Anorexia Nervosa – Diagnostic Interview

OPEN QUESTIONS

Patients are usually guarded and establishing rapport is crucial. They may minimise symptoms. It is essential to maintain a high index of suspicion.

• Take me through a normal day.
• What do you eat at breakfast, lunch, dinner?
• What do you think about your meal intake?

MORBID FEAR OF FATNESS

• Are you concerned about your weight?
• What do you do to prevent putting on weight?
• Are you afraid of gaining weight?
• What is your height? How much do you weigh? (BMI = kg/m2)

BODY IMAGE DISTURBANCE

• What do you see when you look in the mirror?
• What is your ideal weight?
• Here is a piece of paper.  Can you draw an outline of what you look like now and what you would like to look like?

SELF INDUCED WEIGHT LOSS

• How do you lose weight/prevent putting weight on? Sometimes people may use other ways of losing weight such as exercise, thyroid supplements, fat  burners or laxatives (Normalising statement to assist with information gathering)

COMPLICATIONS

• Sometimes people, who lose weight rapidly or have below normal body weight may have medical problems. Have you had any medical issues recently?
• Have you recently been admitted to hospital …? For fractures, fainting, dizziness, chest pain?
• How have your menstrual periods been lately? (Not necessary as a criterion in DSM-5 but still retained for diagnosis in ICD-10)

IMPORTANT POINTS IN CLINICAL PRACTICE

• Keep a high index of suspicion for medical compromise. Hence always examine pulse, BP and request blood tests for electrolytes including Magnesium, Phosphate, Calcium and Zinc
• Physical examination is a must
• Request an ECG is cardiovascular compromise is suspected
• Low pulse and BP with ECG abnormalities may require a hospital admission.
• Beware of the risk of re-feeding syndrome with electrolyte abnormalities
• Family history may reveal genetic predisposition to eating disorder
• Perfectionistic traits are highly associated with Anorexia Nervosa

MEASURES OF SEVERITY AND TYPES OF ANOREXIA NERVOSA

• Mild: BMI >=17 kg/m2
• Moderate: BMI 16-16.99 kg/m2
• Severe: BMI 15-15.99 kg/m2
• Extreme: BMI < 15 kg/m2

Restricting type:

• During the last three months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting and/or excessive exercise.

Binge-eating/purging type:

• During the last three months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting, or the misuse of laxatives, diuretics, or enemas

INIDCATIONS OF HIGH MEDICAL RISK AND INPATIENT TREATMENT

Weight

• BMI <14 kg/m² or rapid weight loss (adults) or <75% of
  expected bodyweight or rapid weight loss (adolescents)

Medical status

• Heart rate <50 bpm
  Cardiac arrhythmia
  Postural tachycardia (increase >20 bpm)
  Blood pressure <80/50 mm Hg
  Postural hypotension >20 mm Hg
  QTc >450 ms
  Temperature <35·5°C
  Hypokalaemia <3·0 mmol/L
  Neutropenia
  Phosphate <0·5 mmol/L

Additional indicators

• Severe bingeing and purging (eg, several times daily)
  Failure to respond to outpatient or day-patient treatment
  Severe psychiatric comorbidity
  Suicidality

Read our comprehensive review on Anorexia Nervosa – Neurobiology, Diagnosis and Management