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Mental Health

Eating Disorders

A framework for recognising restrictive, bingeing and compensatory eating patterns, identifying medical and psychiatric emergencies, and matching the person to specialist, diagnosis-specific treatment.

In a nutshell

Eating disorders are defined by disordered eating and distress, not by body size. Restriction with significantly low weight suggests anorexia nervosa, bingeing with regular compensation suggests bulimia nervosa, and bingeing without regular compensation suggests binge eating disorder. Assess cardiac, electrolyte, refeeding, psychiatric and safeguarding risk in every pattern, then provide diagnosis-specific specialist psychological treatment.

Recognise the pattern and the risk1,2,4,3

Ask directly about restriction, bingeing, loss of control and compensation, then assess cardiovascular, electrolyte, refeeding, psychiatric and safeguarding risk. Refer early to specialist care and do not use BMI, appearance or duration alone to determine whether treatment is needed.

Immediate safety sequence

  1. Escalate emergencies

    Escalate cardiovascular instability, severe electrolyte or glucose disturbance, dehydration, renal injury, arrhythmia, reduced consciousness, gastrointestinal bleeding, suspected refeeding complication or acute suicide risk.1,4,5

  2. Refeed safely

    Use a trained nutritional and refeeding pathway with dietetic and medical input, thiamine and serial electrolytes when malnutrition or refeeding risk is significant.1,4,9

  3. Match the treatment

    Match treatment to the pattern: specialist nutritional and psychological treatment for anorexia, and CBT-based guided self-help followed by CBT-ED for bulimia or binge eating disorder when appropriate.1,6,5,7

Diagnosis-specific treatment anchors

Anorexia nervosa

Specialist nutritional rehabilitation and psychological therapy; adults may receive CBT-ED, MANTRA or SSCM, while family-focused treatment is central for many young people.1,6

Bulimia nervosa

Stabilise purging-related medical risk, then offer bulimia-focused guided self-help for adults and step up to CBT-ED; use family-focused care for many young people.1,5

Binge eating disorder

Offer CBT-based guided self-help followed by group or individual CBT-ED; regular eating is central and weight loss is not the therapy target.1,7

ARFID or OSFED

Use specialist assessment and adapt treatment to the closest clinical pattern, nutritional risk, developmental needs and the reason for food avoidance.1,3

Shared care and escalation1,8,9

Coordinate mental-health, medical, dietetic, paediatric, diabetes, obstetric and safeguarding care. Medication may treat comorbidity but is not the sole treatment for the eating disorder; check the BNF for cardiac, electrolyte and interaction risks.

Exam traps

  • A normal weight does not exclude bulimia or a dangerous electrolyte disturbance.
  • A high weight does not turn binge eating disorder into a lifestyle problem or remove the need for psychological treatment.
  • Do not use a screening score, BMI or one vital sign in isolation to decide on diagnosis, admission or treatment.
  • Medication is not sole treatment for anorexia or bulimia, and antidepressants do not replace CBT-based care for binge eating disorder.
  • A change from bingeing without compensation to regular purging changes the risk assessment and diagnosis.
  • Refeeding risk is assessed from nutritional history and clinical context, not only from a single baseline phosphate.

Illustrations

Palatal dental erosion associated with purgingIntraoral photograph showing smooth enamel loss and exposed dentine on palatal tooth surfaces after repeated gastric-acid exposure; a clinical clue to vomiting, not a diagnostic requirement.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE NG69: Eating disorders: recognition and treatment (NICE guidance on recognition, assessment, treatment, monitoring, refeeding and inpatient care for eating disorders)Published 23 May 2017 | Updated 16 Dec 2020
  2. NICE: 2024 exceptional surveillance of NG69 (NICE surveillance found no change to current NG69 recommendations for psychological therapies, medication or compulsory treatment)
  3. NHS: Overview of eating disorders (NHS information on eating-disorder patterns, warning signs, referral and treatment)
  4. Royal College of Psychiatrists CR233: Medical emergencies in eating disorders (MEED) (UK expert guidance on recognition and management of medical emergencies in eating disorders; supersedes CR168 and CR189)Published 1 May 2022
  5. NHS: Bulimia (NHS information on symptoms, physical complications, treatment and urgent support for bulimia nervosa)
  6. NHS: Treatment for anorexia nervosa (NHS information on specialist therapy, nutritional support, physical monitoring, hospital care and compulsory treatment as a last resort)
  7. NHS: Treatment for binge eating disorder (NHS information on guided self-help, CBT, avoiding dieting during treatment and the limited role of antidepressants)
  8. NHS England: Eating disorder services for children and young people: national guidance (National service guidance on integrated, collaborative and intensive community or inpatient care for children and young people)
  9. BNF online (Check current psychotropic, nutritional-medicine and electrolyte-related monographs for contraindications, interactions, adverse effects and special populations)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.