Law, Ethics and Psychiatry in the General HospitalCivil commitment of the anorexic patient
Introduction
Patients with anorexia nervosa and bulimic anorexia pose enormous problems of management for the clinicians who treat them. When patients’ clinical courses deteriorate, caregivers are often faced with the prospect of watching their patients starve to death or die of the complications of malnutrition. Unless patients are willing to comply with recommendations for intervention, there may be little that can be done to avert those ends. The resulting sense of frustration and impotence takes a major toll on those who work with anorexics.
Analogous situations exist in other areas of mental health practice, involving the treatment of overtly suicidal patients or those so gravely disabled as to be unable to meet their basic needs. Here, too, clinicians may be confronted with the specter of relative powerlessness in preserving the lives of their patients. Yet there is potential recourse for mental health professionals who fear that overtly suicidal or gravely disabled patients may be at imminent risk of serious harm. Commitment laws in every jurisdiction permit suicidal patients to be hospitalized against their will when the threat seems real and reasonably imminent, and similar provisions exist in most jurisdictions for mentally ill persons who are gravely disabled [1]. Civil commitment has become an important tool for working with these patients.
Our experience suggests, however, that this has not been the case for patients with anorexia nervosa. That is, despite the acknowledged threat they pose to their own lives, they are rarely committed involuntarily. There appear to be several reasons for this. First, many clinicians seem to be confused as to whether this group of patients even qualifies for hospitalization under existing commitment laws, since they are not psychotic. Second, many statutes require imminence of risk before a person can be committed, something that may be difficult to establish among patients who have lived with chronic starvation. Third, anorexic patients, whatever the degree of threat to their lives, often do not resemble other patients who are suicidal or gravely disabled, e.g., they are frequently able to provide seemingly rational explanations for their behavior.
Thus, unless patients are explicitly and overtly suicidal, there appears to be a good deal of reluctance to hospitalize anorexics involuntarily. The infrequency of this practice is reflected in the eating disorders and general mental health literatures, where only a handful of papers have addressed this issue 2, 3, 4, 5, 6. A report from one leading eating disorders program noted that they had not used involuntary commitment at all over the preceding 10 years [7]. The American Psychiatric Association’s extensive “Practice Guideline for Eating Disorders” [8] devotes only one vague sentence to the issue (“Legal interventions may be necessary to ensure the safety of treatment-reluctant patients” (p. 220) and one review of medical-legal issues affecting anorexia nervosa omits mention of it entirely [9].
In an effort to advance the discussion, this paper explores the legitimacy of invoking civil commitment proceedings for anorexic patients, considers actual practices in that regard, and suggests guidelines that might be followed when the question of commitment is raised. We begin by considering two episodes that illustrate the difficulties in regard to commitment among this patient population.
Section snippets
Case presentation #1
The patient was a 29-year-old single woman with a long history of anorexia nervosa and bulimia, as well as alcohol and drug abuse, depression, and suicidality. She had made several near-lethal suicide attempts.
Her anorexic symptoms included a distorted body image, laxative abuse, and purging several times daily. Her weight was in the low-normal range. In the months prior to the current evaluation, she had been hospitalized voluntarily for refeeding. Her most pressing problem was laxative abuse.
Case presentation #2
The patient was a woman in her early 30s with a long history of anorexia nervosa and bulimia, alcohol and drug abuse, and severe and persistent depression. She had made a number of near-fatal suicide attempts and during episodes of depression would spontaneously discontinue her antidepressant medications. There was a family history of suicide and the patient often expressed a desire to be reunited with the relative who had died. As the anniversary of the death approached, she reported an
Commitment of the anorexic patient
The most striking difference between these two scenarios is one of expressed intent. The patient in both vignettes is, in fact, the same. Mental health professionals are accustomed to evaluating for commitment persons whose intent to harm themselves is openly expressed—whether by verbal or behavioral means. These patients are routinely recognized as being appropriate for involuntary commitment. Anorexic patients, on the other hand, do not usually manifest an expressed desire to die. On the
Involuntary hospitalization and civil commitment: current practices
As noted above, our impression has been that many clinicians are unaware of the applicability of commitment statutes to anorexic patients. (The small number of case reports involving their use appear to originate uniformly from outside the United States 11, 12, 13, 14. This conclusion is reinforced not only by the paucity of articles that relate to this issue in the vast literature on eating disorders, but also by the similar rarity of consideration by the courts or legal commentators. A review
A reasonable approach to the commitment of anorexic patients
Civil commitment of patients with anorexia nervosa is thus a legitimate option for the clinician. The question remains, however, as to when and under what circumstances it should be employed. When hospitalization is required, many patients will consent to admission, either on their own or under pressure from clinicians or family members. One of our respondents indicated that, in his experience, which is paralleled by our own, this was one reason for the infrequent use of involuntary
Conclusion
Commitment of the anorexic patient is an acceptable intervention under the commitment laws operative in the United States today. Experts in the treatment of the disorder appear to recognize that this is so, although they tend to set strict criteria for patients they might want to commit, thus substantially limiting the use of commitment. In such a chronically ill population, medical prediction is difficult and the perception of imminent harm may vary considerably among clinicians, further
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Involuntary admission: The case of anorexia nervosa
2015, International Journal of Law and PsychiatryCitation Excerpt :There seems although to be scientific basis for the argument for involuntary admission in some cases. According to research, some patients have impaired judgment and behavior and reduced capacity to fend for themselves (Tan & Hope, 2006; Tan, Hope, & Stewart, 2003; Tan, Hope, Stewart, & Fitzpatrick, 2003; Watson, Bowers, & Andersen, 2000) (Appelbaum & Rumpf, 1998). These cases overall concern patients whose life is threatened because of extreme weight loss.
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