Eating disorders: anorexia, bulimia, BED — AU general practice guide

Eating disorders are serious mental health conditions — not choices, phases, or personality traits. The five main categories under DSM-5 are anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other specified feeding or eating disorder (OSFED).

About one million Australians live with an active eating disorder, with lifetime prevalence around 9% — and numbers are rising. The National Eating Disorders Collaboration (NEDC) documents eating disorders across all ages, sexes, and cultural backgrounds. The female-to-male ratio is roughly 3:1 overall, though BED occurs at near-equal rates, and eating disorders in males are significantly under-recognised.

The clinical fact that matters most in general practice: anorexia nervosa carries the highest mortality of any psychiatric disorder, approximately 5–10% over a lifetime, with roughly half of deaths from medical complications and half from suicide. Early recognition, prompt multidisciplinary care, and using the full scope of available MBS pathways can substantially change outcomes.

Weight is not diagnostic. Bulimia nervosa, BED, and many OSFED presentations occur at normal or above-average weight. Failing to screen for eating disorders in normal-weight patients — and in males — is a well-documented failure point in general practice.

A. Core clinical — the AU general practice framework

Screening

In general practice, opportunistic screening is more effective than waiting for patients to self-disclose. Two validated brief tools:

SCOFF questionnaire (5 items) — a score of ≥2 is a positive screen:

1. Do you make yourself Sick because you feel uncomfortably full?
2. Do you worry you have lost Control over how much you eat?
3. Have you recently lost more than One stone (6 kg) in a 3-month period?
4. Do you believe yourself to be Fat when others say you are thin?
5. Would you say that Food dominates your life?

The ESP questionnaire is a validated alternative brief screening tool for use in general practice.

History

Key domains when an eating disorder is suspected:

• Eating behaviours — restriction, bingeing, compensatory behaviours (vomiting, laxatives, diuretics, excessive exercise), dietary rules, ritualised eating patterns
• Body image — body dissatisfaction, weight goals, fear of weight gain
• Weight history — current, premorbid, recent trajectory; menstrual history (amenorrhoea is a clinical marker in AN)
• Compensatory behaviours — frequency, method; purging leaves physical signs on examination
• Triggers — stressors, social media use, occupational or sport pressures (athletes, dancers, models are higher risk)
• Comorbidities — depression, anxiety, OCD, ADHD, autism spectrum disorder, substance use, personality disorder, type 1 diabetes (diabulimia — insulin omission for weight control)
• Suicide and self-harm risk — must be assessed at every consultation; AN has high rates of completed suicide
• Past treatment — prior episodes, hospitalisations, therapists, medication responses

Examination

Physical examination in eating disorders is a medical safety assessment:

• Vital signs — heart rate, blood pressure supine and standing (postural drop), temperature
• Weight, BMI, and trajectory
• General — cachexia, lanugo hair, dry or brittle skin and hair, parotid gland swelling (vomiting), Russell’s sign (knuckle calluses from induced vomiting), dental erosion, peripheral oedema, hypothermia
• Cardiovascular — bradycardia, hypotension, reduced peripheral perfusion
• Neurological — muscle weakness assessed by the squat-sit-stand functional test
• Mental state — mood, suicidal risk, cognitive function (cognition is often impaired with malnutrition)

Investigations

Bloods in all patients with suspected eating disorder:

• FBC (anaemia, leucopenia)
• Electrolytes, urea, creatinine, calcium, phosphate, magnesium (refeeding risk; purging-related losses)
• LFT (hepatic dysfunction common in AN)
• Glucose, HbA1c (especially to detect type 1 diabetes / diabulimia)
• TSH (exclude thyroid cause of weight change)
• Vitamin D, B12, folate, iron studies
• Lipids, albumin, amylase/lipase (parotid, pancreas)
• Urinalysis, pregnancy test in all patients of reproductive age
• ECG — bradycardia, prolonged QTc, T wave changes, U waves (hypokalaemia); essential in AN or with electrolyte abnormalities
• DXA bone density for chronic AN with prolonged amenorrhoea

Medical severity stratification drives management urgency — see When to escalate.

B. Treatment — psychotherapy and pharmacotherapy

ANZAED treatment principles (Hay et al., J Eat Disord 2020), NEDC clinical guidelines, and the RANZCP CPG for Eating Disorders all specify that multidisciplinary team care is non-negotiable.

First-line psychotherapy by diagnosis

Diagnosis	First-line therapy
AN — adolescent	Family-Based Treatment (FBT, Maudsley approach) — gold standard
AN — adult	CBT-E, MANTRA, or SSCM — comparable evidence
Bulimia nervosa	CBT-E first-line; IPT as alternative
Binge-eating disorder	CBT-E first-line; guided self-help CBT for mild presentations; IPT as alternative
ARFID	CBT-AR; FBT-ARFID for children; specialist input recommended

Multidisciplinary team

• GP — lead clinician, medical monitoring, coordination, Eating Disorder Plan preparation
• Psychologist with eating disorder training — first-line psychotherapy; ANZAED-credentialled practitioners are preferred
• Dietitian with eating disorder training — nutritional rehabilitation and meal planning
• Psychiatrist — complex presentations, comorbidity management, medication initiation
• Paediatrician — children and adolescents with medical complexity

Pharmacotherapy (adjunctive role only)

Per eTG Psychotropic and AMH:

• Anorexia nervosa — no medication has clear evidence for weight restoration. Routine antipsychotic use for weight gain is not recommended (modest evidence, metabolic side effects). SSRIs for comorbid depression or anxiety are more effective once nutritional state is improving — response is reduced in low-weight states.
• Bulimia nervosa — fluoxetine 60 mg daily is TGA-approved; reduces binge-purge frequency. Usually initiated alongside CBT-E. PBS General Schedule.
• Binge-eating disorder — lisdexamfetamine (Vyvanse) 30–70 mg daily is TGA-approved (2017) and PBS Authority Required (Streamlined) since 2022. Reduces binge frequency. Requires cardiovascular monitoring; consider substance-use history before prescribing.
• Comorbid depression or anxiety — SSRI as appropriate; timing matters — nutritional restoration should accompany or precede commencement where possible.

Refeeding syndrome

A potentially life-threatening metabolic complication of nutritional rehabilitation in severely malnourished patients. Phosphate, magnesium, and potassium drop in the first days of refeeding as cells take up electrolytes on insulin release. Prevention in hospital: start caloric intake slowly (typically 30–40 kcal/kg/day); thiamine 100–300 mg daily; daily electrolytes for the first 1–2 weeks; gradual caloric increase as electrolytes remain stable. This protocol is managed in specialised eating disorder inpatient settings for severe cases.

C. Differential diagnosis

Eating disorders have a broad differential; investigations help exclude:

Condition	Key discriminator
Hyperthyroidism	TSH suppressed; weight loss with increased appetite, tremor, heat intolerance
Coeliac disease	Weight loss, bloating, diarrhoea; tissue transglutaminase antibodies
Inflammatory bowel disease	Abdominal pain, diarrhoea, blood in stool; CRP, faecal calprotectin
Type 1 diabetes	Polyuria, polydipsia, weight loss; glucose, HbA1c; diabulimia is the coexisting presentation
Malignancy	Constitutional symptoms; age; no body image concern
Depression with anorexia	Appetite loss mood-driven; no weight-gain fear; no body image disturbance
Body dysmorphic disorder	Specific body part preoccupation (not weight); no food restriction pattern
OCD	Food-related rituals can overlap; formal eating disorder assessment clarifies

Always investigate before attributing weight loss or food avoidance to a psychiatric cause.

D. Australian operations

MBS Eating Disorder Plan — the key general practice pathway

The Eating Disorder Treatment and Management Plan (introduced 1 November 2019) is prepared by the GP:

• Item 90250 (face-to-face), 90251 (telehealth video), 90252 (telehealth phone)
• Review: item 90257 (face-to-face)

This provides up to:

• 40 individual psychology sessions per 12 months (eating disorder-specific items 82350–82359)
• 20 dietetic sessions per 12 months

Eligible diagnoses include AN at any weight, BN, BED, ARFID, and OSFED meeting clinical criteria. Reviews at 10 sessions, 20 sessions, and 12 months. NEDC provides a detailed MBS EDP summary and the GPMHSC has GP training resources for preparing these plans.

The EDP can be combined with a standard Mental Health Care Plan (items 2715/2717) for non-eating-disorder mental health needs. Chronic Disease Management plans (items 965/967) can be used for established chronic eating disorders. Standard consultation items (23/36/44) apply for ongoing monitoring.

Finding trained clinicians

ANZAED maintains an Eating Disorder Credential for mental health professionals (expanded to include GPs in 2024), providing a directory of appropriately trained practitioners. InsideOut Institute and NEDC also provide clinician directories and referral resources.

Patient resources

• Butterfly Foundation — national support, community, and advocacy
• NEDC — information for patients and clinicians
• Eating Disorders Victoria — state-based services and support
• HealthDirect — Eating disorders — general public entry point

E. Special populations

Adolescents — peak onset for AN and BN is adolescence. FBT is the gold standard for adolescent AN, with strong evidence for engaging caregivers in nutritional rehabilitation. Prognosis is generally better with earlier intervention. School performance, peer relationships, and family dynamics are commonly affected. Paediatrician co-management for medical complexity is appropriate.

Males — Eating disorders in males are significantly under-recognised. BED occurs at near-equal rates to females. Male presentations may differ: muscle dysmorphia (focus on muscularity rather than thinness), use of supplements or anabolic steroids, and exercise-related restriction are more common. Screening tools designed around female presentations may miss males; maintain a low threshold to ask directly.

Athletes and performers — Elevated risk in weight-category sports, aesthetic sports (gymnastics, dance, figure skating), and endurance events. Relative Energy Deficiency in Sport (RED-S) — the broader syndrome of inadequate energy availability affecting bone health, hormonal function, and performance — affects both sexes and all levels of competition.

Type 1 diabetes (diabulimia) — intentional insulin omission for weight control. This creates a cycle of hyperglycaemia, DKA risk, and accelerated microvascular complications. It is a medical-psychiatric emergency requiring specialist co-management between endocrinology and an eating disorder service.

Pregnancy — eating disorder relapse or new onset during pregnancy significantly increases obstetric and fetal risk. Refer to perinatal psychiatry and eating disorder services for co-management. Nutritional adequacy is critical for fetal development and maternal recovery.

When to escalate

Refer to the emergency department and/or a specialised eating disorder inpatient unit urgently when any of the following are present:

• Heart rate below 40 beats per minute
• Blood pressure below 80/50 mmHg, or postural drop over 20 mmHg
• Temperature below 35°C
• Severe electrolyte disturbance — potassium below 2.5, phosphate below 0.5, magnesium below 0.5, or sodium below 130 mmol/L
• QTc over 450 ms, severe bradycardia, or arrhythmia on ECG
• BMI below 13–14 in adults, or failure to thrive in children or adolescents
• Acute suicidal risk or inability to maintain safety in the community

Refer same-week to an eating disorder multidisciplinary service when a new eating disorder is first suspected, or when symptoms are severe but not yet medically compromising. Butterfly Foundation (1800 33 4673) assists with finding appropriate local services.

Routine referral to eating disorder services (ANZAED-credentialled psychologist, ED-trained dietitian, psychiatrist as required) for ongoing management of established eating disorders and OSFED presentations.

What this article is and is not

This is general health information drawn from current Australian clinical guidelines — ANZAED treatment principles, NEDC resources, RANZCP CPG for Eating Disorders, eTG Psychotropic, and AMH. It is not personal medical advice and does not create a doctor–patient relationship. Assessment and treatment decisions are made with your own GP and treating team.

For urgent support: Butterfly Foundation 1800 33 4673, Lifeline 13 11 14, Beyond Blue 1300 22 4636, 13YARN 13 92 76 (First Nations), Kids Helpline 1800 55 1800. For acute eating disorder crisis with medical compromise, go to your nearest emergency department.

For further reading: NEDC, InsideOut Institute, HealthDirect — Eating disorders, ANZAED.

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Sources cited

1. ANZAED — Practice and Training Standards (Hay et al., J Eat Disord 2020)
2. NEDC — National Eating Disorders Collaboration
3. NEDC — MBS Eating Disorder Plan resources
4. RANZCP — 2014 CPG for Eating Disorders
5. Therapeutic Guidelines (eTG) — Psychotropic
6. Australian Medicines Handbook
7. Butterfly Foundation
8. InsideOut Institute for Eating Disorders
9. ANZAED — Find a credentialled clinician
10. HealthDirect — Eating disorders
11. Department of Health — MBS Eating Disorders Evaluation 2024
12. GPMHSC — Preparing a GP Eating Disorder Treatment and Management Plan
13. Eating Disorders Victoria