• Physical – loss of weight, fainting/dizziness, loss of energy, muscle weakness, sleep disturbance, susceptibility to infection, loss of menstruation, constipation/bloating, repeated vomiting, swollen glands under the jaw or frequent dental problems (if there is repeated vomiting).
• Behavioural changes – counting calories, restricting the amount or range of food eaten, eating alone or missing meals, secretiveness, hiding food, frequent visits to the toilet, taking a long time to eat meals, cutting food into small pieces, excessive body-checking, over-exercising, wearing baggy clothes.
• Psychological – preoccupation with food and eating, concerns about weight and shape, feeling compelled to restrict intake, fear of eating.

Non-specific signs that may accompany eating disorders

• Psychological – low mood, loss of interest, poor concentration, withdrawal, disturbed family relationships
• Social/educational – withdrawal from family and friends, loss of interest in activities, poor concentration, difficult family relationships

NB The non-specific signs may also be a feature of other mental health disorders such as depression or anxiety

Diagnostic features

Anorexia nervosa

• Weight loss at least 15% below the body weight expected (or BMI less than 17.5) or failure to gain weight as part of normal growth and development.
• Weight loss is self-induced by avoidance of “fattening “ foods
• Over-evaluation of weight or shape
• Abnormal hormonal function (loss of menstruation in females)

Bulimia Nervosa

• Recurrent binge eating
• Purging (self-induced vomiting, laxative or diuretic abuse, restrictive dieting or over-exercise)
• Over-evaluation of weight and shape

Other feeding or eating disorders

• Eating disorder symptoms that do not meet all the above criteria although cause significant concern/impact (common in young people)

Clarification of history and symptoms of eating disorder as above, along with a brief summary of family and personal background. Useful questions (some adapted from the SCOFF questionnaire) include:

• Are you trying to lose weight?
• Do you ever make yourself sick after eating?
• Do you worry about losing control of your eating?
• Do you think you are fat when others say you are too thin?
• Would you say that food dominates your life?

Physical assessment and investigations

If an eating disorder is suspected, physical assessment is indicated to exclude other causes of low weight and identify any physical consequences of the disorder.

This will include weight and height, BP and PR as well as more general examination to exclude other causes of weight loss. For those with low pulse rate (under 50) an ECG may be indicated to identify any serious cardiac abnormalities.

Recommended initial blood investigations include: FBC; ESR/CRP; urea and electrolytes (including phosphate, Mg, Ca); liver function tests, glucose, folate, B12; Iron; coeliac screen, thyroid function tests.

Once the referral has been assessed by the CAMHS ED service, any further blood investigations will ordered by the Eating Disorder Service and the patient asked to attend the phlebotomist at their local GP practice or Paediatrics outpatients. In rare circumstances the GP may be asked to regularly review the young person’s weight and physical health (if the patient will not engage with CAMHS and is at risk, but will agree to be reviewed by the GP).

Care Programme Approach

The young person will be treated within a CPA framework. This is a structured approach to care, involving the allocation of a care-coordinator, creating a care plan and having regular reviews. The GP may be invited to join CPA reviews, particularly at the time of discharge. If the GP is unable to attend the review, a clinician from the ED service may approach the GP for an update or to share information.