Compulsory treatment for anorexia nervosa: compassion or coercion?

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined

A recent article (JED 10:23, 2022) proposed defining terminal anorexia to improve access to palliative and hospice care, and to medical aid in dying for a minority of patients with severe and enduring anorexia nervosa (SE-AN). The authors presented three cases and, for two, the first author participated in their death. Anorexia nervosa is a treatable psychiatric condition for which recovery may be uncertain. We are greatly concerned however regarding implications of applying the label "terminal" to anorexia nervosa and the risk it will lead to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.

Recognising and managing eating disorders in the emergency department

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

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.

Mental Capacity, Decision-Making and Emotion Dysregulation in Severe Enduring Anorexia Nervosa

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.

Compulsory treatment in eating disorders: Control, provocation, and the coercion paradox

In eating disorders, the denial of the illness is a central phenomenon. In the most severe forms of anorexia, compulsory treatment may be necessary. The professional acceptance of involuntary treatment is controversial due to the fact that the autonomy of the patient is juxtaposed with the obligation of the health care practitioner to save lives. This paper discusses the major practical and ethical considerations surrounding this controversy. In addition, case vignettes are used to illustrate various strategies to diminish client resistance and enhance motivation toward treatment. Involving the family is nearly always essential for the treatment of patients with eating disorders. In some cases, parental consultation (i.e., treatment without the client) can also be an option. Home visits, though rarely used, can reframe the therapeutic relationship and provide information about family functioning. In general, a lower level of treatment coercion can be achieved through transparent client-parent and client-therapist communication.

When Does the “Duty to Protect” Apply with a Client Who has Anorexia Nervosa?

Individuals with eating disorders, especially those with anorexia nervosa, have the potential to experience significant harm and even death as a result of behaviors related to their condition. Because of this risk, the authors argue that there is a duty to protect (i.e., an obligation to take some action when a person is engaging or considering engaging in a behavior that may lead to self-harm) when a client's anorexia-related behavior has progressed to the point of medical jeopardy—that is, her or his life is in danger. This article reviews information on anorexia, including mortality data; ethical and legal issues when a client is believed to be a harm-to-self; and the literature related to involuntary hospitalization and compulsory treatment of clients with anorexia. The article concludes with a set of guidelines for when the duty to protect when a client has anorexia nervosa begins and with suggestions for interventions.

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.

Adolescents with anorexia nervosa have their say: a review of qualitative studies on treatment and recovery from anorexia nervosa

Anorexia nervosa often begins in adolescence, and there is a growing body of quantitative literature looking at the efficacy of treatment for adolescents. However, qualitative research has a valuable contribution to make to the understanding of treatment and recovery. This paper aims to review qualitative studies on the experience of treatment and recovery for adolescents with anorexia nervosa. Key themes from the 11 studies identified the role of family, peers and professionals, family therapy, the inpatient setting, emphasis on physical versus psychological and conceptualisation of recovery. Future studies would benefit from relating their findings to adolescent theory and considering reflexivity. Implications for clinical practice are also discussed.

The Ontario experience of involuntary treatment of pediatric patients with eating disorders

In this paper, the authors (two clinicians with specialized practices in child and adolescent eating disorders and a lawyer who practices health law in Ontario, Canada) review pertinent aspects of clinical capacity assessment, with elaboration of the specific unique and complex issues which shape that assessment in children and adolescents with eating disorders. The relevant Ontario legislation and institutional framework governing consent and capacity in children and adolescents are reviewed. The literature on involuntary treatment and consent and capacity in patients with eating disorders is reviewed. Specific cases involving child and adolescent patients with eating disorders that have been heard by the Ontario Consent and Capacity Board (OCCB) in the past decade are discussed in order to elucidate the Board's views of consent and capacity in this vulnerable and challenging patient population. Strategies to support clinicians' therapeutic alliances with their patients while both are going through what can be a lengthy and potentially adversarial-seeming legal process are also discussed.

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion

BACKGROUND

The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that patients are often subject to compulsion and coercion even without formal compulsory treatment orders. Research also suggests that patients suffering from anorexia nervosa can change their minds in retrospect about compulsion.

METHODS

Qualitative interviewing methods were used to explore the views of 29 young women concerning compulsion and coercion in the treatment of anorexia nervosa. The participants were aged between 15 to 26years old, and were suffering or had recently suffered from anorexia nervosa at the time of interview.

RESULTS

Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals.

CONCLUSIONS

People with anorexia nervosa appear to agree with the necessity of compulsory treatment in order to save life. The perception of coercion is complex and not necessarily related to the degree of restriction of freedom.

Feeding size 0: the challenges of anorexia nervosa. Managing anorexia from a dietitian's perspective

Anorexia nervosa has the highest mortality rate of any psychiatric condition and its management is complex and multi-faceted, requiring a multidisciplinary team approach. Dietitians are an important part of the multidisciplinary team, offering objective nutritional advice with the aim of helping the patient to develop an improved relationship with food. Refeeding patients with a low body weight requires careful management; nonetheless, refeeding the low-weight patient with anorexia presents many additional complications, largely of a psychological nature. Treatment plans need to consider psychological, physical, behavioural and psycho-social factors relating to anorexia nervosa. Currently, there is no consistent approach and a paucity of evidence to support best practice for weight restoration in this group of patients. Tube feeding is utilised at varying BMI in anorexia nervosa, mainly in an inpatient setting. However, its use should be seen as a last resort and limited to a life-saving intervention. Weight restoration is best managed by an experienced dietitian within a specialist eating disorders team, using normal foods. This approach is ideal for nutrition rehabilitation, promoting skills for eating and normal behaviour and providing a longer-term solution by challenging unhelpful coping strategies from the onset. Dietitians have a unique mix of skills and knowledge in numerous areas including nutrition, physiology, psychology, sociology and behaviour change, which can be applied to support patients with thoughts and behaviours around food, weight and appetite. Further research is required into the effectiveness of dietetic interventions in eating disorders in order to establish an evidence base for best practice.

Forced treatment of patients with anorexia

PURPOSE OF REVIEW

To consider clinical, ethical and legal approaches to forced feeding in patients with anorexia nervosa in the light of recent literature.

RECENT FINDINGS

An Australian retrospective record analysis compared 27 coercive with 96 informal hospitalizations and found more previous inpatient treatments, comorbidities, and a lower BMI at admission of 13.2 (SD 1.67) kg/m, but no significantly different weight gain [4.96 (SD 6.56) kg]. In a higher proportion of the involuntary group a re-feeding syndrome, treatment in a locked ward, and tube feeding were recorded. In Germany 25 women with anorexia nervosa with an admission BMI of 12.09 (SD 1.51) kg/m gained 12.44 (SD 1.21) kg. Twenty were treated involuntarily and 22 received tube feeding- 20 of whom were fed a via transdermal duodenal tube, four of whom as voluntary patients.

SUMMARY

As full recovery is possible in life-threatening anorexia nervosa, detention is sometimes justifiable and may indeed be necessary. Compulsory admission, however, does not necessarily imply a need for forced or tube feeding. Highly skilled nursing seems preferable, and so it may be better to admit the patient before the BMI drops below 13 kg/m. The validity of this proposal should be examined using a prospective research design with a follow-up period.

Coercion is coercion? Reflections on trends in the use of compulsion in treating anorexia nervosa

OBJECTIVE

This paper explores similarities and differences between formal coercion and other forms of 'strong persuasion' in clinical decision-making about medical management of patients with severe anorexia nervosa.

METHOD

The paper builds on findings from analysis of data from 117 successive admissions to an eating disorder facility, where an eating disorder was the primary diagnosis.

RESULTS

The study implications of particular interest in this paper are the findings that legal coercion into treatment was associated with three main indicators: the patient's past history (number of previous admissions), the complexity of their condition (the number of other psychiatric comorbidities), and current health risk (measured either by body mass index or the risk of re-feeding syndrome).

CONCLUSIONS

We conclude that clinicians use legal coercion very sparingly in treating severe anorexia nervosa, distinguishing legal coercion from other forms of close clinical management of patients. While we agree with Monahan et al. and others that there are similarities between legal coercion and other forms of strong clinical management (or power), our results suggest that clinicians recognize the importance of maintaining, rather than blurring that distinction.

Application criteria of enteral nutrition in patients with anorexia nervosa: correlation between clinical and psychological data in a "lifesaving" treatment

BACKGROUND

Data and research increasingly point to multiple factors in the genesis of eating-behavior disorders, but the lack of a clear etiological definition prevents a unique therapeutic or prognostic approach from being defined. Therapeutic approaches, as well as scientific research, have separately analyzed the psychological aspects and the clinical-nutrition aspects without integrating the variables or correlating clinical and psychological data. This work has several goals because it aims at considering the problem from the 2 different perspectives. Psychological and clinical variables are analyzed both separately and together in order to assess (a) the minimal criteria to define a cure as "lifesaving" and submit a patient to artificial nutrition; (b) the kind of implementation artificial nutrition should follow; (c) which indicators of the efficacy of artificial nutrition must be taken into account; (d) the results in nutrition terms that may be obtained during the follow-up; (e) if artificial nutrition may be used as a therapeutic tool; (f) if there are any psychological effects after artificial nutrition; (g) if there are any effects due to the patients' age; and (h) the correlation between the psychological profile of a patient and the acceptance of the nutrition treatment.

METHODS

Several psychological and pharmacologic variables, together with clinical and anthropometric data and blood chemical values, were all considered.

CONCLUSIONS

Besides defining minimal criteria for a "lifesaving" cure and proposing 2 ad hoc scales for the assessment of patients' subjective willingness toward feeding and for the objective measurement of feeding itself, clinical data and correlations with psychological data evidenced the importance of artificial nutrition and specifically of enteral nutrition as a therapeutic tool, allowing us to define the modalities of implementation of enteral nutrition. Results show that, because enteral nutrition did not deteriorate the psychological state of the patients, and was found to be accepted more positively than feeding orally in the most critical initial phase, it should be included in the therapy.

Nocturnal nasogastric refeeding for hospitalized adolescent boys with anorexia nervosa

Boys with anorexia nervosa have nutritional needs exceeding those of their female counterparts. For many males with anorexia nervosa, oral refeeding alone may result in low discharge weight, a critical risk factor in relapse. This study compared the short-term outcomes of oral refeeding (OR) and a combination of OR with supplemental nocturnal nasogastric refeeding (NNGR) in a sample of hospitalized boys. This was a retrospective chart review with a cohort design. Subjects were partitioned into: The OR group (n = 8, mean age = 14.9, SD = 1.7) and the OR + NNGR group (n = 6, mean age = 13.8, SD = 2.0). The NNGR group had greater increase in weight and Body Mass Index. Their average length of hospitalization was also shorter. Nocturnal nasogastric refeeding, complementing oral refeeding, should be considered as an alternative initial therapy for weight restoration in males with anorexia nervosa.

Treatment resistance in anorexia nervosa and the pervasiveness of ethics in clinical decision making

Clinical efforts to treat anorexia nervosa (AN) are constantly resisted by patients. Although the primacy of patient autonomy is a cornerstone of modern medical ethics, clinicians will nonetheless often be justified in pursuing particular interventions despite such resistance, give the reduced competency of patients suffering from this multifactorial psychiatric illness. While a literature exists on the ethical justification for imposing treatment, that literature has focused exclusively on situations in which patients refuse treatment outright. When patients resist rather than refuse treatment, clinicians are faced with the ethical challenge of deciding whether particular interventions constitute justified infringements upon patient autonomy. Given the fact that treatment resistance is endemic to AN, we see that ethical decision making must also be a continual part of the disorder's treatment. This paper argues that the treatment of AN merely constitutes a particularly clear example of what is in fact a general phenomenon: ethical decision making pervades all clinical practice.

Involuntary treatment in anorexia nervosa

It is difficult to predict, on first contact with patients with AN, whether a compulsory admission to hospital may become necessary to protect their lives and health. There are only tentative pointers so far to an entrenched avoidance of treatment: (1) components of a disordered personality associated with a history of childhood physical or sexual abuse or previous episodes of self-harm and (2) the presence of a more severe illness, suggested by numerous previous admissions. An involuntary admission is likely to be beneficial at least in the short term, as shown by a gratifying weight gain, although a longer period of inpatient stay may be necessary. Patients who have required compulsory detention are at a considerable risk in the long-term as shown by their high mortality rates. It is, therefore, essential to organize long-term observation for all patients who required involuntary admission for AN. A compulsory admission for AN does not require compulsory treatment, such as forced feeding by NGT or other intrusive methods. Clinicians who contemplate a compulsory admission for a seriously ill anorexic patient might therefore question the advantages provided by the detention. First, clinicians can be assured that it should be possible to induce a satisfactory weight gain through persistent nursing methods without running the risk of these patients discharging themselves. With inpatients, the goals are nearly always attained, although the admission may be longer than average. Not only do these patients' nutrition improve vastly, but also they are likely to show improvements in their mental state. Secondly, these patients are likely to learn that the professional staff, their families, and outside agencies take their illness very seriously, even if patients themselves do not seem to. This is particularly evident when patients appeal to a Mental Health Review Tribunal for release. They attend the proceedings and hear the evidence presented by their psychiatrists, the nursing staff, and their nearest relatives. The tribunal usually sustains the compulsory admission: the patient may be initially distressed, but in the long run the experience is generally therapeutic. Finally, compulsory admission permits more stringent forms of supervision. For example, patients who vomit may have legitimately restricted access to bathrooms. Patients addicted to exercise may be rationed to sensibly short periods of walking daily. Patients who are extremely anxious or overactive may be required to take appropriate tranquilizing or sedating drugs, such as one of the benzodiazepine drugs. Clinicians sometimes are reluctant to resort to compulsory admission because of a fear of damaging the therapeutic relationship with their patients. Clinical observations, however, point to the converse being the case, as shown in several studies. Tiller et al maintain: "Compulsory treatment may be an act of compassion: it shows that professionals recognize the severity of the illness and that they are prepared to contain the anxieties provoked by weight gain. Often the patients and their families are immensely relieved to hand over the responsibility, temporarily, to the professional team."

Enteric feeding in severe adolescent anorexia nervosa: a report of four cases

OBJECTIVE

Refeeding patients with anorexia nervosa can be one of the more challenging aspects of their treatment, and particularly if all food and fluids are adamantly and persistently refused.

METHOD

If the decision is made to augment or replace oral feeds, the most common intervention is nasogastric feeding.

RESULTS

Although this is often successful, a subset of patients manage to sabotage feeding via this route. Other means of delivering nutrition such as intravenous feeds are often impractical for long-term use. Another alternative in such life-threatening situations is the use of enteric feeds via gastrostomy or jejunostomy. This paper presents the successful use of such enteric feeding in four cases of severe adolescent anorexia nervosa.

DISCUSSION

The psychological, legal, and ethical issues involved are discussed, concluding that gastrostomy and jejunostomy are valid lifesaving methods to feed highly resistant anorectic patients.

Impact of hospitalisation on the outcome of adolescent anorexia nervosa

BACKGROUND

Owing to the lack of controlled trials of treatment setting in adolescent anorexia nervosa, the benefits and costs of in-patient treatment are not established.

AIMS

To clarify the relationship between a range of presenting features, treatment received and medium- to long-term outcome in adolescent anorexia nervosa.

METHOD

A range of presenting variables were rated for 75 cases of DSM-III-R anorexia nervosa at presentation to an adolescent service, including the Morgan-Russell Global Assessment Score. Cases were followed up at 2-7 years and outcome rated according to reliable methods. Setting of treatment received was also recorded.

RESULTS

Two out of 75 cases had died by the time of follow-up. Adequate data for 72 enabled an outcome category to be assigned. The 21 who had received inpatient treatment had a significantly worse outcome than the 51 never admitted to hospital. Multivariate analysis suggests admission to be the major predictor of poor outcome.

CONCLUSIONS

The benefits and costs of admission to hospital require further investigation, ideally in a randomised-controlled trial. The negative consequences of in-patient treatment are neglected in research.

Compulsory treatment in anorexia nervosa. Short-term benefits and long-term mortality

BACKGROUND

Anorexia nervosa is a mental disorder with a high long-term mortality. Patients are ambivalent about treatment and often avoid it. Of necessity, compulsory treatment sometimes must be considered. A report from the Mental Health Act Commission has helped to reduce previous confusion.

AIMS

To identify the premorbid and clinical features that predisposed to compulsory admissions, the short-term benefits of the treatment and the long-term mortality rates (derived from the National Register).

METHOD

Eighty-one compulsory patients were compared with 81 voluntary patients.

RESULTS

Predisposing factors to a compulsory admission were a history of childhood sexual or physical abuse or previous self-harm. Detained patients had more previous admissions. Detained patients gained as much weight during admission as voluntary patients, but took longer. More deaths among compulsory than voluntary patients (10/79 v. 2/78) were found 5.7 years (mean) after admission.

CONCLUSIONS

Compulsory treatment is effective in the short term. The higher long-term mortality in the detained patients is due to selection factors associated with an intractable illness.

Civil commitment of the anorexic patient

Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.

The use of guardianship legislation for anorexia nervosa: a report of 15 cases

OBJECTIVE

This paper investigates compulsory treatment under guardianship legislation for 15 anorexia nervosa patients admitted to four eating disorders units in New South Wales (NSW), Australia, between 1991 and 1994.

METHODS

A retrospective follow-up was conducted. This involved an analysis of sociodemographic, clinical, eating and weight history, and Guardianship Order details obtained from medical records. This small sample was compared to a larger sample of anorexia nervosa patients admitted voluntarily to a specialised eating disorder unit in NSW. Further follow-up included a structured interview using the Morgan-Russell Assessment Outcome Schedule at least 1 year after admission for compulsory treatment.

RESULTS

For those treated involuntarily, a larger number came from metropolitan Sydney and a larger percentage were unemployed, were purgers and required specialist medical consultations. A significantly higher proportion came from higher socioeconomic groups, and the duration of stay in hospital while patients were under guardianship was significantly greater. A high degree of comorbidity was noted. There were similarities between those treated involuntarily and those treated voluntarily for the source of referral, marital status and Body Mass Index on admission and discharge. Only three patients accepted a follow-up interview using the Morgan-Russell Outcome Schedule. Two of them had made a good recovery.

CONCLUSIONS

It was noted that the guardianship sample comprised a more severely III group than anorexic patients treated voluntarily. The nature of guardianship legislation compared to mental health law was discussed and advice offered to clinicians contemplating and implementing compulsory treatment.

Anorexia nervosa viewed as an extreme weight condition: genetic implications

In anorexia nervosa, psychopathological features and reduced body weight are inseparable, suggesting a prominent role of behavioral factors in achievement and maintenance of extreme underweight. Due to the considerably higher prevalence of this eating disorder in females, anorexia nervosa contributes to the left end of the distribution of the body mass index, especially in the female sex. By reviewing the relevant literature we examined whether genetic research in anorexia nervosa can profit from considering this disorder as an extreme weight condition. For this purpose we compared genetic studies pertaining to both anorexia nervosa and the heritability of the body mass index. Whereas previous genetic studies in anorexia nervosa have mostly concentrated on the assessment of the familial psychopathology, further studies are warranted that additionally attempt to analyze the complex phenotype body weight in relatives of affected probands. Further insight into pathogenetic mechanisms underlying anorexia nervosa might be gained by contrasting the epidemiological, psychopathological and prognostic factors with those in severe obesity. Thus, epidemiological studies suggest that females are more likely to develop both extreme underweight and extreme obesity. A possible explanation for this phenomenon is that the, on average, higher percentage of total body weight composed of fat mass might predispose females towards the development of both extreme weight conditions.