Signs and Symptoms

Link for initial screening, please refer to GP screening tool attached

Assessment (DSM-5 criteria)

What is Anorexia Nervosa?

1. Persistent restriction of energy intake leading to significant weight loss (in context of what is minimally expected for age, sex, developmental trajectory and physical health)
2. Either an intense fear of weight gain or becoming fat, or persistent behaviours that interferes with weight gain (despite being significantly low weight)
3. Disturbance in the way one's body weight or shape is experienced, over-evaluation of own weight/shape or persistent lack of recognition of the seriousness of current low weight

What is Bulimia Nervosa?

Triad of:

1. Recurrent episodes of binge eating excessive amounts of food (e.g. 2 hours period) that one cannot stop or control how much one is eating
2. Over-evaluation of shape and or weight with BMI either average or above
3. Recurrent compensatory behaviours to prevent weight gain, this may include self-induced vomiting, laxatives or diuretics or other medications (prescribed or not) misuse, fasting or excessive exercise

What is Binge Eating Disorder?

1. Recurrent & persistent episodes of binge eating (over 3 months)
2. Absence of compensatory behaviours
3. Marked distress regarding binge eating

History and Examination

Please refer to GP screening tool and the Maudsley guide to medical risk assessment

Differential Diagnoses

• Chronic debilitating physical disease
• Brain tumours
• GI disorders e.g.: Crohn's disease, malabsorption syndrome
• Loss of or increase appetite, secondary to drugs e.g. SSRI, amphetamines
• Depression/OCD

Management of Anorexia Nervosa in primary care

• Rapid exclusion of other conditions
• Risk assessment: BMI, Sit up-Squat-Stand (SUSS) Test, bloods, ECG
• Refer if rapid weight loss or BMI less than 17.5, also refer urgently to CMHT if BMI less than 15

Please refer to the Maudsley guide to medical risk assessment

If there are identified physical risks, GP should continue to maintain physical assessment in accordance with NICE recommendations.

Referral Criteria

Severe Eating Disorder Consultation and Assessment Service (SEDCAS)

All external referrals must initially be directed to and assessed by the Community Mental Health Team (CMHT) and accepted onto caseload by CMHT and allocated a care co-ordinator prior to SEDCAS involvement.

If a patient is taken onto CMHT caseload, they will have access to the Plymouth Eating Disorder Care Pathway
If a referral is not accepted onto CMHT caseload, SEDCAS may still provide consultation and advice to professional referrers/GP's etc.

SEDCAS accepts referrals for people age 18 or over who are affected by Anorexia Nervosa and Bulimia Nervosa. Referrals can be accepted for young people aged 17.5 onwards in accordance with PCH current Transition Policy

Community Eating Disorder Service (EDS) – Plymouth

• EDS accepts referrals for people affected by Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder
• The service will accept referrals from professionals as well as self-referrals
• The services works with clients age 18 or over but will accept referrals for clients aged 17.5 onwards to facilitate a gradual transition process. (EDS Transition Policy available on request)
• Referrals can be made via telephone, fax, post and email
• If there are identified physical risks e.g. BMI 15 or below or weight dropping consistently and likely to continue to fall to this level, then clients must be referred to CMHT concurrently in order to access CMHT and SECAS support
• When referrals are received and accepted, dependent on risk levels, see Plymouth Eating Disorders Care Pathway for further clarification
• After assessment, if clients are appropriate for the service, a clear plan of input will be drawn up (post-assessment letters sent to referrers and client), clients will be placed on the waiting list before commencing contracted therapy of 20 – 30 sessions (variable according to the models of input offered)
• Three months must lapse after completion of therapy (either at EDS or other services) before clients can be referred again. This allows time/space for clients to process/assimilate previous input
• Where clients have mental health or other health co-morbidities/risks, it is necessary to have information of services involved to ensure communication or joint working to maintain safety/support

Helpful information for referral – if available

• Eating Disorder history, if relevant and available. Detailed mental health information would help to decide appropriateness of referral or if alternative services may be required
• Physical investigations results e.g. blood chemistry, weight, height and or BMI
• Other physical or psychological (psychiatric) problems/risks (include drug/alcohol dependency) and prescribed medications
• Other social difficulties or potential risks e.g. vulnerable children, child protection, education, employment.
• Other services (statutory or non-statutory) involvement with clients

If there are identified physical risks, GP should continue to maintain physical assessments in accordance to NICE recommendations.

NICE guidelines for eating disorders (2004)

A guide to the medical risk assessment for eating disorders

Referral Instructions

e-Referral Service Selection

• Specialty: Mental Health - Adults of all ages
• Clinic Type: Eating Disorders
• Service: DRSS-Western-Mental Health-Adult- Devon ICB-15N

GP Information

NICE guidelines for eating disorders (2004)

A guide to the medical risk assessment for eating disorders

Plymouth Community Healthcare Severe Eating Disorder Consultation & Assessment Service (SEDCAS)

SEDCAS leaflet

Patient Information

Anorexia and Bulimia Care

Beat – eating disorders charity

NHS Choices - Eating disorders

Long-term Condition Self-Management Programme

GPs and patients can refer to Improving Lives Plymouth for patient support with any long-term physical or low level mental health condition. The service helps people to better manage their condition and to achieve a better quality of life.

Evidence

NICE guidelines for eating disorders (2004)

Pathway Group

This guideline has been signed off by the Psychological Therapies Strategic and Implementation Group on behalf of NHS Devon.

Publication date: December 2015
Updated: October 2018