Eating Disorders
Red Flags — MEED physical emergency criteria: any single criterion = same-day hospital
| Red flag | Why dangerous | Action |
|---|---|---|
| Resting HR <40 bpm; any cardiac arrhythmia | Malnutrition causes cardiac atrophy (the heart is a muscle), bradycardia, and electrolyte disturbances (hypokalaemia; hypophosphataemia; hypomagnesaemia) that prolong QTc and precipitate life-threatening arrhythmias (ventricular tachycardia; ventricular fibrillation). Sudden cardiac death is the leading cause of mortality in AN. Emma’s HR of 52 bpm is borderline — HR <40 would trigger immediate hospital admission. ECG essential at every assessment. | ECG immediately; electrolytes; same-day eating disorder team or medical admission; no vigorous exercise |
| Blood glucose <3 mmol/L | Starvation hypoglycaemia: impaired hepatic gluconeogenesis from malnutrition; glycogen stores depleted. Life-threatening if severe. In AN: hypoglycaemia may occur without the usual adrenergic symptoms (attenuated response). Can cause sudden loss of consciousness without warning. Immediate glucose replacement required; hospital admission for monitoring. | 999 if unconscious; oral glucose if conscious; IV glucose + thiamine (Pabrinex) if malnourished; hospital admission |
| Severe hypokalaemia (K+ <2.5 mmol/L) | Hypokalaemia from purging (BN) or from starvation (AN — renal potassium wasting): extends QTc; precipitates fatal arrhythmias; causes muscle weakness, ileus, rhabdomyolysis. Mild hypokalaemia (3.0–3.5): oral potassium replacement. Severe (<2.5): IV replacement under cardiac monitoring. Never give IV potassium outside hospital without continuous ECG. | Same-day hospital: IV potassium under cardiac monitoring; ECG; MEED pathway |
| BMI <13 kg/m² (adults); or rapid weight loss >1 kg/week | BMI <13: critical malnutrition; multi-organ failure risk; cardiac atrophy; immunosuppression; bone marrow suppression. Even if the patient appears clinically stable at this weight, there is minimal physiological reserve — any intercurrent illness can be rapidly fatal. Rapid weight loss (>1 kg/week even from a higher BMI): trajectory suggests critical deterioration ahead; same-day eating disorder assessment required regardless of absolute BMI. | Same-day eating disorder service or medical admission; MEED pathway; consider compulsory treatment (MHA) if capacity impaired or refusal with life-threatening risk |
| Severe muscle weakness — unable to stand from seated position without using arms | Profound muscle wasting: reliable bedside indicator of very severe malnutrition. The “squat test” or “stand from chair” test — if the patient cannot rise from a standard chair without using their arms — indicates severe proximal myopathy from protein depletion. Carries very high risk of falls, aspiration, inability to protect airway. Inpatient admission required. | Inpatient admission; MEED pathway; supervised nutritional rehabilitation; physiotherapy assessment |
| QTc >450 ms (women) / >430 ms (men) on ECG | QTc prolongation in AN: from hypokalaemia, hypophosphataemia, hypomagnesaemia, and direct cardiac effects of malnutrition. Risk of Torsades de Pointes (polymorphic VT) → ventricular fibrillation → sudden cardiac death. SSRI antidepressants further prolong QTc — this is why SSRIs are CONTRAINDICATED in underweight AN patients. Any medication that prolongs QTc must be avoided or used only with cardiology input. | Same-day cardiology review; hospital admission; cardiac monitoring; stop any QTc-prolonging medication including SSRIs; electrolyte correction under monitoring |
Safeguarding and Risk Assessment
🕑 Physical Risk to Life
- AN has the highest mortality of any psychiatric disorder: 5–10% long-term mortality from cardiac causes, renal failure, infections, and suicide
- Physical risk assessment at every consultation: BMI; HR; BP (sitting and standing); electrolytes; glucose; ECG
- MEED criteria met → same-day hospital referral regardless of patient wishes; GP has a duty of care
- If Emma had BMI <13, HR <40, or severe electrolyte disturbance: medical admission today, discussion with eating disorder team, and potentially MHA assessment
👨🏫 Under-18s — Parental Involvement and CAMHS
- If the patient is under 18: Child and Adolescent Mental Health Services (CAMHS) eating disorder pathway; parental involvement usually appropriate; Fraser competence assessment if refusing parental involvement
- Young people under 18 with AN refusing food: Section 3 MHA assessment if at serious risk
- Emma is 19: adult eating disorder service; parental involvement only with her consent
- Priya (flatmate) has initiated contact — with Emma’s agreement, Priya may be a supportive contact for care co-ordination
😤 Suicide and Self-Harm Risk
- Suicide is a significant cause of death in AN (second most common cause after cardiac); PHQ-9 and direct suicide risk assessment at every consultation
- Emma: first year of university; significant social and academic adjustment; social isolation (eating alone); amenorrhoea (can worsen mood); loss of school social network — multiple risk factors
- Direct enquiry: "Sometimes when people are going through a difficult time, they have thoughts of harming themselves — have you had any thoughts like that?" — normalising framing; always ask in this population
- If active suicidal ideation: crisis team; crisis plan; safety planning alongside eating disorder referral
📰 Mental Health Act Considerations
- Section 2 MHA: assessment; 28 days; for diagnostic assessment in severe AN where patient refuses voluntary admission
- Section 3 MHA: treatment; 6 months; can authorise nasogastric feeding in patients with capacity (precedent: B v Croydon); and in those without capacity
- The eating disorder itself may impair capacity around food-related decisions even if the patient appears logical in other domains; specialist psychiatric assessment required
- Emma: not currently at a severity threshold for MHA; but document risk assessment and escalation plan
🌟 Control and Mastery
The transition to university has removed Emma’s previous sources of control (familiar school routine; family meals; known friendship group; academic track record). Food restriction and exercise provide a domain of certainty and self-mastery in a life that feels unstable. Asking Emma to eat more is asking her to give up her primary coping mechanism. The GP who acknowledges this explicitly — without endorsing the restriction — takes the eating disorder seriously as a response to a real problem.
"It sounds like eating less and exercising is one of the things that gives you a sense of control when other things feel uncertain. I understand why that feels important. Can I ask — are there other areas of your life where you feel that same sense of being on top of things?"👥 Social Isolation and Identity
Emma eats alone; avoids communal meals; has declined social invitations involving food. The eating disorder has replaced social belonging as a source of identity. This is both a clinical sign and a treatment barrier: the illness is filling the role that normal social connection should fill. Eating disorder recovery requires rebuilding the social connection that was lost — and the eating restriction itself prevents this (social meals are avoided). This vicious cycle must be named in treatment.
"You mentioned you tend to eat on your own in your room. How is that working for you socially? Do you miss having meals with other people? Or does that feel like more of a relief?"🎓 Academic Pressure and Perfectionism
Emma is a first-year psychology student — the academic transition from school (where she knew how to succeed) to university (where the academic bar is higher and the feedback less immediate) creates a competence uncertainty that is threatening to a perfectionist. Dietary control and exercise performance become parallel achievement domains where success is immediately measurable and predictable. This “achievement” function is explicitly addressed in MANTRA (Maudsley Anorexia Nervosa Treatment for Adults).
"How is the psychology course going? Is it what you expected? I ask because for some people, when things feel very demanding academically, finding something else where they feel successful — like exercise — can feel very important."🏡 Home and Family Context
Does Emma’s family know? How were mealtimes at home? Was food or body weight commented on at home? Family dynamics and early messages about food and body image are risk factors for eating disorder development. A critical family culture around food or weight; a parent or sibling with an eating disorder; a history of comments about Emma’s weight — all inform the formulation. Family-based treatment is effective for adolescent AN and may be offered with consent to adults; the GP who explores the family context may identify whether family involvement in treatment would be helpful or counterproductive.
"When you were at home, what were mealtimes like? Was food something that was talked about a lot? And does your family know about how things have changed since you started university?"- Leading immediately with weight or BMI before ICE — "your BMI is 16.2 which is underweight" as the opening gambit closes the conversation with an ambivalent patient
- Arguing with the “I’m being healthy” illness model — increases resistance
- Not performing SCOFF questionnaire — validated screening tool required per NICE NG69
- Not asking about suicide risk — AN has significant suicide mortality; PHQ-9 required
Hospital Admission Today
Same-day medical or eating disorder unit- BMI <13 in adults; or BMI 13–15 with rapid deteriorationLife-threatening malnutrition; multi-organ failure risk; cardiac atrophy
- Resting HR <40 bpm; or QTc >450ms (F) / >430ms (M)Fatal arrhythmia risk; sudden cardiac death; continuous cardiac monitoring required
- Severe electrolyte disturbance: K+ <2.5; glucose <3 mmol/LArrhythmia; seizure; loss of consciousness; IV replacement under monitoring
- Unable to rise from chair without arms (proximal myopathy)Severe protein depletion; falls risk; aspiration risk; inpatient rehabilitation
- BP <80/50 mmHg; syncope; collapseCardiovascular compromise; autonomic failure from malnutrition
Eating Disorder Service within 1 Week
NICE NG69: urgent pathway- BMI 15–17.5; SCOFF ≥2; amenorrhoea; significant weight lossEmma’s current category; eating disorder service urgent referral; weekly physical monitoring in GP
- Bradycardia (HR 40–50); mild electrolyte disturbancePhysical monitoring (ECG; electrolytes) alongside urgent eating disorder referral
4-week Pathway
NICE NG69: routine pathway- SCOFF ≥2; BMI >17.5; no physical risk indicators; OSFED or early AN/BNRoutine eating disorder service referral (4 weeks); GP monthly physical monitoring
- BN or BED; normal weight range; no acute physical riskEating disorder service; guided self-help; fluoxetine 60mg (BN); lisdexamfetamine (BED) if criteria met
- Not referring until “confirmed diagnosis” — NICE NG69 mandates referral on SCOFF ≥2 without diagnostic confirmation; delay worsens prognosis significantly
- Not checking pulse — bradycardia is the most important MEED physical criterion and the one most likely to change management urgency
- Not ordering ECG — QTc prolongation is a life-threatening MEED criterion and determines whether Emma can continue exercising; ECG is mandatory at first eating disorder assessment
"I want to share some of the things I have noticed today. Your heart rate is lower than it should be for someone your age — that is the body’s way of conserving energy when it is not getting enough. Your periods have stopped — and that happens when the body decides it can’t safely support a pregnancy, so it turns off that system. These are not random things — they are connected, and they are connected to not getting enough nutrition. I am not saying this to criticise you or to tell you that what you have been doing is wrong — I am saying it because I want you to understand what your body is communicating. These are early warning signs that I need to take seriously, and so do you. The good news is that they are reversible — the periods come back; the heart rate comes back — with support."
"But I am healthy — I exercise and I eat clean."
"I hear that — and I can see that health matters a lot to you. But I want to show you what ‘healthy’ looks like from your body’s perspective. A healthy heart rate at your age is between 60 and 100 beats per minute. Yours is 52. A healthy body in a woman your age maintains periods — yours have stopped. Your body is telling me it is working harder than it should just to keep you going. That is not what a healthy body feels like on the inside."
"I don’t have an eating disorder — I’m not like those people you see in hospital."
"I understand why you think that. But eating disorders exist on a spectrum, and what I am seeing today — the heart rate, the periods, the weight — tells me your body needs help, whatever label we give it. I am not going to insist on a label. What I am going to do is make sure you see a team who can support you properly — and you will be in control of that conversation."
Normal/near-normal BMI; binge-purge cycles
Russell’s sign; parotid swelling; dental erosion; hypokalaemia. NICE: guided self-help (CBT-BN) first; fluoxetine 60mg OD if psychological therapy unavailable; eating disorder service referral.
BED: binge without purge; ARFID: sensory avoidance; OSFED: partial criteria
BED: guided self-help; lisdexamfetamine (NICE TA607). ARFID: dietitian + psychologist. All: eating disorder service referral per NICE NG69.
- Insisting on the “eating disorder” or “anorexia” label in a patient who is ambivalent — provokes resistance; the body-focused framing is more effective and more empathetic
- Referring to general CMHT instead of specialist eating disorder service — NICE NG69 is explicit: eating disorder service, not CMHT; outcomes are significantly worse with CMHT management
Name the fear before it is stated
Most patients with AN who come to a GP appointment are convinced the GP is going to tell them to eat more, gain weight, or go to hospital. Naming this fear directly — before Emma does — demonstrates that the GP understands her situation and disarms the most common defensive response.
"I want to say something before we go any further. I am not going to hand you a meal plan. I am not going to tell you what to eat or how much. And I am not going to call your parents today without your agreement. What I want to do is make sure your body is safe — and to introduce you to a team who can actually help."Validate the control function without endorsing the restriction
Emma’s restriction is working for her in one sense: it provides a sense of control. Asking her to give this up without understanding it — and without offering anything in its place — will fail. The GP who acknowledges the function of the behaviour while being clear about the physical consequences creates the cognitive dissonance needed for change.
"I understand that the way you’ve been eating and exercising gives you a sense of being in control of something when a lot of other things have felt uncertain since you started university. That makes sense to me. What I want to show you is what that control is costing your body — and that there are other ways to feel in control that don’t carry these costs."Frame the referral as expanding options, not removing them
The referral to an eating disorder service must be framed not as a loss of control (which is Emma’s fear) but as gaining access to a team who can help her achieve the things she actually values — energy to study; feeling warm again; having her periods return; being a full participant in university life. The eating disorder is taking those things away; the eating disorder team can help her get them back.
"The team I want to refer you to — they are going to ask you about your life, what matters to you, what you want your time at university to look like. They will not force anything on you. What they will do is help you think about whether the way things are going right now is actually getting you to where you want to be."Until the eating disorder service has assessed and taken over care, the GP is the primary physical safety monitor. Weekly reviews track: BMI trajectory (improving, static, or deteriorating); HR (bradycardia resolving or worsening); postural BP; energy level. MEED threshold assessment at every visit. Any visit where MEED criteria are newly met: same-day hospital referral regardless of eating disorder team appointment timing.
Brief appointments (10–15 minutes) focused on physical parameters. Document each value with date. Graph BMI over time — visual trajectory is more meaningful than a single measurement. If patient refuses weighing: document; safety-net for physical indicators; escalate to eating disorder team. Do NOT create a punitive atmosphere around weighing.
AN causes the most rapid bone density loss of any condition in young people: hypo-oestrogenaemia from amenorrhoea; low IGF-1 (growth hormone insensitivity in starvation); high cortisol; inadequate dietary calcium and vitamin D. Fracture risk elevated even in young patients. Bone density loss begins within weeks of amenorrhoea. Osteoporosis may be established by the time treatment begins.
Calcium + vitamin D supplementation: prescribed from first GP assessment; does NOT replace weight restoration as the primary bone protection intervention; weight restoration is the most effective intervention for bone density recovery. OCP does NOT protect bone density in AN (NICE NG69). Bisphosphonates: NOT recommended in reproductive-age women (teratogenic; long half-life; potential foetal harm). DEXA scan: if BMI below 17.5 for more than 1 year.
Emma exercises 2–3 hours daily with a resting HR of 52 bpm and pending electrolyte results. Vigorous exercise while bradycardic and potentially hypokalaemic or hypophosphataemic carries a genuine risk of exercise-induced fatal arrhythmia (QTc prolongation + catecholamine surge during exercise = Torsades de Pointes risk). This must be communicated clearly and without ambiguity to Emma. Light activity (walking; gentle stretching) can continue; structured vigorous aerobic exercise must stop until cleared.
"I want to be clear about one thing before you leave. Until we have your blood test results back and your heart trace has been reviewed, I need to ask you not to do your usual exercise sessions. I know this will be difficult — and I want to acknowledge that. But the combination of your heart rate and the tests I am waiting for means that vigorous exercise right now carries a real cardiac risk. Light walking is fine. This is temporary, not permanent."
Emma is a first-year university student: her eating disorder is both a clinical problem and a welfare and academic problem. University welfare officers can: monitor attendance and academic performance; arrange academic accommodations (essay extensions; mitigating circumstances); connect Emma with student counselling. The eating disorder and academic performance are interlinked — cognitive function is impaired by malnutrition; concentration and memory decline. Addressing the academic stress simultaneously with the eating disorder improves overall outcomes.
Contact university welfare officer with Emma’s explicit consent. Do NOT contact the university, Priya, or Emma’s family without her consent (she is 19 — adult). Discuss consent explicitly: "Would it be helpful if I wrote a letter to your university welfare office — you do not have to give them any details you do not want to share."
Emma eats alone in her room; avoids communal meals; has declined social invitations. Social isolation is both a symptom and a perpetuator of the eating disorder — it removes corrective social experiences and deepens the illness-driven food rules. Social eating rehabilitation (eating with Priya even one meal per week) is a therapeutic target in eating disorder treatment. Priya (who brought Emma to the GP) is already a welfare resource — with Emma’s consent, supporting her in social engagement is clinically beneficial.
Priya is in the waiting room. With Emma’s agreement: Priya can be informed of the referral (not of clinical details); can be a welfare contact for the community; can be asked to check in with Emma during the week. Do NOT assign Priya an eating disorder monitoring role — that is the eating disorder team’s responsibility.
Suicide is the second most common cause of death in AN after cardiac causes. Depression is present in the majority of patients with AN (secondary to starvation; biochemical effects of low weight; social isolation; psychosocial stressors). PHQ-9 at every review. Direct suicide risk assessment: "Sometimes when people are going through something as difficult as this, they have thoughts of not wanting to be here — have you had any thoughts like that?" Mandatory question in every eating disorder consultation. Crisis plan: Samaritans 116 123; university mental health crisis line; A&E if immediate risk.
Depression in AN: antidepressants (SSRIs) are NOT effective in underweight patients (NICE NG69; insufficient serotonin substrate in malnutrition) AND carry QTc prolongation risk. Do NOT prescribe SSRIs for comorbid depression in underweight AN — treat the malnutrition first; reassess depression at healthy weight.
- No NICE-approved pharmacotherapy for AN. Nutritional rehabilitation (via eating disorder dietitian and specialist team) is the primary treatment.
- SSRIs: NOT effective in underweight AN (serotonin synthesis requires adequate tryptophan from nutrition; NICE NG69) AND carry QTc prolongation risk in a patient with existing bradycardia and electrolyte derangement. Do NOT prescribe for Emma.
- Olanzapine: off-label; some evidence for reducing anxiety and supporting weight gain at very low doses (2.5–5mg); specialist decision; not GP-initiated.
- Prescribe from first assessment: calcium 1000–1500mg/day + vitamin D 800IU (bone protection). Vitamin B complex if nutritionally depleted.
- Fluoxetine 60mg OD: NICE NG69 first-line pharmacotherapy for BN. Reduces binge-purge frequency by approximately 50%. Evidence: NICE systematic review. The dose is 60mg OD — NOT the standard 20mg antidepressant dose. This is a commonly missed prescribing distinction in SCA examinations.
- Start at 20mg; increase to 60mg over 1–2 weeks if tolerated. Can be combined with CBT-BN (guided self-help) for enhanced outcomes.
- Not effective for AN (weight normalisation is required first). Not appropriate for Emma in her current underweight state.
- Monitor: electrolytes (K+ from purging); dental referral; eating disorder service.
- Lisdexamfetamine (Vyvanse) 30mg OD, titrated to 50–70mg OD: licensed for moderate-to-severe BED (≥3 binge eating episodes/week for ≥3 months). NICE TA607 (2019).
- Only licensed pharmacotherapy specifically for BED. Controlled drug (Schedule 2); prescribing: 4-week supply maximum; specialist initiation recommended.
- Mechanism: CNS stimulant; reduces binge eating frequency; reduces compulsive eating. Not a weight loss drug — the licensed indication is specifically BED.
- CI: cardiovascular disease; hypertension; hyperthyroidism; history of substance misuse. Monitor: BP; HR; weight; mood; risk of stimulant misuse.
Select eating disorder subtype — management guidance
"This tablet helps with the cycle you have been describing — the urge to eat and then the need to compensate. It does not make the urges disappear overnight, but over 4–6 weeks most people find those urges come less often and are less intense. The dose I am giving you is higher than the standard antidepressant dose — 60mg — because that is the dose that works for this. Take it in the morning with food. It may make you feel a bit anxious or nauseous in the first couple of weeks — this settles."
Fluoxetine for BN: dose is 60mg OD — NOT 20mg (one of the most common SCA prescribing errors in eating disorders). Start at 20mg; titrate to 60mg over 1–2 weeks. NICE NG69 first-line pharmacotherapy for BN. NOT for underweight AN (not effective; QTc risk). Combine with guided self-help (CBT-BN). PHQ-9 monitoring. MHRA: increased suicidal ideation under-18s — weekly review first 4 weeks. ECG before starting in any patient with eating disorder (QTc baseline).
"This medication helps reduce the urge to binge — it works on the parts of the brain that drive compulsive behaviour. You might notice your appetite is lower during the day — that is a normal effect. Take it first thing in the morning — if you take it in the afternoon it can affect your sleep. I want to know about any changes in your mood, your heart rate, or if you feel anxious. Because it is a controlled drug, I will prescribe a month’s supply at a time and we will review it regularly."
Lisdexamfetamine (BED): NICE TA607; only licensed medication for BED; moderate-to-severe (≥3 episodes/week ×≥3 months). Schedule 2 controlled drug; 4-week supply; specialist initiation. CI: cardiovascular disease; hypertension; substance misuse history; MAOIs; hyperthyroidism; pregnancy. Monitor: BP; HR; mood; BED frequency; misuse potential. Side effect: decreased appetite — monitor for restrictive eating in BED patients. Not for AN or BN. Morning dosing only.
"I want to prescribe you a vitamin supplement — calcium and vitamin D. These help protect your bones. When periods stop for any reason, the bones can weaken quite quickly because they need oestrogen to maintain their density. These tablets help slow that process while we work on the bigger picture. They do not fix the problem on their own — but they are an important part of looking after you while treatment is underway."
Calcium + vitamin D: prescribed from first GP assessment in ALL AN patients with amenorrhoea or BMI below threshold. DOES NOT replace weight restoration as bone protection (NICE NG69). OCP does NOT protect bone in AN (common misconception). Bisphosphonates: NOT recommended in reproductive-age women with AN (teratogenic; very long half-life). DEXA: if BMI below threshold for >1 year. Calcium carbonate with food; cholecalciferol (D3) OD. Check corrected calcium at baseline. Annual DEXA review if ongoing low BMI.
"The blood tests I am doing include checking some important minerals — particularly potassium and phosphate. These affect how the heart works. If they are low, I will prescribe replacement tablets. These are important to take — low potassium in particular can affect your heart rhythm."
Electrolytes: K+ <2.5 = MEED emergency; hospital same day. K+ 2.5–3.5: oral Sando-K; eating disorder urgent referral; weekly bloods. Phosphate: critically low pre-refeeding = high refeeding syndrome risk; must be corrected before nutritional rehabilitation begins. Refeeding syndrome: insulin during refeeding drives electrolytes intracellularly → hypophosphataemia; cardiac failure; respiratory failure; managed by eating disorder specialist team (not GP). Replace Mg2+ alongside K+ (hypomagnesaemia impairs K+ correction). ECG: QTc affected by all electrolytes.
"This tablet has been prescribed by the specialist eating disorder team — it is not a standard prescription for your condition, and it works by reducing some of the anxiety around eating that can make things very difficult. It may make you feel a bit drowsy at first, particularly if you take it at night. I will be monitoring your heart tracing and some blood tests while you are on it."
Olanzapine in AN: off-label; specialist initiation only; NOT NICE NG69 recommended; low evidence base. GPs should NOT initiate for AN. If specialist has started: GP continues with ECG monitoring (QTc); fasting glucose (metabolic syndrome); weight; mental state review. Correct SCA answer for AN medication: "no NICE-approved first-line medication; nutritional rehabilitation is primary treatment; SSRIs not effective in underweight AN." QTc prolongation risk — ECG mandatory before and during treatment.
"I am going to prescribe some vitamin supplements — a B vitamin, a calcium tablet, and vitamin D. These are to support your body while we get the specialist team involved. They are not a replacement for proper treatment but they are important to start now."
Thiamine in AN: oral thiamine 100mg TDS for all nutritionally depleted AN patients in community. Thiamine BEFORE glucose: applies to ED patients as well as alcohol patients — any malnourished patient receiving IV glucose needs thiamine first. IV Pabrinex: hospital refeeding programme and Wernicke’s treatment. Refeeding syndrome (not managed in GP): slow refeeding + electrolyte pre-correction + thiamine + eating disorder specialist oversight. B complex + folate + B12 (if deficient) as part of community nutritional support alongside eating disorder referral.
Identity and the Disorder
The eating disorder often becomes a core identity in AN — “being the disciplined one”; “the one who doesn’t need much”. Recovery threatens this identity and requires the patient to rebuild a sense of self that is not organised around restriction. MANTRA (Maudsley Anorexia Nervosa Treatment for Adults) specifically addresses the meaning of the AN as a “valued and helpful identity.”
"Part of what we will explore with the team is what you get from things being the way they are right now — not to criticise it, but to understand it, and to think about whether there are other ways of getting those same things that do not cost your body this much."Academic and Functional Impact
Malnutrition impairs cognitive function: concentration; memory; executive function; speed of processing. Emma is trying to succeed academically while cognitively compromised. Her academic performance is likely already suffering even if she does not recognise it. Weight restoration improves cognitive function — the eating disorder is making academic success less likely, not more.
"One thing people sometimes notice is that once the body gets what it needs, thinking becomes clearer — concentration improves; memory improves. The restriction that feels like discipline can actually be making it harder to do the things you care about, like your psychology course."Relationships and Social Life
AN causes progressive social withdrawal: meal avoidance; declining social invitations; friendships organised around food; isolation. This social cost is often the patient’s most accessible point of ambivalence — Emma may recognise she has been withdrawing from Priya and others. Naming this gently — without blaming — introduces the social cost of the eating disorder as a reason for change.
"I noticed you mentioned avoiding the communal kitchen and eating in your room. How has that affected things with Priya and your other flatmates? I ask because sometimes the eating disorder starts to affect our relationships before we realise it."Exercise and Physical Pleasure
Emma exercises 2–3 hours daily but this is compulsive exercise, not pleasurable activity. Compulsive exercise in AN generates anxiety rather than pleasure — missing a session causes distress disproportionate to the event. The GP’s observation: “you exercise a lot — but does it feel enjoyable, or does it feel like something you have to do?” creates a moment of self-reflection that can plant a seed for change.
"When you exercise — how does it feel? Is it something you look forward to, or is it more like something you have to do to feel OK? I ask because there is a difference between exercise that energises you and exercise that you are relying on in a way that has become compulsive."Today — Safety assessment, MEED review, investigations, prescriptions, referral
SCOFF documented (3/5). BMI measured and recorded. HR and BP (sitting and standing) documented. ECG performed. Blood tests: electrolytes; glucose; FBC; LFTs; TFTs; bone profile; amylase; B12; folate; pregnancy test. Prescriptions: calcium 1000–1500mg/day + vitamin D 800IU/day; thiamine 100mg TDS; B complex. Eating disorder service referral made today (urgent pathway; within 1 week). Exercise restriction advised (pending ECG and electrolyte results). Priya’s role discussed with Emma’s consent. PHQ-9 administered. Safety plan agreed. University welfare officer discussion (with consent).
3–5 Days — Blood test and ECG results review
Phone or in-person review of ECG (QTc); electrolytes (particularly K+ and PO4); glucose; FBC. If MEED criteria met on results: same-day hospital referral. If mild electrolyte disturbance: oral replacement; eating disorder service contact. If all normal: continue current plan; confirm eating disorder service appointment received. Pregnancy test result discussed. Exercise advice confirmed based on ECG and electrolytes.
1 Week — Eating disorder service first appointment (NICE NG69 target)
Emma should have been seen by the specialist eating disorder team within 1 week (NICE NG69 urgent pathway). GP confirms attendance. If Emma did not attend: welfare check; re-engage; consider MHA assessment if significant deterioration. Weekly GP physical monitoring continues until eating disorder team confirms they have taken over care plan. Repeat BMI; HR; BP; MEED assessment.
Monthly — Shared care physical monitoring
GP continues monthly physical monitoring (BMI; HR; BP; electrolytes) as part of shared care while eating disorder team manages psychological treatment and nutritional rehabilitation. PHQ-9 monthly. DEXA if BMI below threshold for 1 year. Annual review of calcium + vitamin D. MEED criteria reassessed at every visit — if met at any point: same-day hospital referral regardless of psychological treatment status.
The MEED monitoring rule for every GP contact
At every GP appointment for a patient with an eating disorder, assess the MEED physical safety criteria: BMI (measured, not estimated); resting HR (<40 = emergency; 40–50 = urgent); standing and sitting BP (<80/50 = emergency; postural drop >20 mmHg = significant); blood glucose (<3 mmol/L = emergency); K+ (<2.5 mmol/L = emergency); QTc on ECG (>450 ms women = emergency); muscle strength (unable to stand from chair without arms = emergency). Any single criterion = same-day hospital regardless of eating disorder team appointment status.
⚠ Three safety-net conversations for Emma
Documentation requirements
- Prescribing SSRIs for Emma’s mood — contraindicated in underweight AN; not effective; QTc risk; NICE NG69 does not recommend
- Not referring to eating disorder service — or referring to CMHT instead — NICE NG69 specific: specialist eating disorder service
- Waiting for confirmed diagnosis before referral — NICE NG69 mandates referral on SCOFF ≥2 without diagnostic confirmation
- Not assessing suicide risk — AN has significant suicide mortality; PHQ-9 and direct enquiry mandatory
- SCOFF administered and scored; MEED physical assessment complete
- Eating disorder service referral: urgent; within 1 week; not CMHT
- No SSRIs prescribed (underweight AN; QTc risk; not effective)
- Calcium + vitamin D; thiamine; B complex prescribed
- Exercise restriction advised (pending cardiac results)
- ECG ordered (QTc); electrolytes (K+; PO4); pregnancy test
- PHQ-9 and suicide risk assessed
- Reluctance acknowledged; Emma’s consultation not Priya’s
- Illness model ("I’m being healthy") explored not confronted
- Fear of weight gain addressed directly
- Control function of restriction acknowledged
- Referral framed as expanding options, not removing them
- Non-label framing ("what your body is telling me")
Who you are
Emma Carter, 19, first-year psychology student at a city university. High achiever at school (3 A*s at A-level). First time living away from home. Parents are in the Midlands. Flatmate Priya (who came with her) has been her closest friend since starting university. She had a strong friendship group at school but has found it difficult to replicate that at university. She arrived 4 months ago and has been restricting what she eats since then; she tells herself this is about health and discipline. She runs for 2–3 hours daily before lectures. She eats in her room to avoid others seeing how little she eats. She knows something is wrong but is terrified of what it means to admit it. She is extremely bright and articulate — and uses that intelligence to deflect clinical questions.
Hidden details — disclose only if asked
Periods (disclose if asked directly): "They stopped about 3 months ago. I was a bit relieved — less hassle. Is that a problem?" Clearly does not connect this to her eating pattern; if GP links it: visibly unsettled.
Social isolation (disclose if asked about meals or friends): "I eat in my room. It’s just easier. I don’t want people watching me eat — or asking questions." If asked how she feels about eating with others: "It makes me anxious. I don’t know why."
Control (disclose if asked about why the exercise matters or what eating less feels like): "It’s the one thing I have got right since coming here. Everything else feels uncertain — the course is harder than I expected; I don’t know anyone really; home feels very far. But if I stick to what I eat and do my run, I feel like I have done something right." This is the key self-disclosure — the control function. If GP explores it: Emma becomes more thoughtful and less defensive.
Suicide (respond to compassionate direct enquiry): "Not exactly. I sometimes think things would be simpler if I just … stopped. Not in a dramatic way. Just … stopped." This warrants a PHQ-9 and careful safety assessment; she is not actively suicidal but is experiencing passive suicidal ideation. Crisis plan should be discussed; this should not end the consultation without a safety plan.
Reactions
- On "you have an eating disorder / anorexia": defensive; closes down; "I knew you’d say that; I told Priya this was a waste of time." If GP avoids labels and uses body-evidence: more open.
- On "I’m not going to tell you what to eat": visible relaxation; "OK. That’s … actually that’s helpful to hear."
- On amenorrhoea linked to eating: genuine surprise; "I didn’t know those two things were connected." This is a moment of real engagement.
- On control function named by GP: "Yes. That’s … exactly it. I hadn’t said that out loud before." Emotionally significant; GP should pause and stay with it.
- On eating disorder service: initially resistant; if framed as "they will listen to what your life is like and help you decide what you want" — becomes cautiously open: "I suppose I could meet them once."
- Challenge line: "If I go to the eating disorder team, they are going to make me gain weight, aren’t they? That’s what this is all about, isn’t it?"
Clinical details
- BMI: 16.2 (weight 47 kg; height 1.70 m). Loss of approximately 8 kg since university (4 months ago).
- HR: 52 bpm resting (borderline bradycardia)
- BP: 112/68 sitting; 104/62 standing (mild postural drop — not significant)
- Lanugo: absent. Russell’s sign: absent. Parotid: normal. No purging behaviour.
- SCOFF: 3/5 (C, O, F positive)
- PHQ-9: 14 (moderate depression; passive suicidal ideation Q9 = 1)
- No significant PMH. No medications. No substance misuse. No family history of eating disorder that she knows of. Mother comments on food sometimes ("she’s always on some diet"). Father rarely comments on appearance.
Resolution: Emma agrees to attend the eating disorder service if: (1) the GP explicitly states they are not going to impose weight gain on her; (2) the control function is acknowledged without judgement; (3) the referral is framed as a conversation rather than a treatment mandate; (4) the amenorrhoea-eating connection is made clearly (a new piece of information that Emma finds genuinely engaging); (5) the cardiac safety concern is presented factually without alarmism; (6) Emma is told she will be called in 3 days. She says: "OK — I’ll go once. But I’m not promising anything." This is the realistic achievable outcome for this consultation.
| Parameter | Emergency Threshold | Clinical Significance |
|---|---|---|
| Heart rate | <40 bpm | Bradycardia — cardiac arrest risk |
| Blood pressure | <80/50 mmHg | Haemodynamic compromise |
| Potassium | <2.5 mmol/L | Fatal arrhythmia risk |
| Blood glucose | <3 mmol/L | Hypoglycaemia |
| QTc (ECG) | >450ms (F) / >430ms (M) | Ventricular arrhythmia |
| Muscle power | Unable to stand from chair without arms | Severe proximal myopathy |
| Rapid weight loss | >1 kg/week | Trajectory risk |
| Feature | Anorexia Nervosa | Bulimia Nervosa | Binge Eating Disorder |
|---|---|---|---|
| Core behaviour | Restriction ± purging; compulsive exercise | Binge-purge cycles; compensatory behaviour | Binge without compensation |
| Weight | Low — but not always severe | Usually normal or above | Often elevated |
| Amenorrhoea | Common (functional hypothalamic) | May occur | Uncommon |
| First-line Rx | Nutritional rehabilitation; psychological support; NICE eating disorder service | CBT-ED; guided self-help; fluoxetine 60mg OD | CBT-ED; lisdexamfetamine (NICE TA607; specialist) |
| Medication | None (NICE); SSRIs ineffective when underweight — QTc risk | Fluoxetine 60mg OD (NOT 20mg); 3–9 month course | Lisdexamfetamine; Schedule 2; specialist initiation |
| Bone protection | Calcium + VitD; NOT bisphosphonates (teratogenic); OCP does not protect density | Standard fracture risk assessment if amenorrhoea | Standard assessment |
| Investigation | Rationale | Timing |
|---|---|---|
| ECG (QTc) | Arrhythmia risk; baseline before any medication | First assessment; repeat if QTc borderline |
| U&E + electrolytes | Potassium, phosphate, magnesium (purging; refeeding) | First assessment; frequency guided by risk |
| Blood glucose | Hypoglycaemia in severe restriction | First assessment |
| FBC | Anaemia; leucopenia in AN | First assessment |
| LFTs | Hepatic steatosis in AN; before medications | First assessment |
| TFTs | Exclude hypothyroidism (weight loss, amenorrhoea) | First assessment |
| Pregnancy test | Amenorrhoea; not all amenorrhoea is functional | First assessment (if amenorrhoea) |
| DEXA scan | Bone density — refer after 1 year of sustained AN | Via eating disorder service |