Skip to main content Accessibility help

Severe and enduring eating disorders: recognition and management

  • Paul Robinson


Patients with severe and enduring eating disorders (SEED) may constitute a specific group. It is proposed that patients with anorexia nervosa (SEED-AN) or bulimia nervosa (SEED-BN) that requires the regular attention of a multidisciplinary team and is of a duration known to have a low recovery rate should be included in the SEED group. These patients present with a combination of severe symptoms and long-term illness, and may experience serious chronic physical sequelae (e.g. osteoporosis and renal failure), marked social isolation and stigma. Their carers suffer from the stress of caring for them over a prolonged period. Symptoms, treatment and crisis management of SEED-AN are discussed. SEED is a relatively recently described area of eating disorders psychiatry that requires research and service development so that patients and carers are helped to cope with very serious chronic, but not incurable, conditions.

Learning Objectives

  1. Understand the definition of SEED-AN and SEED-BN.
  2. Be able to assess the physical and psychological state of patients with SEED-AN and SEED-BN.
  3. Be able to plan the monitoring and treatment of patients with SEED, involving their carers and families.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Severe and enduring eating disorders: recognition and management
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Severe and enduring eating disorders: recognition and management
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Severe and enduring eating disorders: recognition and management
      Available formats


Corresponding author

Dr Paul Robinson, Barnet, Enfield and Haringey Mental Health NHS Trust, St Ann's Hospital, Block H, St Ann's Road, London N15 3TH, UK. Email:


Hide All

For a commentary on this article, see pp. 402–404, this issue.


All of the case vignettes in this article are fictitious accounts based on real cases.

Declaration of Interest




Hide All
Arkell, J, Robinson, P (2008) A pilot case series using qualitative and quantitative methods: biological, psychological and social outcome in severe and enduring eating disorder (anorexia nervosa). International Journal of Eating Disorders, 41: 650–6.
Chakravarty, EF, Bush, TM, Manzi, S et al (2007) Prevalence of adult systemic lupus erythematosus in California and Pennsylvania in 2000: estimates obtained using hospitalization data. Arthritis and Rheumatology, 56: 2092–4.
Claudino, AM, Hay, P, Lima, MS et al (2006) Antidepressants for anorexia nervosa. Cochrane Database of Systemic Reviews, 1: CD004365.
Couturier, J, Kimber, M, Szatmari, P (2013) Efficacy of family-based treatment for adolescents with eating disorders: a systematic review and meta-analysis. International Journal of Eating Disorders, 46: 311.
Crisp, AH, Gelder, MG, Rix, S et al (2000) Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177: 47.
Davidson, L, Bellamy, C, Guy, K et al (2012) Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry, 11: 123–8.
Department of Health (1999) A National Service Framework for Mental Health: Modern Standards and Service Models. TSO (The Stationery Office).
Donaldson, LJ, Reckless, IP, Scholes, S et al (2008) The epidemiology of fractures in England. Journal of Epidemiology and Community Health, 62: 174–80.
Fairburn, CG (2008) Cognitive Therapy and Eating Disorders. Guilford Press.
Harris, EC, Barraclough, B (1998) Excess mortality of mental disorder. British Journal of Psychiatry, 173: 1153.
Hirsch, SR (1976) Management of schizophrenic patients outside the hospital: results of research and basic principles. Nervenarzt, 47: 469–76.
Hudson, JI, Hiripi, E, Pope, HG Jr et al (2007) The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61: 348–58.
Jones, WR, Morgan, JF, Arcelus, J (2013) Managing physical risk in anorexia nervosa. Advances in Psychiatric Treatment, 19: 201–2.
Kingdon, D, Amanullah, S (2005) Care programme approach: relapsing or recovering? Revisiting… Making care programming work. Advances in Psychiatric Treatment, 11: 325–9.
Leahey, R, Holland, SJF, McGinn, LK (2011) Treatment Plans and Interventions for Depression and Anxiety Disorders (2nd edn). Guilford Press.
Lemma, A, Fonagy, P, Target, M (2011) Brief Dynamic Interpersonal Therapy: A Clinician's Guide. Oxford University Press.
Mehler, PS, Cleary, BS, Gaudiani, JL (2011) Osteoporosis in anorexia nervosa. Eating Disorders, 19: 194202.
Misra, M, Klibanski, A (2011) Bone health in anorexia nervosa. Current Opinion in Endocrinology, Diabetes and Obesity, 18: 376–82.
Mulvany, J (2000) Disability, impairment or illness? The relevance of the social model of disability to the study of mental disorder. Sociology of Health and Illness, 22: 582601.
National Institute for Clinical Excellence (2004) Eating Disorders: Core Inter ventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders (Clinical Guideline CG9). NICE.
Office for National Statistics (2013) Age Structure of United Kingdom, 1971–2085. ONS (—dvc1/index.html). Accessed 19 Sep 2014.
Robinson, PH (2006) Community Treatment of Eating Disorders. Wiley.
Robinson, P (2009) Severe and Enduring Eating Disorder (SEED): Management of Complex Presentations of Anorexia and Bulimia Nervosa. Wiley.
Robinson, P (2012) Avoiding deaths in hospital from anorexia nervosa: the MARSIPAN project. Psychiatrist, 36: 109–13.
Royal College of Psychiatrists (2012) Eating Disorders in the UK: Service Distribution, Service Development and Training (College Report CR170). Royal College of Psychiatrists.
Royal College of Psychiatrists (2014) MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa (2nd edn) (College Report CR189). Royal College of Psychiatrists.
Ruggeri, M, Leese, M, Thornicroft, G et al (2000) Definition and prevalence of severe and persistent mental illness. British Journal of Psychiatry, 177: 149–55.
Slade, M (2010) Mental illness and wellbeing: the central importance of positive psychology and recovery approaches. BMC Health Services Research, 10: 26.
Smink, FR, van Hoeken, D, Hoek, HW (2012) Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14: 406–14.
Steinhausen, HC (2002) The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry, 159: 1284–93.
Tan, J, Richards, L (2015) Legal and ethical issues in the treatment of really sick patients with anorexia nervosa. In Critical Care for Anorexia Nervosa: The MARSIPAN Guidelines in Practice (eds Robinson, PH, Nicholls, D) Springer. In press.
Theander, S (1985) Outcome and prognosis in anorexia nervosa and bulimia: some results of previous investigations, compared with those of a Swedish long-term study. Journal of Psychiatric Research, 19: 493508.
Touyz, S, Le Grange, D, Lacey, H et al (2013) Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychological Medicine, 43: 2501–11.
Treasure, J, Murphy, T, Szmukler, G et al (2001) The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis. Social Psychiatry and Psychiatric Epidemiology, 36: 343–7.
Treasure, J, Whitaker, W, Todd, G et al (2012) A description of multiple family workshops for carers of people with anorexia nervosa. European Eating Disorders Review, 20: e1722.
Vestergaard, P, Emborg, C, St⊘ving, RK et al (2002) Fractures in patients with anorexia nervosa, bulimia nervosa, and other eating disorders: a nationwide register study. International Journal of Eating Disorders, 32: 301–8.
Williams, ES, McKeran, RO (1986) Prevalence of multiple sclerosis in a South London borough. BMJ (Clinical Research Edition), 293: 237–9.
Wonderlich, S, Mitchell, JE, Crosby, RD et al (2012) Minimizing and treating chronicity in the eating disorders: a clinical overview. International Journal of Eating Disorders, 45: 467–75.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Severe and enduring eating disorders: recognition and management

  • Paul Robinson
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *