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Growth of fine hair on the face or back. Preoccupation with weight and weighing Concerns expressed by parents, teachers or others involved with the individual.


available (see Box 1).6


A simple five-question screening tool known as ‘SCOFF’ is If there are two or more positive answers


then this should raise suspicion that the individual may have an eating disorder and further assessment is required.


ASSESSMENT To undertake further assessment the following areas need to be included: Eating disorder symptoms/behaviours/history. Co-morbidity. Physical concerns: weight, height, menstruation. Treatment history: what worked in the past? Goals for any treatment. Carers concerns/information


As noted earlier, individuals may disguise their illness out of fear


that the control they have will be taken away. This can be frustrat- ing for clinicians, so keeping a focus on engagement and the initial clinical management, weight, height, and biochemistry can help to establish stability in a crisis. Then, building motivation for change is important, and this can be achieved by adopting an empathic approach to encourage the individual to tell you about their illness and its impact.7


The clinician avoids making the case for change


but through skilful listening and reflection prompts the individual to consider the pros and cons of the effects the disorder has on their life, and how they see their life in the future with and without it.8 Referral onward should, where possible, be to a specialist ED


start to when they begin an attempt to lose weight. This drive to lose weight often occurs at times in the individual’s life when they are confronted by issues that they find difficult; for example, at puberty where issues of sexuality and responsibility arise. Also, ED behaviours, such as restricting intake, binge eating or purging, can alter brain chemistry and make the ED worse and recovery harder.


RECOGNITION EDs can be difficult to detect because illness-related factors, such as shame, denial, and secrecy can mean that those with these disorders hide the full extent of their difficulties.5


For primary care


clinicians, the relative rarity of EDs may mean that they have limited experience of recognising these disorders. It is important to remember that anyone can have an eating disorder, although they mainly affect young women. However, men, younger children and older people are also at risk of developing an ED. A key factor in identifying those with an ED is for the clinician to think that an eating disorder is a possible diagnosis. To help with this, other signs to look out for are outlined below: Weight loss or weight fluctuations between consultations. Reporting feeling cold most of the time, even in warm tempera- tures. Changes to, or loss of, menstruation in women. Swelling around the cheeks, calluses on knuckles, or damage to teeth caused by vomiting or fainting. Complaining of being fat when a healthy weight or underweight. Complaining of tiredness. Reporting excessive exercise.


service, and clinicians in primary care should be aware of how and where to refer to their local ED service. The service should also provide telephone advice and support if you are uncertain about the care of an individual you suspect may have an ED.


TREATMENTS The National Institute of Health and Clinical Excellence (NICE) published guidance on the treatment of EDs in 2004, with a total of 102 recommendations of which 51 had particular relevance to primary care.9


A small proportion of those with EDs require


inpatient treatment, however the vast majority of treatment should be carried out on an outpatient basis.9


NICE highlighted the special


attention to be given to children and adolescents with EDs as their needs differ significantly from adults, for example the increased risks associated with weight loss in this group and the differing legal frameworks that are used to determine compliance with care. Also, the treatment of choice for younger patients is family therapy, in contrast to the individual therapies recommended for adults. Cognitive behavioural therapy (CBT) is the treatment of choice


for BN. CBT focuses on helping the individual to establish a regular eating pattern, to reduce binge and purge episodes, and challenge the concern with body shape and weight which is the central drive for the ED behaviours. Other psychological interventions focus on the interpersonal life of the individual. Adults with BN may be offered a trial of an antidepressant, and selective serotonin reuptake inhibitors (specifically Fluoxetine) are the only drugs recommended. Very few drugs are recommended for children and adolescents younger than 18 years of age; and they should not be


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