This is a UKMLA-centred history guide about eating disorders.

Introduction 

It is estimated that eating disorders affect over 725,000 people in the UK alone. Mortality rates are up to 5x higher for those with anorexia nervosa than for the general population, with anorexia nervosa being the mental health disorder with the highest mortality rate. Understanding eating disorders and their complications is not only important for medical exams, but also means that, as doctors, we can identify, diagnose, and treat those with eating disorders in both primary and secondary care settings. This article covers the definitions, diagnostic tools and features, and management of the most common eating disorders. 

General information on eating disorders 

Definition of an eating disorder 

Ongoing disturbance to eating and/or behaviours related to eating which leads to altered intake or absorption of food. This can have a significant impact on physical and psychological functioning. 

Risk factors for eating disorders 

The cause of eating disorders is not fully understood but is thought to be multifactorial. It is likely that a combination of biological, psychological, and social factors contributes to the development of an eating disorder, with some specific examples outlined below:

General 

• Female sex
• Young age 
• Being overweight as a child 

Biological

• Differences in neurotransmitter activity (eg. serotonin and dopamine)
• Differences in satiety-related hormones (eg. adiponectin and ghrelin)

Psychological 

• Anxiety and depression 
• Neurodivergence
• Personality disorders 
• Traits of perfectionism 
• Poor self-esteem 
• History of sexual abuse 

Social 

• Household stress and poor support 
• Societal pressures 
• Family history of an eating disorder 
• Family history of a psychiatric disorder 
• Family history of substance abuse 

Diagnosis of eating disorders 

Tools 

• The SCOFF questionnaire: https://www.rightdecisions.scot.nhs.uk/media/go5jp0zr/scoff-questionnaire.pdf

• Medical Emergencies in Eating Disorders: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf?sfvrsn=2d327483_67

History taking 

• Ask about symptoms of eating disorders (see below)
• Ask about complications of eating disorders (see below)
• Ask about symptoms of organic causes (eg. changes to bowel habit which may suggest IBD/coeliac) 
• Ask about mental health history and risk 
• Ask about social support and stressors 
• Ask about family history of mental health disorders 
• Ask about medication history 

Examination 

• Calculate BMI 
• Check physical observations (red flags include hypothermia, bradycardia, postural tachycardia, hypotension, and orthostatic hypotension)
• Assess muscle strength using Sit up-Squat-Stand test (scores <2 are red flags) 
• General physical examination

Investigations 

Extensive investigation is seldom required in primary care, although may be helpful in ruling out complications of eating disorders. 

Management of eating disorders 

Primary care

• Consider the need for admission (see below criteria)
• Ensure referral for specialist assessment by eating disorder services in the first instance. Whilst awaiting this, complete the following below:
  • Advise on where to locate support for individuals and their families 
  • Regular review of risk to physical and mental health
  • Monitor and manage potential complications 
  • Advice on dental hygiene for those using self-induced vomiting 
  • Advise gradual reduction of weight-controlling medications 
  • Ensure there is an alert in prescribing records for risks associated with malnutrition 
  • Manage co-morbidities in conjunction with specialists 

When to consider admission 

https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf?sfvrsn=2d327483_67

• Weight or BMI below a safe range 
• Unstable cardiovascular system (e.g. bradycardia/orthostatic hypotension or tachycardia/prolonged QTc)
• Reduced muscle power, as demonstrated on the Sit up-Squat-Stand Test
• Hypothermia
• Infection, otherwise poor health or rapid deterioration 
• Abnormal investigation results (bloods)
• At risk of refeeding syndrome 
• Risk of self-harm or suicide 
• Lack of support at home

Complications of eating disorders 

• Psychological disturbance and social difficulties 
• Changes in family relationships, including carer stress
• Physical health problems due to poor nutritional state (including osteoporosis, infertility, delayed/arrested puberty)
• Death 

Information on specific eating disorders 

Anorexia nervosa 

Definition 

Deliberate restricted intake of food and/or behaviour that interferes with weight gain, due to an intense fear of weight gain and significant distortion of body image, leading to a low body weight. 

Features (not an exhaustive list)

Behavioural changes 

• Selective eating/ruling out certain food groups 
• Avoiding eating in social settings 
• Repeated weighing 
• Body checking 
• Compensatory behaviours, including self-induced vomiting, laxative abuse, excess exercise, medications that suppress the appetite, or diuretics 

Psychological changes 

• Perfectionism 
• Fear of being overweight 
• Body dysmorphia 
• Poor self-esteem

Hormonal changes 

• Amenorrhoea 
• Loss of libido 

Physical changes 

• Weight loss
• Dry skin and hair loss 
• Bradycardia and orthostatic hypotension 
• Hypothermia 
• Loss of muscle strength 
• Constipation 
• Dizziness and fatigue 

Treatment 

Children and young people 

• Anorexia Nervosa-Focused Family Therapy (FT-AN)
• Individual Eating-Disorder-Focused Cognitive Behavioural Therapy-(CBT-ED)
• Adolescent-Focused Psychotherapy for Anorexia Nervosa (AFP-AN)

Adults 

• Individual Eating-Disorder-Focused Cognitive Behavioural Therapy-(CBT-ED)
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
• Specialist Supportive Clinical Management (SSCM)
• Eating Disorder-Focused Focal Psychodynamic Therapy 

Bulimia nervosa 

Definition 

Binging – episodes of uncontrolled eating, consuming a large quantity of food over a short time.

Purging – behaviour to compensate for this uncontrolled eating. Compensatory behaviour can include self-induced vomiting, use of laxatives or excess exercise to avoid weight gain. 

Features (not an exhaustive list)

Binge eating (large quantity over a short time with loss of control) once weekly for at least 3 months, with recurrent compensatory purging once weekly for at least 3 months 

Psychological changes 

• Fear of being overweight 
• Self-worth seen in terms of body weight 
• Depression and anxiety 
• Guilt and shame; secrecy (particularly around eating)
• Self-harm 

Physical changes

• Often a ‘normal’ weight 
• Abdominal pain and bloating 
• GORD and sore throat
• Russell’s sign (calluses on the knuckles from vomiting)
• Parotitis (swelling of the salivary glands)
• Erosion of the dental enamel 

Treatment 

Children and young people 

• Bulimia nervosa focused family therapy (FT-BN)
• Individual Eating-Disorder-Focused Cognitive Behavioural Therapy-(CBT-ED)

Adults 

• Bulimia-nervosa-focused guided self-help 
• Individual Eating-Disorder-Focused Cognitive Behavioural Therapy-(CBT-ED)

Binge eating disorder

Definition 

Binging –  eating a large quantity over a short time without compensatory behaviour. The binge may result in increased eating speed or eating until uncomfortably full. 

Features (not an exhaustive list)

Physical changes 

• Increased weight or obesity 
• Tiredness, difficulty sleeping
• Abdominal pain, bloating and constipation
• Poor skin condition

Behavioural changes 

• Buying large amounts and hoarding food 
• Eating quickly or when not hungry 
• Social withdrawal and isolation
• Irritability and mood swings 

Psychological changes 

• Guilt and shame 
• A sense of being out of control 
• Low confidence and self-esteem 

Treatment 

• Evidence-based self-help programmes 
• Group Cognitive Behavioural Therapy-ED
• Individual Eating-Disorder-Focused Cognitive Behavioural Therapy-(CBT-ED)

Atypical eating disorders 

Definition 

Symptoms of an eating disorder that do not fully meet the full diagnostic criteria. Atypical eating disorders are the most common type of eating disorder.   

Features 

May be a combination of features from different eating disorders 

Treatment 

Consider treatment based on the eating disorder that the presentation most closely resembles 

Further reading and References
 
1. https://cks.nice.org.uk/topics/eating-disorder

2. https://www.who.int/standards/classifications/classification-of-diseases

3. https://www.beateatingdisorders.org.uk

4. https://www.rcpsych.ac.uk/home

5. Oxford Handbook of Psychiatry Fourth Edition, Chapter 9: Eating and impulse-control disorders

6. Medical Emergencies in Eating Disorders: Guidance on Recognition and Management college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf

Written by Dr Emily Ross (FY1)

Reviewed by Dr Harriet Kinahan (CT2)

Edited by Daniel Arbide (FY2)