shape

• Level of self-criticism (whole body and specific regions)

• Perception of shape

• Perceptions of others’ attitudes about their weight and shape

• Fear of weight gain

• Denial of illness severity

• Presence of body checking behaviours (weighing, mirror checking, feeling / touching specific areas, using a piece of clothing as a ‘ruler’, mirror checking pre / post intake)

• Family attitudes towards food, weight and shape (including family history of dieting)

Physiological Assessment

• Observations

• Heart rate and BP

• Temperature

Skin Examination

• Acrocyanosis (blue discolouration)

• Jaundice

• Carotenaemia (orange skin)

• Dry skin

• Hair loss / thinning

• Lanugo hair (soft downy hair on back, arms)

• Callused knuckles (repeated induced vomiting)

• Skin infections and lesions from self-harm

• Brittle nails

Assess for Dehydration

• Sunken eyes

• Dry lips and tongue

• Poor skin turgor

• Slow capillary return

Oral Examination

May occur with recurrent vomiting:

• Dental erosions

• Pharyngeal redness

• Parotid enlargement

Assess for Signs of Vomiting

• Swollen parotid glands

• Recurrent sore throat

• Bouts of tonsillitis

• Halitosis

• Callused knuckles (repeated induced vomiting)

• Bloodshot eyes, broken capillaries in the cheeks and eyelids

Cardiovascular / Respiratory

• Blood pressure (seated and standing)

• Heart rate (seated and standing)

• A fall or rise of 10-20 beats per minute on standing indicates cardiac compromise

• Bradycardia / tachycardia on minimal exertion indicates deconditioning

• Core temperature

• Shortness of breath (orthopnoea, paroxysmal nocturnal dyspnoea, exercise tolerance)

• Palpitations (sudden onset, frequency, duration)

• Chest pain (onset, frequency, duration, associated symptoms, precipitating factors)

Gastrointestinal & Renal

• Delayed gastric emptying (causes prolonged fullness)

• Post prandial symptoms (distension, abdominal pain, bloating and early satiety)

• Reflux

• Diarrhoea, constipation

• Urinalysis (may show high specific gravity and ketones)

Musculoskeletal

• Stress fractures and overuse injuries

Pubertal Status