Eating Disorders Service (Adult)

A screening tool for eating disorders called the SCOFF Questionnaire has been developed by John Morgan at Leeds Partnerships NHS Foundation Trust.  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.

We’ve been involved in developing a short video to help GPs to recognise and help people with eating disorders access treatment as early as possible.

Monitoring of physical risk is a crucial part of treatment for individuals with eating disorders and treatment with CONNECT is contingent on regular physical health monitoring by the individuals GP. 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 MARSIPAN (2014) 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 1. 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

Eating disorders encompass physical, psychological and social pathologies that increase risk. Eating disorders cause significant psychiatric morbidity and the adverse physical consequences of dieting, weight loss and purging can sometimes prove fatal with anorexia nervosa having the highest mortality of any psychiatric. In response to these concerns the Royal College of Psychiatrists published the “Management of Really Sick Patients with Anorexia Nervosa” (MARSIPAN) report (2014) which provides guidance on:

• standards of physical assessment for eating disorders
• criteria for admission to both medical units and specialist eating disorder units as well as non-specialist psychiatric units and criteria for transfer between services
• the development of MARSIPAN pathways and a MARSIPAN expert working group for every hospital which admits patients with eating disorders.
• the medical, nutritional and psychiatric management of service users with eating disorders in medical units, including the appropriate use of mental health legislation
• commissioning of services for MARSIPAN service users

CONNECT MARSIPAN pathways

CONNECT provides a consistent approach to MARSIPAN across the West Yorkshire and Harrogate region and formalised MARSIPAN pathways and expert working groups have been developed through partnership arrangements with local mental health providers, primary care services and local acute hospital providers in each of the following delivery areas:

East catchment area

• Leeds: Gastroenterology team, J91/92, Bexley Wing, St James University Hospital.
• Wakefield and Dewsbury: Gastroenterology team, W44, Pinderfields General Hospital.
• Harrogate: Gastroenterology team, Harrogate District Hospital

West catchment area

• Bradford and Airedale: Gastroenterology team, Bradford Royal Infirmary and Airedale General Hospital.
• Calderdale and Huddersfield: Gastroenterology team, Calderdale Royal Hospital and Huddersfield Royal Infirmary

MARSIPAN pathways

An urgent MARSIPAN admission, i.e. admission to a local medical ward for stabilisation of physical risk, should be considered if an individual meets any of the criteria outlined in Table 2. All MARSIPAN referrals should be made to the receiving medical team using the CONNECT MARSIPAN referral form.

Table 2. Criteria for a MARSIPAN admission

Acute medical risk	Clinical Presentation
Starvation with high risk of sudden cardiac death and re-feeding syndrome	BMI <13 Recent weight loss of ≥1 kg for 2 consecutive weeks Little or no nutrition for >5 days
Serious abnormalities in blood parameters	Na <130 mmol/L K <3.0 mmol/L Neutrophils<1.0 x 109/L Raised transaminases (>5 x normal upper limit) Glucose <3.0 mmol/L Raised urea or creatinine
Other symptoms or signs indicating a high level of physical risk	Cardiovascular symptoms (e.g. palpitations, chest pain, postural dizziness, collapse) Proximal myopathy Heart rate <40bpm Core temperature <35°C Serious ECG abnormalities (e.g. QTc >450 ms)

If a MARSIPAN admission is required for a CONNECT service user they will receive weekly support from their lead professional whilst they are on the medical ward. In addition to this a senior doctor from the CONNECT team will provide advice and consultation to the medical and liaison psychiatry teams if required.  Recommended medical treatment options for MARSIPAN patients are outlined in Table 3.

Table 3. Medical treatment options for MARSIPAN patients

Acute medical risk	Setting	Recommended treatment
Starvation with high risk of sudden cardiac death or re-feeding syndrome	Gastroenterology ward	Nasogastric feeding Refeeding supplements Liaison Psychiatry support CONNECT Inreach support
Serious abnormalities in blood parameters	Gastroenterology or medical ward	Stabilisation of physical risk Liaison Psychiatry support CONNECT Inreach support
Other symptoms or signs indicating a high level of physical risk	Gastroenterology or medical ward	Stabilisation of physical risk Liaison Psychiatry support CONNECT Inreach support

 

The CONNECT community teams have a team of link workers who support local community mental health teams (CMHTs) to provide a tier 1 level advice and consultation service which allows CMHT-based mental health practitioners and allied health professionals to provide safe and effective evidence-based treatment (e.g. guided self-help) for individuals who 1) do not meet CONNECT referral criteria or 2) 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 and Harrogate 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 MARSIPAN pathways

General websites and useful resources

• Beat Eating Disorders (BEAT) website
• NICE guidelines for Eating Disorders
• Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
• 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)

CONNECT is one of only four sites in the UK to be involved in the national FREED study. It went live in Leeds in January 2017 in association with South London and Maudsley NHS Foundation Trust (SLaM), the Health Foundation, and the Institute of Psychiatry, Psychology and Neuroscience, where the team is being led by Professor Ulrike Schmidt.

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 4 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.

The FREED study is due to finish in November 2018. However the study has been such a success that the FREED model has been incorporated and upscaled as part of the new CONNECT service.

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 MARSIPAN (2014) guidelines.
• formal training and supervision to acute providers on Management of Really Sick Patients with Anorexia (MARSIPAN) and support in developing regional and national MARSIPAN pathways
• 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.

Our expert clinicians work closely with the media to promote public education, training and awareness of eating disorders. We’ve worked with the BBC, ITV, Sky News, the Guardian, the Times and the Yorkshire Evening Post. Here are a few recent examples:

• Nigel Owens: Bulimia and Me – BBC documentary about male eating disorders broadcast July 2017
• FREED and early intervention – Yorkshire Evening Post
• Eating disorders awareness week 2018 – Yorkshire Evening Post

If you work for a media organisation and you’re interested in eating disorders, you can find out more on how to contact us through our Media page.