Eating Disorders Service (Adult)

We recommend professionals use the SCOFF Questionnaire to help determine whether or not a person has an eating disorder. This questionnaire uses five simple screening questions and has been validated in specialist and primary care settings as a reliable screening tool for detecting the existence of Anorexia Nervosa or Bulimia Nervosa in primary or secondary care settings.

A score of 2 or more indicates that there is an 80% chance that the individual has either Anorexia Nervosa or Bulimia Nervosa and that further assessment by specialist eating disorders services is indicated.

Monitoring of physical risk is a crucial part of treatment for individuals with eating disorders. When a service user is under treatment with CONNECT, we request their GP to undergo regular physical health monitoring. CONNECT works closely with primary care services to ensure that GPs are aware of:

• what physical health monitoring is required
• the frequency of physical health monitoring required in each individual case and how this links in with other aspects of an individual’s care plan
• what actions are required if and when concerns are raised
• how to seek advice and consultation if required

A physical health screening assessment should include a minimum of:

• body mass index (BMI) (weight/height²)
• blood investigations (full blood count, urea and electrolytes, phosphate, glucose, creatine kinase, liver function tests)
• tests for proximal myopathy (stand-up, squat test)
• examination of blood pressure (erect and supine), pulse and core temperature
• an electrocardiogram (ECG)

The screening assessment should be completed and interpreted in conjunction with the Physical Risk in Eating Disorders Index (PREDIX) (Table 1), which categorises service users into moderate- or high-risk groups on the basis of the clinical history, physical examination and laboratory investigations. Features from the history that indicate a higher level of physical risk include rapid weight loss (>1 kg/week), excessive exercise at low weight, evidence of infection, symptoms of dehydration, haematemesis, pregnancy and comorbid physical conditions. Cardiovascular symptoms and signs are particularly pertinent, as cardiac arrhythmia is an important cause of death. Urgent medical admission should be considered for service users who fall into the high-risk category as per MEED (2022) guidelines. A medical admission should also be considered for patients in the moderate-risk group, especially if the level of risk is increasing. However, some patients in the moderate-risk group can often be safely managed in a specialist eating disorders unit (SEDU) or in the community with support from the CONNECT community and outreach service. Decisions regarding physical risk should also take into account the service user’s capacity to consent to treatment, motivation to change and availability of local resources.

Table one. Physical Risk Management in Individuals with Eating Disorders (PREDIX) (Jones et al, 2013)

SYSTEM	TEST/INVESTIGATION	MODERATE RISK	HIGH RISK
Nutritional state	BMI Rate of weight loss	<15 >0.5kg/week	<13 >1kg/week
Cardiovascular system	Blood pressure Postural drop Pulse rate Peripheral cyanosis	<90/60 mmHg >10 mmHg <50 bpm	<80/50 mmHg >20 mmHg <40bpm Yes
Musculoskeletal	Stand up or sit up test (proximal myopathy)	Grade 2	Grade 0-1
Temperature		<35°C	<34.5°C
Bone marrow	White cell count Neutrophils Haemoglobin Platelets	Concern if outside normal limits	<2.0 x 109/l <1.0 x 109/l <9.0 g/dl <110 x 109/l
Biochemistry & Liver Function	Potassium Sodium Phosphate ALT	Concern if outside normal limits	<2.5 mmol/l <130 mmol/l <0.5 mmol/l >200 IU/l
Electrocardiogram	Pulse rate Corrected QT interval (QTc) Arrhythmias	<50 bpm	<40 bpm >450 ms Yes

Evaluation of physical risk in eating disorders should be seen as a longitudinal process, with medical monitoring a cornerstone in longer-term care, alongside standard psychological and social interventions. Ongoing physical risk monitoring should include a minimum of:

• BMI
• blood investigations (full blood count, urea and electrolytes, liver function tests, phosphate, magnesium, calcium, glucose, bicarbonate).

For advice and consultation on physical health monitoring, healthcare professionals from primary and secondary care services should contact the service user’s lead professional for further guidance.

In May 2022 The Royal College of Psychiatrists launched the Medical Emergencies in Eating Disorders (MEED) guidance, which replaces both the previous MARSiPAN guidance. MEED guidance is primarily aimed at any clinician likely to encounter someone with an eating disorder but is also relevant to the person themselves and their relatives and carers.

The guidance provides advice on recognising a clinical emergency in a person with any eating disorder and how to provide for the physical, nutritional and psychiatric care in that emergency situation. The goal of this guidance is to make preventable deaths from eating disorders a thing of the past.

The guidance can be found on the Royal College of Psychiatrists website.

Urgent medical admission should be considered for persons presenting with any of the red flag parameters indicating high impending risk to life, bearing in mind that even when seriously unwell, people with eating disorders can appear to be well, with normal blood tests right up to the point of collapse.

The Link-ED Team comprises of link workers and specialists who support local community mental health teams (CMHTs) to provide a tier one level advice and consultation service.

This allows CMHT-based mental health practitioners to provide safe and effective evidence-based treatment (e.g. guided self-help) for individuals who do not meet CONNECT referral criteria or have been discharged from CONNECT after a period of treatment.

As part of the tier 1 level advice and consultation service CONNECT encourages the use of evidence-based guided self-help and endorses the use of the following resources which service users, carers and health professionals may find beneficial:

• Overcoming anorexia nervosa (Freeman and Cooper, 2009). Little Brown Book Group.
• Overcoming bulimia self-help course: A self-help practical manual using cognitive behavioural techniques (3 Book Set) (Cooper, 2007). Robinson.
• Overcoming Bulimia Nervosa and Binge Eating: A Guide to Recovery (Cooper, 1993). Robinson.
• The Invisible Man: A Self-help Guide for Men with Eating Disorders, Compulsive Exercise and Bigorexia (Morgan, 2008). Routledge.
• Skilled-based learning for caring for a loved one with an eating disorder: The new Maudsley method (Treasure, Smith and Crane, 2007). Routledge.

Each region of the West Yorkshire catchment area will have an identified link worker from the local CONNECT community team who:

• provides regular supervision to mental health practitioners and allied health professionals about eating disorder cases
• regular training to CMHT staff on eating disorders, guided self-help and local care pathways
• advice and consultation on accessing the CONNECT service and local MEED pathways

General websites and useful resources

• Beat Eating Disorders (BEAT) website
• NICE guidelines for Eating Disorders
• Medical emergencies in eating disorders (MEED) Guidance on recognition and management
• The Royal College of Psychiatrists – Faculty of Eating Disorders
• Driving and Eating Disorders – Information for Service Users
• Social media and eating disorders

First Episode and Rapid Early Intervention for Eating Disorders (FREED)

FREED stands for ‘First Episode and Rapid Early Intervention Service for Young Adults with Eating Disorders’ and is an early intervention pilot service for young people aged 18 to 25 who have developed an eating disorder within the last three years.

As part of FREED, assessments and treatment are streamlined for early intervention cases as follows:

• the service makes initial contact with the service user by phone or email within 48 hours of receiving the completed referral form to explore the person’s views on treatment and to arrange an initial assessment
• the offer of an initial assessment within 2-4 weeks
• commencement of evidence-based treatment within 2-4 weeks following assessment
• separate FREED therapy groups (MANTRA and CBT-ED)

In addition to this the service has a dedicated FREED champion who supports the four CONNECT Teams in managing the FREED pathway and ensuring that the FREED principles of early intervention, engagement and carers support is upheld across the entire CONNECT service.

Previous studies have shown that the FREED early intervention service model speeds up treatment for eating disorders and has a wide range of benefits, including:

• shorter waiting times
• reducing dropout rates
• promoting more rapid recovery and improved prognosis
• increased service user and carer satisfaction.

For more information on FREED visit www.freedfromed.co.uk

Publications

You can download a full list of publications including original research, policy documents, books and book chapters and training modules.

Training and supervision

We can offer the following training and supervision to health care professionals:

• formal training and supervision to primary care and secondary care professionals to manage eating disorders in primary care/community in line with the NICE (2017) and MEED (2022) guidelines.
• formal training and supervision to acute providers on Medical Emergencies in Eating Disorders (MEED) and support in developing regional and national MEED
• support to develop clinical guidelines and resources including information leaflets and self-help packages
• consultation in complex cases, where an eating disorder is part of the co-morbidity of an individual’s presentation
• training programmes for improving health professionals’ knowledge of eating disorders for timely detection and referrals to appropriate services.