History Taking · Advanced · Psychiatry

Recurrent Episodes of Overeating

Practise this PLAB 2 history taking station on Bulimia Nervosa. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in general practice. Shireen Farooq, a 24-year-old woman, has attended with concerns about her eating patterns and mood. She reports recurrent episodes of eating large amounts of food, which she compensates for through excessive exercise. Please take a focused history of eating disorder symptoms and discuss management.

Background notes: PMH: Nil significant; Menarche age 13, Periods now irregular

What this station tests

  • Binge-purge cycle identification: loss of control eating followed by compensatory behaviours
  • Medical complications of purging: hypokalaemia, dental erosion, parotid swelling, Russell's sign
  • CBT-BN as first-line treatment per NICE: most effective for breaking the binge-purge cycle
  • Fluoxetine 60mg: higher dose than for depression, the pharmacological option for bulimia
  • Normal BMI does not exclude severity: bulimia patients are often normal weight

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Bulimia nervosa presents differently from anorexia: the patient is often normal weight, which can mask the severity. The candidate must identify binge-purge cycles, assess medical complications, and engage a patient who feels ashamed. Shireen is 24, attending about her eating pattern. She is ashamed. Open with: 'Shireen, it takes courage to come and talk about this. Tell me what has been happening with your eating.'

Core approach

Identify the binge-purge cycle. Bingeing: episodes of eating large amounts in a short period with a sense of loss of control (she cannot stop once she starts). Purging: self-induced vomiting after binges. Ask about other compensatory behaviours: laxative misuse, excessive exercise, fasting. Frequency: multiple times per week suggests moderate to severe bulimia.

Assess medical complications of purging. Dental erosion (acid damage to tooth enamel), parotid gland swelling ('chipmunk cheeks'), Russell's sign (calluses on knuckles from self-induced vomiting), electrolyte disturbance (hypokalaemia from vomiting, metabolic alkalosis). Hypokalaemia can cause cardiac arrhythmias: ask about palpitations and muscle weakness. Oesophageal tears (Mallory-Weiss).

Psychological assessment. Self-worth excessively tied to weight and shape. Often normal BMI (unlike AN). Comorbid depression, anxiety, self-harm. Relationship with food: restricting leads to bingeing in a cycle.

Closing and safety netting

Treatment: CBT for bulimia (CBT-BN) is first-line per NICE (most effective psychological treatment). SSRI (fluoxetine 60mg, higher dose than for depression) is the pharmacological option if CBT alone is insufficient. Eating disorder service referral. Urgent bloods: U&E (potassium), ECG if electrolyte concern.

Reassure: 'Bulimia is treatable. CBT has good evidence for breaking the binge-purge cycle.' Address shame directly: 'Many people experience this. It is not about willpower or greed.' BEAT charity for support. Safety net: palpitations, chest pain, or blood in vomit require urgent attendance. Follow-up within 2 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for bulimia nervosa. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Binge-purge cycle characterised. Frequency assessed. Compensatory behaviours identified. Medical complications screened. Electrolytes checked.

Costs marks: Not identifying the cycle. Not screening medical complications. Not checking electrolytes.

Domain 2 (Primary focus)

Scores well: CBT-BN recommended. Fluoxetine 60mg as option. Eating disorder referral. Urgent bloods. ECG if needed. BEAT signposted.

Costs marks: Not knowing CBT-BN. Wrong fluoxetine dose. No specialist referral.

Domain 3 (Primary focus)

Scores well: Acknowledging shame. Normalising without minimising. Not using 'greed' or 'willpower' framing. Creating a safe space for disclosure.

Costs marks: Making her feel judged. Minimising the severity. Not addressing shame.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Missing the diagnosis because BMI is normal: bulimia patients are often normal weight unlike anorexia
  2. Not checking potassium: hypokalaemia from vomiting can cause fatal arrhythmia
  3. Not addressing shame: shame prevents disclosure and treatment engagement

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a bulimia nervosa history in PLAB 2?

Bulimia nervosa presents differently from anorexia: the patient is often normal weight, which can mask the severity. The candidate must identify binge-purge cycles, assess medical complications, and engage a patient who feels ashamed. Shireen is 24, attending about her eating pattern.

Where are marks won and lost in this bulimia nervosa station?

Examiners reward: Binge-purge cycle characterised. Frequency assessed. Compensatory behaviours identified. Medical complications screened. Electrolytes checked. Candidates are penalised for: Not identifying the cycle. Not screening medical complications. Not checking electrolytes.

Where do candidates most often go wrong in this station?

Missing the diagnosis because BMI is normal: bulimia patients are often normal weight unlike anorexia.

Can I do well in this station without real-world experience of bulimia nervosa?

Structure beats experience here. Focus on medical complications of purging: hypokalaemia, dental erosion, parotid swelling, Russell's sign. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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