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Kiely L, Conti J, Hay P. Severe and enduring anorexia nervosa and the proposed "Terminal anorexia" category: an expanded meta synthesis. Eat Disord 2024:1-32. [PMID: 39099227 DOI: 10.1080/10640266.2024.2379635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
This updated meta-synthesis explores further dimensions of the lived experience of severe and enduring anorexia nervosa (SE-AN) since recent contention regarding proposed "terminal anorexia nervosa (T-AN)". The paper aims to update the original synthesis and to situate participant responses to the category of "T-AN". Thus, extending the proposed conceptualization of the SE-AN experience. A systematic search identified published scholarship (between August 2022 and July 2023), derived from five bibliographic databases. A comprehensive methodology combining Interpretative Phenomenological Analysis and a meta-ethnographic framework enabled the synthesis of meta-themes across 9 new studies. These meta-themes were mapped onto the primary synthesis to further develop upon the earlier LE conceptualization of SE-AN. Nine extracted papers expanded the voices to 447 people within 45 studies. All papers affirmed and enriched the previous themes, and a novel theme was generated from the recent papers. The new theme, "walking on a knife's edge, caught between worlds", informed an expanded conceptualization of SE-AN, termed the Web of Hope. Thus, demonstrating how participants held onto hope in the face of the SE-AN experience. Death, dying and "terminality", were notably absent in the 36 papers in the previous meta-synthesis. Since the proposal of the category of "terminal anorexia" in 2022, studies on the lived experience of SE-AN increasingly focused on how people hold onto hope alongside SE-AN. The findings further drive the field to reflect on therapeutic interventions, labelling and diagnosis, in the face of unknowns, on the premise of "first, do no harm".
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Affiliation(s)
- Laura Kiely
- School of Medicine, Translational Health Research Institute, Western Sydney University, Campbelltown, Australia
| | - Janet Conti
- School of Psychology, Translational Health Research Institute, Western Sydney University, Penrith, Australia
| | - Phillipa Hay
- School of Medicine, Translational Health Research Institute, Western Sydney University, Campbelltown, Australia
- Mental Health Services, Camden and Campbelltown Hospitals, SWSLHD, Campbeltown, NSW, Australia
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Abry F, Gorwood P, Hanachi M, Di Lodovico L. Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2024; 32:179-187. [PMID: 37690079 DOI: 10.1002/erv.3033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN. METHODS 23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up. RESULTS At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05). DISCUSSION Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.
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Affiliation(s)
- Florent Abry
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | - Philip Gorwood
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Mouna Hanachi
- Clinical Nutrition Unit, Paul Brousse University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Villejuif, France
- UMR Micalis Institute, INRA, Paris-Saclay University, Jouy-En-Josas, France
| | - Laura Di Lodovico
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- NeuroCentre Magendie, INSERM U1215, Bordeaux, France
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3
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Schölin L, Tucker Z, Chopra A, Borschmann R, McKay C. Detention of children and adolescents under mental health legislation: a scoping review of prevalence, risk factors, and legal frameworks. BMC Pediatr 2024; 24:12. [PMID: 38178014 PMCID: PMC10765764 DOI: 10.1186/s12887-023-04464-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND For individuals with severe mental illness, involuntary assessment and/or treatment (hereafter detention) can be a necessary intervention to support recovery and may even be lifesaving. Despite this, little is known about how often these interventions are used for children and adolescents. METHODS This global scoping review set out to: (1) map the current evidence around mental health detentions of children and adolescents (< 18 years); (2) identify the clinical, sociodemographic, and behavioural factors associated with detention; and (3) document the views of professionals and young people on the implementation of mental health legislation. RESULTS After searching databases of peer-reviewed literature and citation chaining, 42 articles from 15 jurisdictions were included. About one fifth of psychiatric admissions in national register data were detentions, however trends were only available for a few high-income Western countries. The circumstances justifying detention and the criteria authorising detention varied between studies, with a mix of clinical factors and observed behaviours reported as the reason(s) warranting/precipitating a detention. Particular groups were more likely to experience detention, such as children and adolescents from minority ethnic communities and those with a documented history of abuse. There was a notable absence of qualitative research exploring the views of professionals or children and adolescents on detention. CONCLUSION Further research is needed to explore the impact of detention on those aged < 18 years, including national register-based studies and qualitative studies. This is particularly relevant in nations currently undergoing legislative reform.
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Affiliation(s)
- Lisa Schölin
- Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK.
| | - Zack Tucker
- Masters student at University of Edinburgh, Edinburgh, UK
| | - Arun Chopra
- Mental Welfare Commission for Scotland, Edinburgh, UK
| | - Rohan Borschmann
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - Colin McKay
- Centre for Mental Health and Capacity Law, Edinburgh Napier University, Edinburgh, UK
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Haran M, Killeen D, Healy M, Brophy P, Donohue A, Whyte I, Doody B. Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study. Ir J Med Sci 2023; 192:2929-2936. [PMID: 36813877 PMCID: PMC10692034 DOI: 10.1007/s11845-023-03316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND There has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland. AIMS The purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics. METHODS This is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed. RESULTS Of 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively. CONCLUSIONS Identifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.
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Affiliation(s)
- Maeve Haran
- Department of Psychiatry, School of Medicine, University College Dublin, Dublin, Ireland.
- Children's Health Ireland at Crumlin, Dublin, D12N512, Ireland.
| | - David Killeen
- Dublin North City and County CAMHS - Ballymun CAMHS, Ballymun Civic Centre, Dublin, Ireland
| | - Mike Healy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Peadar Brophy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Aoife Donohue
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Imelda Whyte
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Brendan Doody
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
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Donald BM, Bulik CM, Larsen JT, Carlsen AH, Clausen L, Petersen LV. Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors. Psychol Med 2023; 53:1999-2007. [PMID: 37310331 PMCID: PMC10811565 DOI: 10.1017/s003329172100372x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN. METHODS In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics. RESULTS IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these. CONCLUSIONS High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.
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Affiliation(s)
- Benjamin Mac Donald
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Cynthia M. Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Janne T. Larsen
- The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
| | - Anders H. Carlsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Loa Clausen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Liselotte V. Petersen
- The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
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Mac Donald B, Gustafsson SA, Bulik CM, Clausen L. Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events. J Eat Disord 2023; 11:40. [PMID: 36915181 PMCID: PMC10010243 DOI: 10.1186/s40337-023-00765-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
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.
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Affiliation(s)
- Benjamin Mac Donald
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens-Boulevard 99, 8200, Aarhus, Denmark. .,Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, Entrance K, 8200, Aarhus, Denmark.
| | - Sanna A Gustafsson
- School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Loa Clausen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens-Boulevard 99, 8200, Aarhus, Denmark.,Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, Entrance K, 8200, Aarhus, Denmark
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7
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Baile JI, González-Calderón MJ, Rabito-Alcón MF. [Non-voluntary internment in patients with anorexia nervosa in Spain]. Med Clin (Barc) 2023; 160:85-89. [PMID: 36283852 DOI: 10.1016/j.medcli.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/05/2022]
Affiliation(s)
- José I Baile
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España.
| | - María J González-Calderón
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España
| | - María F Rabito-Alcón
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España
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Abstract
LEARNING OBJECTIVES After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. ABSTRACT Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.
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Mac Donald B, Bulik CM, Petersen LV, Clausen L. Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa. Eat Weight Disord 2022; 27:3157-3172. [PMID: 35864298 PMCID: PMC9805523 DOI: 10.1007/s40519-022-01446-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/03/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment. METHODS This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)). RESULTS Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment. CONCLUSIONS Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Benjamin Mac Donald
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark.
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Liselotte V Petersen
- The National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-Based Research (CIRRAU), Aarhus University, Aarhus, Denmark
| | - Loa Clausen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
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10
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Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord 2022; 10:135. [PMID: 36068601 PMCID: PMC9450436 DOI: 10.1186/s40337-022-00659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Premature deaths are estimated to occur in 5-20% of patients with anorexia nervosa (AN). Among them, some patients with severe and enduring anorexia nervosa (SE-AN) will die due to the medical complications of malnutrition or to suicide. Almost no literature provides guidance to patients, clinicians, and loved ones regarding clinical characteristics of those with SE-AN who recognize and accept the fact that they will not be able to survive their disease. Consistent with general medical literature on terminal illness and based on the authors' work with patients at this phase of life, we previously described four clinical characteristics of the small group of SE-AN patients who may be considered to have a terminal eating disorder. Following publication of this article, several opinions objecting to these formulations were published. The goals of this article are to respond to the key themes of concern posed by these objections, to extend our discussion of the palliative care and associated needs of these patients and their families, and to suggest ways in which the eating disorder and palliative care fields might develop more definitive criteria and consensus guidelines for the assessment and management of these patients. METHODS Based on a selective narrative review of the literature, our combined experiences with these patients, and clinical reasoning, we address critiques grouped around five major themes: that (1) labels such as terminal AN are dangerous; (2) since AN is a treatable disorder, no SE-AN patients should be considered terminal; (3) a terminal psychiatric condition cannot be defined; (4) the proposed definition is not specific enough; and (5) considerations regarding mental capacity in the proposed criteria do not sufficiently account for the psycho-cognitive impairments in AN. RESULTS Our analysis responds to the critiques of our original proposed clinical characteristics of those with terminal AN. While refuting many of these critiques, we also appreciate the opportunity to refine our discussion of this complex topic and identify that there are multiple stages of SE-AN that can result in good clinical outcomes. Only when all of these have failed to provide adequate amelioration of suffering do a low number of patients progress to terminal AN. CONCLUSIONS By further refining our discussion of terminal AN, we aim to encourage eating disorders and palliative care specialists to develop expert consensus definitions for terminal AN and to generate authoritative clinical guidance for management of this population. By validating terminal AN as a distinct condition, patients with this subcategory of SE-AN, their families, and their caregivers facing end-of-life concerns may be better able to access palliative and hospice care and related services to help improve their overall experiences at this phase of life.
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Affiliation(s)
- Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jonathan Treem
- Department of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Zhang R, Birgegård A, Fundín B, Landén M, Thornton LM, Bulik CM, Dinkler L. Association of autism diagnosis and polygenic scores with eating disorder severity. EUROPEAN EATING DISORDERS REVIEW 2022; 30:442-458. [PMID: 35855524 PMCID: PMC9544642 DOI: 10.1002/erv.2941] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 12/18/2022]
Abstract
Among individuals with eating disorders (ED), those with co‐occurring autism are often considered to have more severe presentations and poorer prognosis. However, previous findings have been contradictory and limited by small sample size and/or cross‐sectional assessment of autistic traits. We examine the hypothesis that autism diagnosis and autism polygenic score (PGS) are associated with increased ED severity in a large ED cohort using a broad range of ED severity indicators. Our cohort included 3189 individuals (64 males) born 1977–2000 with current or previous anorexia nervosa who participated in the Anorexia Nervosa Genetics Initiative‐Sweden (ANGI‐SE) and for whom genotypes and linkage to national registers were available. We identified 134 (4.2%) individuals with registered autism diagnoses. Individuals with confirmed autism diagnosis had significantly more severe ED across three sets of severity indicators. Some of the largest effects were found for the proportion of individuals who attempted suicide and who received tube feeding (higher in autism), and for the time spent in inpatient care (longer in autism). Results for autism PGS were not statistically significant. Adapting ED treatment to the needs of individuals with co‐occurring autism is an important research direction to improve treatment outcome in this group. Among 3189 Swedish individuals with current or previous anorexia nervosa, those with confirmed autism diagnosis (4.2%) experienced higher eating disorder severity across 27 out of 29 indicators. Some of the highest risk increases were found for having attempted suicide, having received tube feeding, and time spent in inpatient care for eating disorders. Repeating the analyses with autism polygenic score instead of autism diagnosis yielded non‐statistically significant results for all 29 eating disorder severity indicators.
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Affiliation(s)
- Ruyue Zhang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Birgegård
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Fundín
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Landén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Laura M Thornton
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cynthia M Bulik
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lisa Dinkler
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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12
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Hindley K, Fenton C, McIntosh J. A systematic review of enteral feeding by nasogastric tube in young people with eating disorders. J Eat Disord 2021; 9:90. [PMID: 34294163 PMCID: PMC8299614 DOI: 10.1186/s40337-021-00445-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/13/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Adolescents with severe restrictive eating disorders often require enteral feeding to provide lifesaving treatment. Nasogastric feeding (NG) is a method of enteral nutrition often used in inpatient settings to treat medical instability, to supplement poor oral intake or to increase nutritional intake. This systematic review sets out to describe current practice of NG in young people with eating disorders. METHODS A systematic review following PRISMA guidelines was conducted by searching AMED, EMBASE and MEDLINE databases from 2000 to 2020. Inclusion terms were: enteral feeding by nasogastric tube, under 18 years, eating disorders, and primary research. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18 years. Titles and abstracts were screened by all authors before reviewing full length articles. Quality assessment, including risk of bias, was conducted by all authors. RESULTS Twenty-nine studies met the full criteria. 86% of studies were deemed high or medium risk of bias due to the type of study: 34.4% retrospective cohort and 10.3% RCT; 17.2% were qualitative. Studies identified 1) a wide range of refeeding regimes depending on country, settings, and the reason for initiation; 2) standard practice is to introduce Nasogastric feeds (NG) if medically unstable or oral intake alone is inadequate; 3) NG may enable greater initial weight gain due to increased caloric intake; 4) there are 3 main types of feeding regime: continuous, nocturnal and bolus; 5) complications included nasal irritation, epistaxis, electrolyte disturbance, distress and tube removal; 6) where NG is routinely implemented to increase total calorie intake, length of stay in hospital may be reduced; however where NG is implemented in correlation to severity of symptoms, it may be increased; 7) both medical and psychiatric wards most commonly report using NG in addition to oral intake. CONCLUSIONS NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. There are currently no direct comparisons between continuous, nocturnal or bolus regimes, which may be used to direct future treatment for YP with ED.
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Affiliation(s)
| | - Clare Fenton
- Leeds and York Partnership NHS Foundation Trust, Mill Lodge, 520 Huntington Rd, York, YO32 9QA, UK
| | - Jennifer McIntosh
- Leeds and York Partnership NHS Foundation Trust, Mill Lodge, 520 Huntington Rd, York, YO32 9QA, UK
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13
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Westermair AL, Buchman DZ, Levitt S, Trachsel M. Palliative Psychiatry for Severe and Enduring Anorexia Nervosa Includes but Goes beyond Harm Reduction. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:60-62. [PMID: 34152919 DOI: 10.1080/15265161.2021.1926594] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Anna L Westermair
- University of Zurich (UZH)
- University Hospital Basel (USB) and University Psychiatric Clinics (UPK)
| | - Daniel Z Buchman
- Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, University of Toronto
- University of Toronto Joint Centre for Bioethics
| | | | - Manuel Trachsel
- University of Zurich (UZH)
- University Hospital Basel (USB) and University Psychiatric Clinics (UPK)
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14
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Atti AR, Mastellari T, Valente S, Speciani M, Panariello F, De Ronchi D. Compulsory treatments in eating disorders: a systematic review and meta-analysis. Eat Weight Disord 2021; 26:1037-1048. [PMID: 33099675 PMCID: PMC8062396 DOI: 10.1007/s40519-020-01031-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Anna Rita Atti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.
| | - Tomas Mastellari
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Valente
- Department of Mental Health, Local Health Authority of Bologna, Bologna, Italy
| | - Maurizio Speciani
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Fabio Panariello
- Department of Mental Health, Local Health Authority of Bologna, Bologna, Italy
| | - Diana De Ronchi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
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15
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van Elburg A, Danner UN, Sternheim LC, Lammers M, Elzakkers I. Mental Capacity, Decision-Making and Emotion Dysregulation in Severe Enduring Anorexia Nervosa. Front Psychiatry 2021; 12:545317. [PMID: 33776810 PMCID: PMC7991306 DOI: 10.3389/fpsyt.2021.545317] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022] Open
Abstract
Severe and Enduring Anorexia Nervosa (SE-AN) is a chronic eating disorder characterized by long-term starvation and its physical and psychological sequelae, and severe loss of quality of life. Interactions between neurobiological changes caused by starvation, vulnerability (personality) traits, and eating behaviors play a role. Several other factors, such as increased fear and decreased social cognition, have also been found in relation to SE-AN. With this in mind, we aim to add to the understanding of SE-AN by introducing the concept of mental capacity (MC), which refers to the ability to understand and process information-both on a cognitive and an emotional level-and then make a well-informed choice. MC may be an important construct within the context of SE-AN. Furthermore, we will argue how impaired decision-making processes may underlie, fuel, or contribute to limited MC in SE-AN. We will speculate on the importance of dysfunctional emotion processing and anxiety-related processes (e.g., a high intolerance of uncertainty) and their potential interaction with decision-making. Lastly, we will propose how these aspects, which to our knowledge have previously received little attention, may advise research and treatment or help in dealing with the "want but cannot" situation of life-threatening AN.
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Affiliation(s)
- Annemarie van Elburg
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands.,Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
| | - Unna Nora Danner
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands.,Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
| | - Lot Catharina Sternheim
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | | | - Isis Elzakkers
- Rintveld Center for Eating Disorders, Altrecht Mental Health Institute, Zeist, Netherlands
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16
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Wonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: Update and observations about the current clinical reality. Int J Eat Disord 2020; 53:1303-1312. [PMID: 32359125 DOI: 10.1002/eat.23283] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/22/2022]
Abstract
Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.
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Affiliation(s)
- Stephen A Wonderlich
- Sanford Research, Center for Bio-behavioral Research, Fargo, North Dakota, USA.,Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ulrike Schmidt
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Howard Steiger
- Eating Disorder Continuum, Douglas Mental Health University Institute, Montreal, Canada.,Psychiatry Department, McGill University, Montreal, Canada
| | - Hans W Hoek
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, USA.,Parnassia Psychiatric Institute, The Hague, The Netherlands
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17
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18
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Fuller SJ, Philpot U, Barrett N, Cooper E, Doyle M, Druce‐Perkins J, Elliott H, Falcoski P, Forster R, Hickley Y, Jennings R, Manson D, Street O, Vlachou P, Wade S, White S. The development of consensus‐based guidelines for dietetic practice in nasogastric tube feeding under restraint for patients with anorexia nervosa using a modified Delphi process. J Hum Nutr Diet 2020; 33:287-294. [DOI: 10.1111/jhn.12731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Blikshavn T, Halvorsen I, Rø Ø. Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up. J Eat Disord 2020; 8:20. [PMID: 32514349 PMCID: PMC7262758 DOI: 10.1186/s40337-020-00297-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/23/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome. METHOD Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up. RESULTS A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up. CONCLUSIONS Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.
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Affiliation(s)
- Thomas Blikshavn
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Department of Child and Adolescent Mental Health, Akershus University Hospital, Lørenskog, Norway
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Clausen L. Perspectives on Involuntary Treatment of Anorexia Nervosa. Front Psychiatry 2020; 11:533288. [PMID: 33192651 PMCID: PMC7641604 DOI: 10.3389/fpsyt.2020.533288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 01/12/2023] Open
Abstract
Involuntary treatment of anorexia nervosa is an option in cases in which the patient's life or other people's lives are at risk or, in some countries, to prevent the deterioration of the illness. Involuntary treatment is often regarded as controversial and has been intensely debated, although typically with few references to documented knowledge. This paper provides a research perspective of the topic by examine data in the field of the involuntary treatment of anorexia nervosa to pinpoint present knowledge as well as areas demanding clinical action or research attention. The prevalence of involuntary treatment in general as well as specific measures is described and possible early markers of patients at risk of involuntary treatment are discussed. Studies including patients' perspectives of involuntary treatment show the complexity of this treatment, its initiation, and its consequences. To qualify future discussions, improve current practice, and minimize involuntary treatment in general as well as on an individual level, at least four areas need attention: (i) the present specific symptoms of anorexia nervosa and their imminent consequences, (ii) illness history, (iii) overall psychiatric symptoms and general functioning, and (iv) contextual sphere of the patient. In particular, the last two require attention from both clinicians and researchers. Furthermore, critical evaluation of the attitudes of both patients and health care professionals toward each other and the treatment is recommended.
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Affiliation(s)
- Loa Clausen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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21
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Forbush KT, Crosby RD, Coniglio K, Haynos AF. Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders. Int J Eat Disord 2019; 52:493-496. [PMID: 30788850 PMCID: PMC6499674 DOI: 10.1002/eat.23050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA. METHODS AND RESULTS We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers. DISCUSSION We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.
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Affiliation(s)
| | - Ross D. Crosby
- Sanford Research, Neuropsychiatric Research Institute, Fargo, North Dakota
| | - Kathryn Coniglio
- Department of Psychology, Rutgers University, Piscataway, New Jersey
| | - Ann F. Haynos
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
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