Reflections on involuntary treatment in the prevention of fatal anorexia nervosa: a review of five cases

Involuntary treatment: A qualitative study from the perspectives of individuals with anorexia nervosa

OBJECTIVE

Involuntary treatment for anorexia nervosa (AN) is sometimes necessary and lifesaving but can be experienced negatively by some individuals. The purpose of this qualitative study was to better understand participants' perceptions about their experience with involuntary treatment for AN.

METHOD

Thirty adult participants, who had been treated involuntarily for AN in the past, completed self-report measures and qualitative interviews. Interview transcripts were coded using thematic analysis.

RESULTS

Three themes were identified: (1) mixed perceptions about involuntary treatment, (2) the impact of involuntary treatment on external factors, including relationships, education, and employment, and (3) lessons learned from the experience. Participants who endorsed a positive shift in perspective regarding the need for involuntary treatment also reported favorable changes in their eating disorder recovery, whereas individuals whose perspective about their involuntary treatment remained negative, showed no changes in their recovery post-treatment.

CONCLUSIONS

Involuntary treatment for AN was recognized, in retrospect, as being beneficial by individuals with AN who were doing well, but individuals who continued to struggle with their eating disorder reported negative consequences.

Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events

BACKGROUND

A small but significant group of patients with anorexia nervosa (AN) undergo multiple involuntary treatment (IT) events. To enhance our understanding of IT and potentially inform treatment, we explored experiences and perspectives on IT of these patients.

METHODS

We designed a qualitative semi-structured interview study and used reflexive thematic analysis. Participants were at least 18 years of age, had multiple past IT events (≥ 5) related to AN over a period of at least one month of which the last IT event happened within the preceding five years. Participants had no current IT, intellectual disability, acute psychosis, or severe developmental disorder. We adopted an inductive approach and constructed meaning-based themes.

RESULTS

We interviewed seven participants. The data portrayed a process of living and leaving a life of coercion with a timeline covering three broad themes: living with internal coercion, coercive treatment, and leaving coercion; and five subthemes: helping an internal battle, augmenting suffering, feeling trapped, a lasting imprint, and changing perspectives. We highlighted that patients with AN and multiple IT events usually experienced internal coercion from the AN prior to external coercion from the health care system. IT evoked significant negative affect when experienced, and often left an adverse imprint. Moreover, IT could help an internal battle against AN and perspectives on IT could change over time.

CONCLUSIONS

Our study suggests that feeling internally coerced by AN itself sets the stage for IT. Clinicians should be conscious of the potential iatrogenic effects of IT, and reserve IT for potentially life-threatening situations.

Compulsory treatments in eating disorders: a systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes.

METHODS

Relevant articles were identified following the PRISMA guidelines by searching the following terms: "treatment refusal", "forced feeding", "compulsory/coercive/involuntary/forced treatment/admission", "eating disorders", "feeding and eating disorders", "anorexia nervosa", "bulimia nervosa". Research was restricted to articles concerning humans and published between 1975 and 2020 in English.

RESULTS

Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies).

CONCLUSIONS

Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

[Eating disorders and care without consent]

It is not usual to use care without consent in the management of eating disorders when the patient refuses the care indicated. Yet, these are psychiatric disorders responsible for a high mortality rate and a high risk of chronicity. Their management is complex, multidisciplinary and the refusal of care in the most severe cases raises ethical questions. It is important for the clinician to know the impact of these disorders, notably on the patient's cognitive and judgment capacities, in order to evaluate the necessity of implementing a restraint measure.

'It's Always About the Eating Disorder': Finding the Person Through Recovery-Oriented Practice for Bulimia

Bulimia is an eating disorder characterised primarily by binging and 'inappropriate' compensatory behaviours, such as purging or excessive exercise. Many individuals with bulimia experience chronic disordered eating, dissatisfaction with treatment, and difficulty establishing a 'new life'. Recovery-oriented practice, which focuses holistically on the person and their own aspirations for treatment, has recently been advocated in the treatment of eating disorders in Australia and other countries. However, questions have been raised about how this practice might be integrated into existing treatment approaches. Taking a social constructionist approach and using a case study of one woman's account, together with literature on patients' treatment experiences, we examined recovery from bulimia. Three themes were identified: bulimia was constructed as 'consuming one's life', an experience protracted through treatment ('treatment and becoming the eating disorder'), which makes life 'beyond treatment and attempting to live without bulimia' challenging. Based on this analysis, we argue that recovery-oriented practice, while seemingly commensurate with patients' needs, may be challenged by long-standing meanings of mental illness and experience of bulimia specifically.

Futility in adolescent anorexia nervosa and the question of withdrawal of care

Anorexia nervosa is a chronic disorder of children, adolescents and young people typically characterised by self-starvation and resistance to interventions. Staff dealing with these young people frequently question patient motivations and the ethics of interventions that may be applied against the wishes of patients. The question of withdrawal of care in a subgroup of these patients has been raised. Futility is not an appropriate response to adolescent anorexia nervosa, and treatment withdrawal is not appropriate for a disorder in which most patients can be expected to recover, in which opposition to treatment is a characteristic of the disorder and in which brain dysfunction is precipitated by severe malnutrition.

Barriers to hospital admission among people with eating disorders: A qualitative internet-based study

We seek to describe the barriers that people with eating disorders (EDs) face when undertaking a decision about whether to be admitted for inpatient treatment. Data were retrieved from a moderated ED Internet community website. A descriptive phenomenological approach was used to explore the shared experiences of community members who posted information about their viewpoints on inpatient admission. Three themes emerged: (i) 'Can I let others help me?' addressed the question of participants' ability to cooperate with hospital staff; (ii) 'Can I give up my daily routine?' focused on participants' meaningful lives outside of their ED (school, work, family, friends); and (iii) 'Can inpatient treatment work?' revealed a general lack of faith in the ability of inpatient treatment to make a substantial positive contribution. Our findings highlight the difficulties associated with making a decision about inpatient admission and suggest implications for mental-health professionals.

Caring for Patients With Severe and Enduring Eating Disorders (SEED): Certification, Harm Reduction, Palliative Care, and the Question of Futility

Anorexia nervosa is a serious mental illness with a high mortality rate. The body image distortion inherent to this disorder and the impaired judgment and cognition due to malnutrition frequently result in patients refusing treatment. Treatment is most effective if patients are treated early in the course of their illness and undergo a full course of treatment. Involuntary treatment may therefore be both life-saving and critical to recovery. Between April 2012 and March 2016, 109 patients (5.2% of patients admitted to the Eating Recovery Center in Denver, CO) were certified, 39% of whom were transferred from the ACUTE Center for Eating Disorders at Denver Health Medical Center. Of these 109 certified patients, 31% successfully completed treatment, and 42% returned for a further episode of care; 24% of the certifications were terminated as involuntary treatment was not found to be helpful. Conclusions supported by these data are that patients with anorexia nervosa who are the most medically ill often require involuntary treatment. In addition, although many patients who are certified successfully complete treatment, involuntary treatment is not helpful approximately 25% of the time. Many of the patients for whom certification is ineffective are those who suffer from a lifetime of illness that is severe and enduring. Patients with severe and enduring eating disorders (SEED) typically undergo cyclical weight restoration and weight loss. Many of these patients question the value of serial treatments, especially when they have few (if any) illness-free intervals. Patients, families, and treating physicians often wish to explore other models of care, including harm reduction and palliative care. In addition, patients with SEED may also contemplate whether a compassionate death would be better than an ongoing lifetime of suffering. In this review, we outline arguments for and against the concept of futility in SEED, and explore whether (or when) patients are competent to make the decision to die.

Mortality in eating disorders - results of a large prospective clinical longitudinal study

OBJECTIVE

To report on long-term mortality in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (ED-NOS), causes of death, and predictors of early death.

METHOD

A large sample of consecutively admitted inpatients (N = 5,839) was followed-up on vital status through the German civil registry office. Of these patients 1,639 were treated for AN, 1,930 for BN, 363 for BED, and 1,907 for ED-NOS. Data from the main inpatient hospital treatment were applied to bivariate and multivariate Cox regression analyses on survival time from onset of eating disorder to death or end of observation. Standardized mortality ratios (SMR) were computed matched for age, gender, and person-years.

RESULTS

SMR were 5.35 for AN, 1.49 for BN, 1.50 for BED, 2.39 for narrowly defined ED-NOS, and 1.70 for widely defined ED-NOS. Patients with AN died earlier than patients with BN, BED, or ED-NOS who did not differ. A diagnosis of AN, chronicity, later age of onset, not living in a relationship, and an irregular type of discharge from index inpatient treatment were major predictors of a shorter time to death. Suicidality was a univariate predictor of a shorter time to death in BN only. AN patients mostly died from natural causes related to their eating disorder.

DISCUSSION

Mortality in AN is excessive and considerably higher than in BN, BED, and ED-NOS.

Crisis on campus: Eating disorder intervention from a developmental-ecological perspective

OBJECTIVE

The purpose of this article is to review a crisis intervention using the developmental-ecological protocol (Collins and Collins, 2005) with a college student presenting with symptomatology of an active eating disorder.

PARTICIPANTS

Participants included University Wellness Center employees responding to the crisis.

METHODS

Methods include an informal review of the crisis intervention response and application of the ABCDE developmental-ecological crisis model.

RESULTS

Results reported include insight into crisis intervention when university counseling and health center is not available as resources.

CONCLUSIONS

ABCDE Developmental-ecological model recommendations for university faculty and staff are included.

Involuntary admission: the case of anorexia nervosa

Involuntary treatment of psychiatric disorders has always been controversial; this is especially true for eating disorders. Patients with anorexia nervosa of life threatening severity frequently refuse psychiatric hospitalization. Ambivalence toward treatment is characteristic of eating disorders and patients are often admitted to inpatient programs under pressure from family and doctors. In this article, we report research on the positive or negative impact of involuntary admission in the treatment of eating disorders, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders. A literature review was done. From a total of 134 publications which were retrieved from the literature search, 50 studies were directly relevant to the scope of this review and fulfilled all inclusion criteria. There are trends and arguments for both sides; for and against involuntary treatment in anorexia nervosa. The scientific literature so far is inconclusive, although in the short term, involuntary hospitalization has benefits. This review has also shown that involuntary hospitalization can have adverse long-term consequences for the patient-therapist allegiance. We conclude that in some cases, involuntary treatment can save lives of young patients with anorexia nervosa; however, in other cases, it can break the psychotherapeutic relationship and make the patient abandon treatment. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.

Compulsory treatment in anorexia nervosa: a review

OBJECTIVE

Compulsory in-patient refeeding of patients with severe anorexia nervosa (AN) has caused considerable controversy. The effects of such treatment on longer-term outcome are not well known. The objective of this article is to review the evidence on the outcome of compulsory treatment for AN.

METHOD

Three large databases were searched for studies regarding compulsory treatment in AN.

RESULTS

Detained patients have more severe symptoms and comorbidity and a longer duration of inpatient stay. In the short term compulsory refeeding in AN appears to be beneficial, but the longer term effects remain uncertain. Clinicians report no worsening of the therapeutic relationship after compulsory treatment.

DISCUSSION

In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN.

Eating disorders among patients incarcerated only for repeated shoplifting: a retrospective quasi-case-control study in a medical prison in Japan

BACKGROUND

Shoplifting is a serious problem among patients with eating disorders. For more than a decade, we have treated many patients with eating disorders incarcerated in Hachioji Medical Prison only for repeated shoplifting.

METHODS

We analyzed the prison records and medical records of female psychiatric patients transferred to Hachioji Medical Prison between 2002 and 2011. Based on the offense listed at the time of sentencing, we extracted a shoplifting group and a drug-offense group from among all patients with eating disorders. One patient from the former group who had used substances and two from the latter group who had never shoplifted were excluded from the study. The groups had 41 and 14 patients, respectively. A control group comprised patients with other mental disorders (n = 34). We compared eating disorder histories and subtypes, weight changes, comorbidities, life histories, past behavioral problems, and clinical behavioral problems among the three groups.

RESULTS

The shoplifting group exhibited less impulsive behavior, substance abuse, antisocial features, borderline personality disorder, and past bulimia than did the drug-offense and control groups. The shoplifting group had higher educational achievement and steadier employment; however, their eating disorder histories and interpersonal dysfunction were more severe, and they had a higher psychiatric treatment dropout rate. There were also significant relationships with low body weight, anorexia nervosa-restricting type, obsessive-compulsive behaviors, and obsessive-compulsive personality disorder in the shoplifting group. During the clinical course, food refusal, excessive exercise, food hoarding, and falsification of dietary intake amounts were more frequently observed in the shoplifting group. Conversely, drug requests and occurrences of self-harm were less frequent in the shoplifting group than in the drug-offense group.

CONCLUSIONS

Although these results may be associated with specific characteristics of patients with eating disorders in the medical prison setting, we concluded that the repeated shoplifting by these patients is unrelated to antisocial or impulsive characteristics but is deeply rooted in these patients' severe and undertreated eating disorder psychopathology. Strong supportive treatment should be considered for patients with eating disorders who develop shoplifting behaviors. Further research is required to elucidate the mechanisms responsible for the relationship between shoplifting and eating disorders.

A systematic review of the frequency, duration, type and effect of involuntary treatment for people with anorexia nervosa, and an analysis of patient characteristics

OBJECTIVE

Involuntary treatment of anorexia nervosa is controversial and costly. A better understanding of the conditions that determine involuntary treatment, as well as the effect of such treatment is needed in order to adequately assess the legitimacy of this model of care. The aim of the present study was to investigate the frequency and duration of involuntary treatment, the characteristics of this group of patients, the kind of involuntary actions that are applied and the effect of such actions.

REVIEW

Relevant databases were systematically searched for studies investigating the involuntary treatment of individuals diagnosed with anorexia nervosa.

RESULTS

The studies included in the review contained people treated in an inpatient setting for severe or severe and enduring anorexia nervosa. People that were treated involuntarily were characterised by a more severe psychiatric load. The levels of eating disorder pathology between involuntary and voluntary groups were similar and the outcome of involuntary treatment was comparable in terms of symptom reduction to that of voluntary treatment.

CONCLUSION

Despite inconsistent findings, the comparable levels of eating disorder pathology observed between involuntary and voluntary patient-groups together with findings of higher co-morbidity, more preadmissions, longer duration of illness and more incidences of self-harm for involuntary patients suggest that involuntary treatment is not a reaction to the severity of eating disorder symptoms alone, but is most likely a response to the complexity of the patient's situation as a whole.

Clinical Problems Encountered in the Treatment of Adolescents with Anorexia Nervosa 1Both authors contributed equally

The conceptualization of anorexia nervosa (AN) depends on the diagnostic criteria. Most patients with teenage onset AN seem to remit within 3–10 years depending on the definitions of recovery. The mortality of adolescent onset anorexia nervosa (AN) has fortunately decreased over the last two decades. Based on randomized controlled trials, we review different treatments including individual and group psychotherapy, family therapy, psychopharmacology, and hormone therapy. Treatment settings vary over time for any individual patient. Despite high rates of inpatient treatment, the respective evidence for effectiveness is meager. In underage patients with severe AN clinical, ethical and legal aspects need to be dealt with systematically if intermittent compulsory treatment is deemed necessary. The prolonged and frequently chronic course of AN often entails therapeutic discontinuity; the transition into adulthood requires a graded therapeutic concept that considers the severity of the disorder, developmental and chronological age, and parental involvement. Finally, we consider future clinical and research options to improve treatment and outcome of this eating disorder.