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."