This resource has been compiled using a variety of sources. It includes references to the NICE guidance on eating disorders and a section on reference material contains links to material for professionals and patient information sites.

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What are eating disorders?

The term eating disorder is used to define a number of conditions, affecting adolescents and adults. Eating disorders cause significant morbidity and mortality, leading as they do to multiple medical problems associated with both the physical and psychological consequences. There are considerable social issues to be addressed in many cases as the family of the individual are a key part of the package of care.

They are broadly classified into:-

• Anorexia nervosa a psychiatric illness that describes an eating disorder. A combination of altered body image and in most cases extremely low weight may lead to an individual employing extreme measures to maintain or lose weight. Excessive exercise, a near starvation diet or the use of laxatives and diuretics may be employed by the individual.
• Bulimia nervosa this condition is characterised by repeated binge eating usually followed by measures to compensate. Self induced vomiting (either through stimulating the gag reflex or by ingesting medication is to induce vomiting e.g. ipecac), fasting and the use of laxatives and enemas may be employed by the individual.
• Atypical eating disorders this refers to patients with disorders of eating that do not fit into the diagnostic criteria for anorexia or bulimia. Examples might include individuals that use vomiting or a laxative abuse to control weight but do not binge eat, or patients with very low body weight who do not meet the criteria for anorexia. Binge eating disorder falls into this classification.

The impact of eating disorders

Eating disorders taken as a whole are a common condition. Anorexia nervosa affects about 1 in 250 females and about 1 in 2000 males. Whilst most of these patients present in adolescence and early adulthood the condition is well recognised in later adulthood. Bulimia is far more common affecting up to 5 times as many individuals as anorexia. The numbers of sufferers of atypical eating disorders is not known; many patients do not come to medical attention but the numbers are thought to be greater than the numbers of sufferers of anorexia and bulimia combined.

The onset of an eating disorder is most commonly seen in adolescence. The impact on the physical development of the individual may be crucial in this growth phase, the impact on the educational and social development may also have far reaching consequences with many sufferers not reaching their full academic potential. Family life may be disrupted with further consequences for carers and siblings of sufferers. Patients with eating disorders often have depressed mood and are ambivalent to health care. Anorexia nervosa has the highest mortality rate for psychiatric illness in adolescence.

Access to appropriate healthcare is crucial. The services for patients with eating disorders vary across the country, early intervention appears to affect outcome however access to specialist services is not always possible locally. This patchy nature of services combined with the ambivalence of the sufferer may have negative consequences.

The outcome of an individual with anorexia nervosa is variable. Many sufferers do not access formal medical care and the prognosis in this group is unknown. A review of 68 studies published before 1989 showed that 43% recover completely, 36% improved, 20% develop a chronic eating disorder and 5% die from anorexia nervosa. The overall mortality in the studies varied from 0-21% from a combination of physical causes and suicide. An individual with bulimia has about a 50% chance of full recovery with 20% experiencing ongoing bulimia with a further 30% experiencing some symptoms but below the diagnostic threshold. Atypical eating disorders may have a higher remission rate than either anorexia or bulimia, however long-term studies are lacking in this condition.

Screening for eating disorders in general practice

In the UK the average GP will only have one or two patients who suffer with anorexia nervosa. The prevalence of eating disorders in young women may be as high as 5%. Patients with eating disorders consult more frequently than the norm prior to their diagnosis; this gives a window of opportunity to the GP. The very nature of anorexia increases the diagnostic difficulty for the GP; the patient may be secretive, dismissive and have an ambivalence toward seeking health care.

It is impractical to screen the entire general practice population for eating disorders, however high-risk groups can be targeted using a simple validated questionnaire. An example of this is the SCOFF tool, and automated version can be found by clicking here.

SCOFF tool

• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone in a 3 month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?
• One point for every "yes"; a score of >2 indicates a likely case of anorexia nervosa or bulimia

Opportunistic screening of high risk groups in general practice should include:-

• Young women
• Patients with low or high BMI
• Adolescents consulting with weight concerns
• Women with menstrual disturbances or amenorrhoea
• Patients with gastrointestinal disturbances
• Patients with psychological problems

There is evidence that early intervention improves outcomes and therefore screening is a valuable tool.

Anorexia nervosa-making a diagnosis

In order to establish a diagnosis of anorexia nervosa either the classification suggested by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or by the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) should be used.

There is no biochemical or haematological test for anorexia nervosa, however every case that is suspected should have a diagnostic work to exclude other causes of weight loss and to check for biological parameters that may be affected by the illness itself. The diagnosis relies on a combination of exploring the beliefs of the patient, the experience of the patient and others and the physical characteristics exhibited by the patient. Notably, diagnostic criteria are intended to assist clinicians, and are not intended to be representative of what an individual sufferer feels or experiences in living with the illness.

The diagnostic criteria used in the DSM-IV-TR are:-

• A refusal to maintain body weight at or above a minimally normal weight for age and height: weight loss leading to maintenance of body weight
• An intense fear of gaining weight or becoming fat, even though under weight.
• A disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
• The absence of at least three consecutive menstrual cycles (amenorrhea) in women who have had their first menstrual period but have not yet gone through menopause(postmenarce, premenopausal females)

Furthermore, the DSM-IV-TR specifies two subtypes:

• Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behaviour (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). Weight loss is accomplished primarily through dieting, fasting, or excessive exercise.
• Binge-Eating Type or Purging Type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating OR purging behaviour (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas).

The ICD-10 criteria are similar, but in addition, specifically mention

• The ways that individuals might induce weight-loss or maintain low body weight (avoiding fattening foods, self-induced vomiting, self-induced purging, excessive exercise, excessive use of appetite suppressants or diuretics).
• Certain physiological features, including "widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhoea and in men as loss of sexual interest and potency. There may also be elevated levels of growth hormones, raised cortisol levels, changes in the peripheral metabolism of thyroid hormone and abnormalities of insulin secretion".

If onset is before puberty, that development is delayed or arrested.

How does anorexia nervosa present?

Anorexia nervosa particularly in its early stage may be difficult to spot both for healthcare professionals and for close members of the family. Once established the physical, psychological and social effects of the condition may lead to a number of conditions:

Physical conditions that may be associated with anorexia nervosa

• Significant weight loss
• Postural hypotension
• Body mass index below 17.5 in adults
• Anaemia
• Less than 85% of expected weight in children/adolescents
• Reduced white cell count
• Amenorrhoea
• Reduced function of the immune system
• Slow heart rate, reduced metabolic rates which may lead to hypotension
• Stunted growth
• Electrolyte disturbance
• Dental caries
• Mineral deficiency notably zinc
• Oedema
• Constipation
• Poorly developed secondary sexual characteristics
• Weak or brittle fingernails
• Thinning of the hair
• Decreased sexual drive in males

Psychological symptoms that may be associated with anorexia nervosa

• Obsessional thoughts/actions regarding food and weight
• Distorted body image thinking they are fat even when they are under weight
• Low self-esteem
• Phobic thoughts about weight gain
• Poor insight into condition
• Depressed mood, clinical depression, mood swings and anxiety
• Difficulty interacting with others either being short tempered or socially withdrawn
• Obsessive-compulsive disorder
• Refusal to accept the concept of a normal weight even in the context of a dangerously low weight
• Feeling that control over their weight gives them control over their life
• Evaluating themselves mainly in terms of their body shape and weight

Social behaviours that may be associated with anorexia nervosa

• Excessive exercise
• Being secretive about behaviours e.g. eating or exercise
• Social withdrawal
• Deliberate self harm
• Substance abuse
• Short tempered and argumentative or even aggressive around the subject of food
• Frequently checking body shape in a mirror or weight on a scales

Identification of anorexia nervosa in general practice

The primary care team may have the opportunity to screen high-risk groups and is also likely to be the first point of contact with the patient. Frequently initial contact was made by a worried relative or school teacher who has observed weight loss or specific food related behaviours such as skipping meals, hiding food or adopting a restricted diet. Indeed any of the physical, psychological or social behaviours listed. There is a danger that the inexperienced practitioner may make light of the symptoms or feel that they are self-inflicted. The history must be taken with a sympathetic ear and in an empathetic and non-judgemental manner. A careful history should be taken and matched against the diagnostic criteria. The mean age of onset is 16-17.

The NICE guidance lists the following factors to be considered

• Risk factors – family history of eating disorder, Type 1 diabetes, previously overweight, occupation (e.g. athlete, dancer, model). Although adolescent girls and young women constitute the principal population at risk, it should be remembered that eating disorders also occur in ethnic minorities, men and children.
• Differential diagnosis of weight loss – includes malabsorbtion (e.g. coeliac disease, inflammatory bowel disease), neoplasm, illicit drug use, infection (e.g. TB), autoimmune disease, endocrine disorders (e.g. hyperthyroidism).
• Differential diagnosis of amenorrhoea – includes pregnancy, primary ovarian failure, poly cystic ovary syndrome, pituitary prolactinoma, uterine problems and other hypothalmic causes.
• Psychiatric differential diagnosis – includes depression, obsessive-compulsive disorder, somatisation and, rarely, psychosis.

A physical examination is required to calculate the BMI (or use centile charts are aged less than 18) and pulse and blood pressure should be taken. In patient showing a degree of emaciation, core temperature, examination of the peripheries for circulation and oedema, a check for postural hypotension and a squat test to check muscle power should also be performed. The patient is asked to squat and then rise without using their arms. If the patient needs to use their arms the balance then this may indicate a moderate risk, if the patient needs to use their arms to leverage themselves up in this is an indication of profound muscle weakness and high risk.

Full blood count, ESR, U+E, Creatinine, liver function tests, random blood glucose and urinalysis would screen for most of the common differential diagnoses. An ECG may be appropriate particularly if there is bradycardia, electrolyte imbalance or a BMI of less than 15. In more severe cases calcium, magnesium, phosphate, serum proteins and creatinine kinase may also be required. In the differential diagnosis of amenorrhoea with weight loss thyroid function, follicle stimulator hormone, luteinising hormone, prolactin and a chest x-ray should be performed.

A DXA scan may be required to identify bone loss in chronic cases or in cases with prolonged amenorrhoea.

The Royal College of psychiatrists has produced an algorithm for the initial diagnosis and management of suspected cases of eating disorder - click here for more.

Management and treatment strategies in anorexia nervosa

When considering the management and treatment of anorexia nervosa a multi-professional strategy must be adopted. The individual may require physical therapy for complications of their eating disorder, psychological therapies such as CBT, psychopharmacological intervention for associated depressive symptoms and family therapy to repair damage to relationships. There may also be issues around supporting the carer and certainly there are information needs in close family members or carers in different contexts. Central to interventions is obviously the patient, the consent to involvement of others is vital; however with the inherent ambivalence and risk of denial of the problem, the healthcare professionals need to tread carefully.

In children and adolescents family therapy tends to be a key intervention. There is however a poor evidence base to this, and indeed, other interventions in this condition. The availability of specialist child and adolescent services is variable, however if available family interventions dealing with eating behaviour have some evidence base. Specialist services may offer cognitive behavioural therapy, psychodynamic psychotherapy, motivational enhancement therapy and other family interventions.

Psychological interventions

The initial aim of psychological intervention must be to engage the patient in that intervention. The denial of a problem and the ambivalence to health care exhibited in this condition is a barrier that must be overcome before psychological intervention can work. Healthcare professionals must build a relationship based on trust and empathy with the patient, their carers and their family as appropriate. There must be an ethos of collaboration with the patient and the patient needs to engage with the process in the same spirit. This engagement may wax and wane with time, the therapist must be sensitive to this, gaining small victories where possible.

In general the aim of the interventions are to promote healthy eating and weight gain, to reduce the impact of other eating disorder related psychological issues and in this way promote psychological recovery. In the context of the patient who has gained weight following a period of hospitalisation the aim of intervention is to maintain the weight gained. In the proportion of patients that go on to develop chronic anorexia nervosa the goals of treatment with psychological intervention may differ, and improvement in the quality of life and maintenance of a safe weight may be paramount.

The evidence base the psychological intervention is poor, family therapy in adolescence has some evidence to support its use, however other interventions show variable results.

Pharmacological interventions

No drug therapy has been shown to alter the course of anorexia nervosa unless there is co-morbid depression or OCD. Antidepressants and antipsychotics risked doing harm specifically by prolonging the QT interval, evidence of benefit is minimal.

Hospital admission

Hospital admission is required when the weight or biochemical disturbances place the patient at risk. Detention under the mental health act is occasionally required and forced feeding is reserved as a last resort. Useful weight gains can be made in hospital and are supervised conditions and it also gives the

NICE clinical practice recommendations in anorexia nervosa

• In most patients with anorexia nervosa an average weekly weight gain of 0.5 to 1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3500 to 7000 extra calories a week.
• Regular physical monitoring and in some cases treatment with a multivitamin/multi-mineral supplement in oral form is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration.
• Health care professionals should advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase the likelihood of falls.In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought.
• Nasogastric feeding can confer some benefit in terms of increased rate of weight gain or actual weight gain, as part of a treatment programme. There was insufficient evidence that either TPN (total parenteral nutrition) or zinc supplementation confer any benefit in terms of weight gain.
• TPN appears to be associated with more adverse events in one small study. Some limited benefit, on symptoms but not on weight gain, has also been identified from one small trial investigating massage.

NICE recommendations on managing risk

• Health care professionals should monitor physical risk in patients with anorexia nervosa. If this leads to the identification of increased physical risk, the frequency and the monitoring and nature of the investigations should be adjusted accordingly.
• People with anorexia nervosa and their carers should be informed if the risk to their physical health is high.
• The involvement of a physician or paediatrician with expertise in the treatment of physically at-risk patients with anorexia nervosa should be considered for all individuals who are physically at risk.
• Pregnant women with either current or remitted anorexia nervosa may need more intensive prenatal care to ensure adequate prenatal nutrition and foetal development.

Nice recommendations on feeding against the will of the patient

• Feeding against the will of the patient should be an intervention of last resort in the care and management of anorexia nervosa.
• Feeding against the will of a patient is a highly specialised procedure requiring expertise in the care and management of those with severe eating disorders and the physical complications associated with it. This should only be done in the context of the Mental Health Act 1983 or Children Act 1989.
• When making the decision to feed against the will of the patient the legal basis for any such action must be clear.

The role of the GP in anorexia nervosa

NICE recommends that the treatment of anorexia nervosa includes primary secondary and sometimes tertiary healthcare providers. A multidisciplinary approach is required and the Royal College of psychiatrists have produced an algorithm for diagnosis and initial management.

The role of the GP is therefore:-

• Screening of high-risk groups
• Assessment at initial presentation
• Evaluation of initial severity
• To give patients and carers information
• To refer as appropriate
• To support patient and carer even if treatment is commenced in secondary care
• To onwardly support patients with chronic anorexia nervosa with the least an annual health check

Bulimia nervosa making a diagnosis

The diagnostic and statistical manual of mental disorders (DSM-IV TR) lists the criteria for diagnosing a patient with bulimia nervosa as:-

• Recurrent episodes of binge eating
• binge eating must have the following two characteristics
• eating an amount of food that is definitely larger than most people would eat in a fixed period of time
• a lack of self-control during that time-feeling that they cannot stop or control what or how much they eat
• Exhibiting inappropriate compensatory behaviour to mitigate against this bingeing to avoid weight gain
• self-induced vomiting (purging)
• misuse of laxatives
• misuse of diuretics
• misuse of other medications (thyroxine, amphetamine)
• fasting
• excessive exercise
• Body weight and shape dominate self perception
• Symptoms occur twice a week on average for a minimum of three months
• The symptoms do not occur during episodes of anorexia nervosa

Two subtypes are identified:-

Purging - here the individual self induce vomiting either by triggering the gag reflex or ingesting emetics. This is an attempt to rapidly remove food from the body before it can be digested. Laxative, diuretics and enemas may also be used for the same reason.

Non-purging - less than 10% of sufferers of bulimia nervosa adopt excessive exercise or excessive fasting to offset the binge eating.

How does bulimia nervosa present?

Bulimia nervosa is far more common than anorexia nervosa and up to 5 in 100 of young women (the mean age of onset is 18-19) attending their GP may have the condition. Patients with bulimia tend to have a body weight that is either just below, normal or just above average BMI. Many patients will not exhibit physical symptoms however excessive use of purging techniques can lead to dehydration, electrolyte imbalance and cardiac arrhythmias.

Although the binge eating and purging is normally performed in secret, patients with bulimia are often relieved to tell somebody else about it. When directly questioned many will answer truthfully, even in extreme cases of frequent bingeing and purging.

In most patients physical examination is entirely normal, as are biochemical and haematological parameters. Possible physical effects include:-

• Oesophagitis
• Dehydration
• Electrolyte imbalance
• Cardiac arrhythmia (cardiac arrest and death)
• Constipation
• Severe dental caries and/or erosion of the enamel
• Oral trauma from eliciting the gag reflex

Mood disturbance is extremely common in bulimia nervosa with symptoms of anxiety being prominent. Low self esteem and self loathing, along with a feeling of disgust at themselves over the overeating and purging may be present. When compared to anorexics more bulimics will have clinical depression. Bulimia nervosa sometimes arises out of a pre-existing anorexic illness, where the patient has lost the control over restriction of eating manifesting itself in uncontrolled bingeing.

Some sufferers leave obvious clues about their problem such as leaving the wrappers from food for others to find and even bags of vomit left in prominent places. The binge eating episodes are usually planned, with food purchased in advance and prepared to be consumed in secret. An individual may also avoid situations where they are exposed to food in the presence of others. This tends to lead to further social isolation.

Identification of bulimia nervosa in general practice

The primary care team are likely to have opportunities to diagnose patients with bulimia nervosa. Sufferers have a much higher consultation rate pre-diagnosis than the general population. Use of screening with the SCOFF questionnaire is appropriate. As with anorexia the first contact may be with worried family members, friends or schoolteachers. Risk factors for bulimia nervosa include:-

• Receiving critical comments about body shape or size
• Parental or sibling history of eating disorder
• Being female (1 in 10 sufferers is male)
• Parental and childhood obesity
• Excessive family dieting

Other factors that may have a bearing include a history of sexual or physical abuse, pre-morbid psychiatric disorder (including anorexia) and disruptive events in childhood.

The diagnosis of bulimia nervosa mainly hinges on a good history as physical examination is likely to be normal however BMI should be measured, the BP should be taken both sitting and standing to check for postural hypotension. Laboratory investigations again are likely to be normal although urea, electrolytes and creatinine should always be measured.

The Royal College of psychiatrists has produced an algorithm for the initial diagnosis and management of suspected cases of eating disorder.

Management and treatment strategies in bulimia nervosa

Uncomplicated bulimia nervosa can be treated in primary care (given access to appropriate support services), referral should be made if there is a lack of progress, the patient is pregnant or has a pre-existing condition such as diabetes.

General considerations about the patients health or mental wellbeing may also prompt referral as should suicidal tendencies. With the most effective treatments 50% of patients can be expected to be free of symptoms between two and 10 years after diagnosis. 20% of patients will develop chronic bulimia nervosa and the remaining 30% were either follow a relapsing and remitting course or develop chronic subclinical bulimic symptoms (other studies show even larger numbers in sustained remission – described in the NICE guideline).

Although long-term follow-up studies in this condition are few, it seems that untreated, the majority of bulimics will continue to be symptomatic for many years.

Psychological intervention

Cognitive behavioural therapy has strong evidence to support its use. A specific therapy has been developed for use in bulimia and it utilises three distinct but overlapping phases:-

• Education – the patient and where appropriate the carer receive education dealing with the aetiology, risk factors, clinical features, epidemiology and treatments for bulimia nervosa. Using this information the patient is given strategies for resisting the urge to binge or purge. A food diary may be introduced with encouragement for the patient to eat normal portions of food more regularly.
• Behavioural experiments - in this phase patient is encouraged to broaden their diet and introduce food they have been avoiding. The patient's beliefs around certain food categories are explored and the introduction of previous “forbidden” elements is tried.
• Maintenance phase - strategies to avoid relapses are agreed, coping mechanisms for relapses are introduced.

A Clinical Evidence report on 34 randomised controlled trials of CBT showed a significant increase in the proportion of patients abstaining from a binge-purge cycle of 43% with only 5% in the control group abstaining.

The same review uncovered insufficient evidence to recommend any other form of psychotherapy. Guided self-help cognitive behavioural therapy conducted in the primary care setting was as good as specialist CBT in one randomised control trial.

Pharmacological intervention

The use of antidepressant medication in the treatment of bulimia has been studied in adults. There is no evidence base for the use in adolescents and they do not have a licence for use in this indication. In adolescents drug treatment should not therefore be a first line intervention.

In adults there is evidence for the efficacy of tricyclic antidepressants, irreversible monoaimine oxidase inhibitors (but not moclobamide) and to a lesser extent SSRIs.

There is also evidence that a combined approach of CBT and antidepressant use enhances the effect of CBT. Doses of antidepressants used in the trials are similar to those used to treat depression (with the exception of fluoxetine at 60mg daily).

It is thought that the use of irreversible monoaimine oxidase inhibitors may cause further problems, as the exclusion of tyramine from the diet may focus the patient further on food.

NICE clinical recommendations in bulimia nervosa

• As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant drug.
• Patients should be informed that antidepressant drugs can reduce the frequency of binge eating and purging, but the long-term effects are unknown. Any beneficial effects will be rapidly apparent.
• Selective serotonin reuptake inhibitors (SSRIs) (specifically fluoxetine) are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability and reduction of symptoms.
• For people with bulimia nervosa, the effective dose of fluoxetine is higher than for depression (60 mg daily).
• No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa.

And when comparing a combined approach of antidepressants and CBT verses CBT alone NICE makes the following points:-

• There have been few comparisons of psychological and pharmacological treatments, and their combination, with the result that any practice recommendations must be tentative.
• Few studies have included post-treatment follow-up periods, a problem with almost all the studies that have used drugs.
• The comparisons of Cognitive behavioural therapy – bulimia nervosa (CBT-BN) with antidepressant drugs indicate that CBT-BN is the more potent treatment.
• The combination of CBT with antidepressant drugs is superior to antidepressant drugs on their own.

A typical eating disorders making a diagnosis

This classification of eating disorders is sometimes called eating disorders not otherwise specified (EDNOS – US classification) and includes binge eating disorder. This categorisation covers individuals that meet some but not all of the diagnostic criteria for anorexia nervosa or bulimia. Individuals in this category may shift to a different diagnostic entity, occasionally meeting all the diagnostic criteria for both anorexia nervosa and bulimia.

Examples include: -

• Frequent self- induced vomiting as a compensatory behaviour in the absence of binge eating (for example self-induced vomiting after eating a small chocolate)
• Bulimic behaviour which is less than twice a week or has not lasted for 3 months
• Chewing food and spitting it out on a repeated cycle
• In a female patient – all diagnostic criteria are met but experiencing regular menses
• Binge eating disorder – individuals indulge in binge eating but do not exhibit the compensatory behaviour

In order to diagnose binge eating disorder the eating episodes are associated with three or more of the following:

• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not physically hungry
• Eating alone through embarrassment at the amount one is eating
• Feeling disgust or extreme guilt after overeating.

Marked distress regarding binge eating is present and social avoidance is common.

Management and treatment strategies in a typical Eating Disorder

Nice recommendation for a treatment strategy states:-

• In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient’s eating disorder.
• There has been no research specifically directed at the treatment of atypical eating disorders other than BED (binge eating disorder). The view of the GDG (guidelines development group) is that clinicians should manage the large number of these cases according to the guidelines for anorexia nervosa or bulimia nervosa depending on the clinical presentation and age of the patient.
• With regard to BED, given the apparently good response, at least in the short term, to a range of different psychological interventions including self-help and given the lower level of acute physical and psychiatric risk compared to anorexia and bulimia nervosa, treatment for BED may often be deliverable in primary care through the use of evidence based self-help manuals. Children and adolescents with binge eating problems should receive the same type of treatment as adults but adapted to suit their age, circumstances and level of development, with appropriate family involvement.

Eating disorders suggestions for general practice

After completing this learning tool you may feel that you wish to incorporate some of the learning points in your own practice.

It is clear that anorexia nervosa is the most serious eating disorder however the numbers dealt with in general practice will be low.

The overall incidence of eating disorders in the young female population that presents to general practice is approximately 5%.

By raising awareness and being equipped to deal with these patients when they present access to appropriate treatment will be easier for your patients.

Suggestions for identifying patients

• screen high risk individuals using the SCOFF tool
• do a simple search of your computer system looking for patients with recorded BMI less than 17.5
• ask frequent attendees if they have issues with food
• consider an eating disorder in patients presenting with mood disorder
• make all staff aware of the risk of eating disorder and the signs to look for

Suggestions for improving practice

• find out what services are available to patients with eating disorders in your locality
• become familiar with guided self-help cognitive behavioural therapy
• be receptive to concerns from parents, friends or schoolteachers
• remember that adolescents and adults have different treatment needs
• become familiar with and make a list of appropriate resources you can refer your patience or carer to

Suggestions for improving service

• if specialist eating disorder services are not available for both adolescents and adults then you may wish to lobby your primary care organisation
• find out if there are practitioners using CBT-BN in your locality and if not why not?

Summary

The term eating disorders covers a spectrum of conditions that are classified into:-

• anorexia nervosa
• bulimia nervosa
• atypical eating disorder

Anorexia nervosa carries a significant risk of morbidity and has the highest mortality rate for adolescent mental health conditions.

Patients with eating disorders are often secretive about their condition.

Initial presentation may be from a worried parent, friend or schoolteacher.

Primary care has a role to play in all eating disorders

Therapy for eating disorder may be multidisciplinary and multimodal. There is evidence for the use of psychotherapy (particularly CBT-BN) and pharmacotherapy (notably antidepressants)

Many patients who have eating disorder are unidentified

Young females are at highest risk although young males with the condition may remain undiagnosed

Patients with an eating disorder have a higher consultation rate than the general population in general practice

There is a validated screening tool (SCOFF) that consists of five simple questions

References and resources

• Morgan, J. F., F. Reid and J. H. Lacey. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 319: 1467 - 1468, Dec 1999
• Kings college hospital institute of psychiatry 'help for patients and professionals'
• BMJ learning module on anorexia nervosa
• BMJ learning module on bulimia nervosa
• Royal College of psychiatrists template for the initial diagnosis and management of eating disorders
• Eating disorders association. Help and information available to patients and carers.
• A medical risk assessment tool for general practitioners to use in patients with anorexia nervosa
• Durand MA, King M. Specialist treatment versus self-help for bulimia nervosa: a randomised controlled trial in general practice. Br J Gen Prac 2003;53:371-7
• The Royal College of Psychiatrists information site for eating disorders - Professional and patient support with advice for carers.

Books

For professionals

• Treasure J, Schmidt U, Van Furth E. Handbook of eating disorders. Second edition. Hoboken, NJ: John Wiley and Sons Inc, 2003.

Self help (CBT)

• Schmidt U, Treasure J. Getting better bit(e) by bit(e): A survival kit for sufferers of bulimia nervosa and binge eating disorders. London: Psychology Press, 1993.
• Cooper P. Binge eating and bulimia nervosa: a guide to recovery. London: Constable and Robinson, 1995.