Tier 3 Specialist Eating Disorders Service
Link Lecturer: Anne-Marie Evans
Nursing Mentor: Emma-Jayne Hagerty
December 2014
1
Introduction ................................................................................................................ 3
What to expect. ...................................................................................................... 3
Student Philosophy .............................................................................................. 3
Team members ...................................................................................................... 4
The service.................................................................................................................. 4
Service aim ............................................................................................................. 4
Functions of the Tier 3 Service ......................................................................... 5
Research within the service ............................................................................... 6
Referral Pathway ....................................................................................................... 8
Specialised Community Eating Disorder Service .......................................... 10
Functions of SCEDS meetings ........................................................................ 10
The Designated Contact .................................................................................... 11
Policies and Procedures ....................................................................................... 13
National Guidelines and Policies .................................................................... 13
Aneurin Bevan Health Board Policies, Procedures and Guidance ....... 13
The Eating Disorders Framework for Wales .................................................... 14
Intelligent Targets ................................................................................................... 15
Eating Disorders...................................................................................................... 17
Effects of eating disorders ................................................................................... 18
Assessment tools ................................................................................................... 19
Interventions provided by Tier 3 ......................................................................... 21
Placement Checklist ............................................................................................... 25
Learning Section ..................................................................................................... 25
Evaluation ................................................................................................................. 32
2
Introduction
Welcome to the Tier 3 Specialist Eating Disorder Service; we are small team
of Specialist clinicians based in Maindiff Court Hospital, Abergavenny allowing
an accessible proximity to all 5 boroughs in Gwent and across South Powys.
What to expect.
Your first day will begin with meeting with your mentor and an introduction to
other members of the team. You will be orientated to the building and your
mentor will go through all relevant health and safety aspects. Once this has
been completed, your learning objectives for the placement will be discussed.
This pack contains information regarding our service and a learning section
which you will be encouraged to complete during your time here.
Our working hours are Monday-Friday 9am-5pm excluding bank holiday. In
order to make the most of your placement you need to be prepared for a lot of
travelling as we cover a wide geographical area. If you have any difficulties
with this, please speak to your mentor. We do not have any on site access to
food; however, we do have a microwave, toaster, kettle and fridge that you
are welcome to use. You can purchase food from the shops or bakery in the
local town which is a short drive away. Due to the cost of parking in town you
may find it preferable to bring your own food.
Student Philosophy
Our aim is to provide a welcoming, supportive environment that promotes
learning and professional development. We will be flexible to your individual
needs in order to assist you in achieving your personal and educational
objectives. We hope you build relationships with the members of the team
that will promote open discussion and enhance your learning.
3
Team members
Tier 3 Clinical Lead
Gerrard
McCullagh
01873 735575
Specialist Clinician
Emma Hagerty
01873 735519
Bev Davies
01873 735517
Donna Williams
01873 735537
Occupational Therapist
Dietitian
Admin
01873 735500
The service
Service aim
Our aim is to ensure that service provision for eating disorders is high quality,
and innovative, equitably delivered across Gwent and South Powys. We will
do this in partnership with; Tier 1, Tier 2 mental health and acute medical
colleagues, service users and carer and third sector services.
Our aim is to
nurture a working ethos that values the sufferers’ and carers’ knowledge and
experience as a valid source of evidence in tandem with scientific evidence
and expert opinion, to inform clinical practice and service development.
ABHB and South Powys have a robust tier 2 infrastructure for eating
disorders. There is a designated contact with 2 ring fenced sessions for eating
disorders within each CMHT in Gwent and South Powys and a Specialist Tier
2 Eating Disorder Lead Clinician post to support the CMHT and the
implementation of the 5 Standards identified within the Eating Disorders
Framework.
4
Functions of the Tier 3 Service
The Tier 3 Specialist Eating Disorder Service (SEDS) for Gwent and South
Powys provide consultation, support and direct joint working to Tier 2 and
allied clinicians. The Tier 3 Specialist ED Service provides individual, group
and family interventions and has an explicit 'Gate keeping' role for any
patients requiring referral to the Tier 4 provision and non emergency access to
the Acute medical Bed at ward 4/3 in Nevill Hall hospital.
The Tier 3 SEDS works in partnership with colleagues across the disciplines
within Tier 2 Community mental health teams n.b care coordinator role
remains with the CMHT. The majority of referrals will be planned through the
Specialized Community Eating Disorders Service (SCEDS). Fortnightly
SCEDS meetings are hosted by the Tier 3 SEDS and attended by the
Designated ED Contacts from each of the CMHTs, the Dietitians and any
clinician requesting a consultation/formulation slot.
The Tier 3 SEDS will offer consultation and joint assessment for any case
where there is:

A lack of clarity about diagnosis

Lack of progress in Tier 2 services

Escalating risk or complexity across any of the presenting
dimensions
The Tier 3 SEDS will in collaboration with CMHTs:

Work with high risk and or complex cases of eating disorders that
require specialist intervention and meet DSM IV criteria for
anorexia
nervosa,
bulimia
nervosa
and
binge
eating
disorder.

Provide community interventions delivered to try to prevent
escalation of risk and complexity.

Provide a gate keeping role for those patients whose level of risk
and complexity are such that they would require admission to a
Tier 4 specialist eating disorder unit.
5

Provide a lead role in the planned admission of patient with high
medical risk to the designated ED bed on ward 4/3 at Nevill Hall
Hospital.

Undertake a joint assessment of eating disorders manifesting
across physical, psychological, psychosocial and risk domains.

Provide a range of individual, group and family therapies for
medium to high risk presentations informed by the available
evidence base and consensus expert opinion.

Liaison and consultation to tier 2 mental health and acute medical
services.

Provide supervision and training for tiers 1 and 2 staff.

Lead
the
eating
disorders
research
and
audit
agenda.
Research within the service
The department is currently developing a research agenda for eating
disorders. The team have been involved in a number of studies and recent
interests include:-

the design and development of questionnaires to assess patient
and clinical perspectives of recovery from an eating disorder

an investigation into the impact of specific and non-specific
factors in the therapeutic process

a nationwide multi-centre study of Expert Carers Helping Others
(ECHO)

subjective experiences of patients and their journeys through
specialist and generic mental health services

eye tracker studies of patients with eating disorders, investigating
how body-image-based material is read/looked at

content analysis of pro-anorexic websites

mental health professionals’ perceptions of skills competence and
confidence of working with patients with eating disorders.
6
The Clinical Lead and Specialist Clinician are members of the Wales Eating
disorders Research group and there are some exciting projects in planning.
The team are interested in all aspects of eating disorders research and
welcome individuals wanting to participate in, or contribute to the research
agenda. Please feel free to share any ideas you may have with us.
7
Referral Pathway
8
9
Specialised Community Eating Disorder Service
In addition to the SEDS team, we also have a Specialised Community Eating
Disorder Service (SCEDS); a team of clinicians from the Health Board with an
interest / experience in working with Eating Disorders and consist of:






Designated Contacts from Community mental health teams;
Community Psychiatric Nurses, Psychologists, Occupational Therapists
Tier 3 Specialist ED team.
Representatives from Child and Adult Mental Health Services
Dietitians
Consultant Psychiatrist.
Anyone who has an interest in Eating Disorders or would like to have
support with a client.
The team meet on a fortnightly basis and the aims of the meeting are outlined
below. This meeting will provide you with opportunities to learn from a wide
variety of professionals and clinical examples.
Functions of SCEDS meetings











To discuss and review all medium to high risk patients with Eating
Disorders.
To plan care for patients with Eating Disorders.
An opportunity to present new cases to the team.
An opportunity to present difficult or challenging cases.
Provides an opportunity for Multidisciplinary support and advice.
To be informed of any upcoming transitions from CAMHS to adult services
and start planning care for those individuals.
Forum for group supervision.
Information sharing between disciplines and clinicians from different
areas.
Discuss and plan service developments.
To learn about training opportunities.
Opportunity to learn about interventions available from Tier 3 e.g. groups.
10
The Designated Contact
In order to achieve the standards outlined in the Framework, the Welsh
Assembly Government requires all Community Mental Health Teams within
Wales to assign a member of the team to be a Designated Contact for Eating
Disorders.
The role of the Designated Contact is further substantiated and an
outline of this role is provided below. It is recommended that you spend some
time with a Designated Contact during your placement.
The Designated Contacts will work with the Tier 2 clinical lead and within
their own teams to implement drivers 1 and 2. In order to achieve this, the
role of the Designated Contact will be to:

Provide 2 sessions a week to support the implementation of the intelligent
targets.

Be a point of contact for primary care and within their team for advice,
supervision, consultancy and support regarding eating disorders.

To monitor and record contacts for advice / support /supervision /
consultancy and provide evidence to Tier 2 lead.

Attend the Specialised Community Eating Disorders (SCEDS) meetings
(please see information sheet regarding function of SCEDS) on a
minimum of a monthly basis.

Provide feedback on any medium to high risk patients via SCEDS, if
unable to attend meeting, to provide feedback prior to the meeting via Tier
2 clinical lead.

Attend 2 out of the 3 All Wales Eating Disorders Specialist Interest Group
(AWEDSIG) conferences throughout the year.

Attend relevant training events or nominate colleagues to attend.

Cascade information back to CMHT.

Provide monthly statistics regarding Eating Disorder clients.

Work with Tier 2 Clinical Lead to provide training opportunities for local
area.

Networking with Tier 1.
11

Promoting awareness of Eating Disorders and available services.

Raise practise issues with Tier 2 / Tier 3 Leads.

Assist Tier 2 Lead in audit.

Support colleagues in attending SCEDS and presenting cases as
required.

Identify clients that require Tier 3 services within their team and discuss
with Tier 3 team.
The Designated Contact does not take responsibility for the care of all
patients with eating disorders within the team.
Their role is to act as a
resource to assist their team in increasing confidence and competence in
working with eating disorders.
Designated Eating Disorders Contacts
North Monmouthshire
Tel:
01873 735500
South Monmouthshire
Alex Price
Tel: 01291 636700
Blaenau Gwent
Sharon Probert
Tel: 01495 363258
Newport
Wendy Rees
Rebecca Lowther
Tel: 01633 786000
North Caerphilly
Ruth Dodd
Tel: 01633 618045
South Caerphilly
Caroline Pember
Tel: 02920 862035
Pontypool
Mike Larner
Tel: 01495 765729
South Powys
Cath Arnold
Tel:01874 615050
In addition to working with SCEDS, the SEDS team also work closely with other
specialist services where there is evidence of dual diagnosis. Further information
on these services can be obtained via the intranet or through discussion with
your mentor.
12
Policies and Procedures
Below is a list of some of the national and local guidelines, policies and
procedures relevant to our area of work. The list is not exhaustive and access to
these and all other ABHB policies can be obtained via the Health Boards intranet
site. We recommend you take the time to familiarise yourself with these
documents.
National Guidelines and Policies

Eating Disorders - A Framework for Wales (2009) Welsh Assembly
Government

MARSIPAN - Management of Really Sick Patients with Anorexia Nervosa
(2010) Royal College of Psychiatrists

NICE - Eating Disorders - Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa and related eating
disorders (2004) NICE

1000 Lives + How to Guide: Eating Disorders (2012)
Aneurin Bevan Health Board Policies, Procedures and Guidance

All Wales Policy and Procedure for the Protection of Vulnerable Adults

Accompanying Patients Policy

Care and Treatment Planning Policy

Care and Treatment Planning Procedure

Child Protection Policy and Procedures

Consent Policy

Dignity and Respect in Care Policy

Gwent 117 Section Procedure

Lone working Policy

Mental Capacity Act Policy

Mental Capacity Assessment Procedure

Mental Health Measures
13
The Eating Disorders Framework for Wales
The Welsh Assembly Government launched the ‘Eating Disorders Framework for
Wales’ in 2009. The document describes the services that should be available to
those with an eating disorder and their carers across all Tiers of service (see fig
1). It also includes 5 standards to guide implementation (see box 1).
In patient Eating
disorders Unit 6 beds for
Wales Marloborough
TIER
4
Specialist ED Team
Referrals from CMHT’s
Specialist Interventions
Gatekeeper for Tier 4
Tier 2 CMHTs
Designated Eating
Disorders contacts in
each CMHT for advice
Screening Assessing
Information
joint working
Annual health Checks
Counselling
TIER 3
TIER 2
TIER 1
PRIMARY CARE
Fig 1.
Box 1: Standards
1. Role of General Practitioners and primary care teams in identification,
assessment and treatment of people with an eating disorder.
2. Role of local Mental Health Services in the provision of advice and
support to primary care staff and community groups.
3. Role of local Mental Health Services in the provision of assessment and
care planning.
Intelligent
Targets
4. Role of local Mental Health Services in the provision of direct treatment
interventions for people suffering from an eating disorder
5. Provision of a range of Acute and general medical treatment and
services.
14
Intelligent Targets
Eating Disorders have been added to the 1000 lives plus campaign with
Intelligent Targets designed to improve care for those with Eating Disorders. The
intelligent targets have 4 main drivers:
Driver
Interventions
Driver 1: Tier 2 to improve specialist
advice and support to Primary care,
including pre-referral advice and shared
care arrangements.
This
includes
providing
advice,
supervision, consultancy and education.
Driver 2: Improved assessment, care coordination and interventions across Tier 2
mental health services for CAMHS and
CMHTs.
Driver 3: Improved provision of specialist
Tier 3 ED services in local health
communities.
15
1. Tier 2 to provide consultancy,
liaison, and education bundle to
Tier 1 service.
2. Tier 3 SEDS leads available for
consultation/support via
standardised staff supervision
tool/checklist based on agreed
Tier 2 annual delivery.
1. Implementation of the Tier 2 Care
Programme Approach eating
disorders assessment bundle for
all eating disorders referrals to all
Adult CMHTs and Tier 2 eating
disorders ‘review’ assessment
bundle for CAMHS.
2. For high risk eating disorder
presentation Tier 2 teams will
secure medical assessment
within 48 hours and a psychiatric
assessment within five working
days.
3. Formulation and delivery of
treatment plan delivered within a
structured care programme
approach/CAMHS equivalent.
4. Written information to be given to
patient and carer/nearest relative
at all stages. Evidence of
patient/carer involvement in
planning and outcome monitoring.
5. Tier 3 SEDS leads to
monitor/support via standardised
staff supervision tool/checklist
based on agreed Tier 2 annual
delivery plans.
1. Tier 3 SEDS to ensure clear
provision of consultancy,
education, liaison, and joint
working bundle to Tier 2 services.
2. For high risk eating disorders
presentation, Tier 3 to provide
specialist interventions care
bundle.
3. Tier 3 SEDS will lead the
formulation and planning of all
Tier 4 care. All patients
undergoing Tier 4 treatment will
have their care reviewed at
regular CPA meetings - reviewers
to include involved Tier 2, 3, and
4 clinicians, the patient and
involved carers. Reviews may be
face-to-face or via teleconferencing.
4. Written information to be given to
patient and carer/ nearest relative
at all stages. Evidence of patient
and carer involvement in planning
and outcome monitoring.
Driver 4: Improved acute medical care
for patients with anorexia nervosa.
1. The high risk re-feeding bundle
will be implemented for all
admissions to the designated
eating disorders acute medical
bed within 24 hours.
16
Eating Disorders
Anorexia Nervosa (AN) – where sufferers starve themselves, lose weight to
15% or more below normal, are terrified of weight gain, and have a loss of sexual
interest (man) or loss of periods (women) although this may not be present (e.g.
with women on the contraceptive pill) and is not a necessary requirement for
diagnosis. Some people with AN also binge and purge.
Bulimia Nervosa (BN) – where sufferers binge-eat and then induce vomiting,
abuse laxative or other weight control drug, exercise excessively or starve in
odder to compensate for the binging. Sufferers are very concerned about weight
and shape, but stay within the normal weight range.
Binge eating Disorder (BED) – where sufferers binge-eat but do not carry out
any compensatory behaviours their weight may increase to above the normal
range (NB obesity is not categorized as an eating disorder).
Eating Disorders Not Otherwise Specified (EDNOS) – where sufferers have
many of the above symptoms but do not quite meet the criteria for AN, BN or
BED.
17
Effects of eating disorders
The list below outlines some of the effects of eating disorders.
Physical effects include:Circulatory Problems
Electrolyte Imbalance
Gastric Problems
Bowel Damage
Stunted Growth
Infertility
Kidney Failure
Heart Failure
Osteoporosis
Dental Enamel Erosion
Psychological effects include:Impaired Cognitive Functioning
Reduced Capacity
Depression
Anxiety
Obsessive Behaviours
Drug Abuse
Self Harm
Social effects include:Erratic Behaviours
Social Withdrawal
Debt
Shoplifting
Damage to Relationshi
18
Assessment tools:
Below is a list of some of the assessment tools we use, this list is not
exhaustive and where appropriate other tools are used. All tools can be found
on our intranet page http://howis.wales.nhs.uk/sitesplus/866/page/47905
or with Alison.
The Clinical Impairment Assessment Questionnaire (CIA)
A 16 item self report scale measuring the severity of psychosocial impairment
due to the eating disorder, covering the following domains:
1. Mood
2. Self perception
3. Cognitive functioning
4. Interpersonal functioning
5. Work performance
Eating Disorder Examination Questionnaire (EDE-Q)
Adapted from the Eating Disorders Examination (a semi-structured interview
conducted by a trained clinician to assess the psychopathology associated
with the diagnosis of an eating disorder).
The EDE-Q is a self report
questionnaire measuring:
1.Restraint
2.Eating concern
3. Shape concern
4. Weight concern
Clinical Outcomes in Routine Evaluation (CORE)
A self report tool used to measure the outcome of therapy, it covers four
domains: subjective well-being, problems/symptoms, life functioning and risk
19
Care and Treatment Planning (CTP) Assessment Template
Aneurin Bevan Health Board’s Care Programme Approach assessment tool
with guidance and prompts on it’s use in Eating Disorders.
Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ)
The ANSOCQ is a 20-item self-report questionnaire assessing a broad range
of anorexic symptomatolgy including aspects of body shape and weight,
eating behaviours, weight control strategies, emotional difficulties, problematic
personality characteristics, and interpersonal difficulties.
The following documents are also recommended for use in the assessment of
an eating disorder:
Bulimic Investigatory Test
Guide To Medical Risk Assessment
Eating Disorders Physical Risk Assessment
The SCOFF Questionnaire
BMI Table
20
Interventions provided by Tier 3
The Tier 3 specialist eating disorders service provides a variety of therapies
and interventions in individual, group and family settings. Below is a list of
some of these interventions. We are currently in the process of developing
additional group therapy packages across the Tiers of healthcare.
Cognitive Behavioural Therapy Enhanced (CBT-e) - Time limited intervention
focusing on what is maintaining the eating disorder. Interventions include in
session weighing, food diaries, behaviour changes and body image work.
Interpersonal Psychotherapy (IPT) - A form of therapy in which the focus is on
a patient's relationships and the way they see themselves. The goal is to help
people to identify and modify interpersonal problems, to understand and to
manage relationship problems.
Dialectical Behavioural Therapy (DBT) - Includes up to one year of individual
therapy and weekly attendance of two and a half hour group sessions. The
group is solely dedicated to the training of specific skills which help people to
deal more effectively with themselves and the world around them.
Motivational Enhancement Therapy (MET) - A directive, client-centred
approach for helping clients explore and resolve ambivalence about behaviour
change.
21
Specialist Occupational Therapy- Carries out individual assessments to
determine how their eating disorder is affecting their ability to function within
their everyday lives. Individual goals are then developed to minimise the
effects of the eating disorder on their everyday functioning and maximise their
independence.
Specialist Dietetic intervention– Assesses and compares individuals nutritional
requirements with actual nutritional intake. Behavioural factors influencing
eating habits are also considered. Using education on the role of food in the
body and the effects of starvation allows realistic goals to be negotiated to
promote improvements in health.
These sessions can be 1 to 1, where
applicable in group format or joint; to include other health professionals such
as OT or include carers/supporters.
Individual Psychology - In general terms, psychological therapy aims to
explore core-belief systems, attachment issues, ineffective interpersonal
relationships, emotional dysregulation and dysfunctional patterns of behavior.
Through a process of guided exploration and increased awareness patients
are encouraged to develop new ways of thinking, behaving and managing
difficult emotions. The individual psychological therapy carried out in the
department is holistic and draws on a number of theoretical perspectives e.g.
psychodynamic, CBT, CBT-E, CAT, Systemic, DBT, Solution-focused therapy
and Motivational approaches.
22
Family Therapy- Family therapy is a branch of psychotherapy that works with
families to nurture change and development. It has been shown to be an
effective intervention for children and young people experiencing eating
difficulties. It tends to view change in terms of the systems of interaction
between family members and sees family relationships as an important factor
in psychological health.
Psycho-education- Designed to provide people with enough information on
eating disorders for them to make an informed decision regarding change.
Subjects covered include: what eating disorders are; types of eating disorders;
how eating disorders develop and are maintained; costs and risks of eating
disorders, dietetic advice, the process of recovery and an introduction to the
various therapies available for eating disorders.
We have a wide variety of books and additional resources available for you to
use to increase your knowledge in these areas. Please see your mentor for
access to the resource area. When possible, you will get opportunities to
observe / participate in some of these interventions in practice. Due to the
nature of eating disorders; some people will not feel comfortable with a
student being present, therefore, it may not always be possible to accompany
us on visits to patients.
In order to make the most of your placement within the Specialist Eating
Disorders Service you are encouraged to widen your learning experience by
visiting other eating disorders services. Some suggested places are:
23
Child and Adolescent services 01633 436831
STEPS eating disorders service Bristol 0117 4145428
Cardiff and Cwm Taf SHED team 029 20336467
Cwm Taf Tier 2 Clinical Lead for Eating Disorders 01443 486222
B-eat Cymru m.bushell@b-eat.co.uk
If there are any other places you would like to visit please discuss this with
your mentor.
24
Placement Checklist
Date
Meet mentor
Introduced to team members
Fire equipment and procedures
Location of learning resources
Discussion re objectives
Location of policies and procedures
Functions of the team and team
members
Spend time with:
OT
Dietitian
Psychologist
Tier 2 lead
Designated contact
Attendance at SCEDS
Attendance at SEDS team meetings
Visit to Eating Disorders inpatient
setting
Visit to STEPS
Learning pack completed and
reviewed
Student pack evaluation
25
Signed
Learning Section
We have compiled this section to assist you with your learning needs during
your placement. We encourage you to work through this book during your
time here. This will help increase your knowledge regarding eating disorders,
interventions used and the policies relevant to this area of work. You may find
some of the answers within this pack and we also have a wide variety of
resources available to assist you with this. Your mentor and other members
of the team will also be happy to help. Your mentor will review your progress
with this at your review meetings and you will be able to keep this at the end
of your placement as evidence of learning.
26
The following scenarios have been compiled to assist your learning. Please
select 2 of these and answer the following questions on a separate sheet.
1. What would be your main priorities for your initial assessment?
2. What do you think the sufferers main priorities are?
3. What do you think the carers’ priorities are?
4. What skills would you use to encourage engagement in the
assessment process?
5. Who else could contribute to the assessment / formulation?
6. What treatment options are there?
7. What would an initial care plan entail?
8. Who else would be involved in the care planning process?
27
SYLVIA
David
78
Connie
70
Sylvia
54
Father diagnosed with cancer.
Mother care focused on her
husband.
Sylvia’s rituals increasing.
Exercise increased following
increase in weight.
50
Severe weight loss admitted
privately to SEDU by parents.
Returned to local services after 6
weeks. CMHT support continued
BMI 15 no engagement with
psychological therapies.
40
Severe weight loss admitted to
acute medical ward for re-feeding
Transferred to in patient
psychiatric ward.
Transferred to specialist ED unit
30
Returned home to live with
parents. Engaged with local
services.
Began University unable to cope
Weight loss admitted to ED In
patient unit
20
Very high achiever
Struggled with peer relationships.
AN diagnosed age 17 referred to
private ED specialist.
10
Sent to Boarding School age 7
Private Nanny
Normal birth
28
Sylvia has been rereferred by the GP.
She has a long history
with psychiatric
services. First
diagnosed with an ED
age 17 yrs. She has
since been treated by a
range of clinicians both
in patient and out patient
services and on three
occasion a specialist ED
in patient service. She
had an original diagnosis
AN co morbid with
severe ED adaptive
obsessive compulsive
traits which confines her
to her small flat which is
on the upper story of her
parents home.
Ritualised exercising for
5 hours every day.
Sylvia will not allow her
parents access to her flat
but does accept money
from them and support
from her mother when
her weight was severely
low. Currently Sylvia’s
BMI is 16 and has been
for the last 2 years. She
has is now physically
compromised by the
long term consequences
of her illness and is
seeking further help
from the CMHT. She
does not want to give up
her eating disorder but,
anticipating her parents’
demise, she recognises
the need to improve her
quality of life and self
sufficiency.
MARY
Doug
70
Lilly
60
Mary
John
40
33
Events & Trans
Age
BN behaviours increase.
Socially isolated depressed
GP refs to CMHT
33
Divorced
30
Debt accumulates
Binge vomit increases
Married –
Lives near parents but
doesn’t see much of them
20
Gets an office job in a local
factory meets husband in
work
17
Discovers laxatives
16
Discover vomiting
15
Unsuccessfully diet
12
Over weight Bullied
Move to Comp on her own
11
One friend in school
Dad Start working away
7
Difficult move
To school
Shy in Nursery
Normal Birth
0-4
29
You have been referred Mary
(age 33 years). Mary has been
suffering from Bulimia Nervosa
for 10 years. Her weight has
fluctuated within relatively
normal parameters during that
time. She had successfully
reduced her self-induced
vomiting to 3 times per week
but has told her GP that her
impulse to binge eat has
increased and requested a rereferral to her CMHT.
R
RICHARD
Dora
47
John
55
Anne
20
Richard
22
Events & Transitions
Age
Referred to CMHT
22
Severe weight loss
Dizzy spells
21
Exams
Started university
Referred to CMHT
A’ level examination
Severe weight loss
Parents withdrew him
from CAMHS Tier4
Richard is a 22 year old student
attending a local college
referred to you by the GP
following rapid weight loss
over the previous four months.
He is 5ft 10inches tall weighs 8
stone.
His current BMI is 16.
18
He is very bright but worries
about missing lectures and not
studying enough.
He describes himself as
unattractive and feels he looks
fat. He says he wants to lose
weight and ideally would like
to be 7 stone. He lives with his
parents and younger sister with
whom he has a very poor
relationship. Richard has very
few social contacts preferring
to spend most of his free time at
the library or at the local gym
where he trains daily.
16
Referred to CAMHS
Severe weight loss
GCSE Examinations
11
Move to Comp
Teasing about weight
and glasses bullying in
the first week
10
Best friend moved
away
8
Richard has been referred to
mental health services twice
before but has always failed to
attend. He agreed to this
referral because he was feeling
tired and dizzy and was worried
that his academic standards
might be compromised.
Recognised high
achiever.
6
Junior school
New friend
Infant school
Difficult start
Full time nursery
Anne born
Normal birth
4
2
30
HANNAH
Joe
Died
1yr ago
ALLAN
28
Ada
Luke
42
HANNAH
36
18
Age
Events & Transitions
Ref to CMHT
Depressed
Binge eating increased
Depressed
Miscarriage
Pregnant
36
Partner moves in
30
Begins new relationship
28
Weight loss socially active
25
New job at leisure centre
22
34
33
Divorce
21
Marital problems
Weight increases following pregnancies some
purging behaviours.
20
Episode of depression following birth of second
child
18
Post natal depression following birth of her son
who is diagnosed with severe learning disabilities.
17
Meets husband conceives within first month of the
relationship gets married at 3 months pregnant.
Discharged from CAMHS
Diagnosed with Atypical ED
Referred to CAMHS
Restrictive and binge eating purging and self
harm.
16
14
13
31
Moved from Haiti to the UK with her parents
16
12
Hannah is from Haiti. She
is 36 year old and has two
children; the oldest has a
severe learning disability
and currently needs a
transition to adult
services.
Hannah works in admin at
a local leisure centre. Her
GP has referred her to the
CMHT with a history of
worsening depression
following a miscarriage
six-month ago.
The GP also reports that
Hannah was treated by the
CAMHS age 13 following
her families move to the
UK. At that time she had
been severely bullied at
school and was treated for
an atypical eating disorder
and self harming
behaviours.
Evaluation
Now that you have completed the pack it would help us if you could complete
the following evaluation.
Was this pack useful to you as a student?
Which part of the pack enhanced your learning most?
Which part was the least useful?
Was the layout clear and easy to follow?
Is there anything else you would have liked in the package?
32