The adolescent with disordered eating symptoms, who may still be a minor, presents a special case with respect to diagnosis and treatment. The symptoms and severity of anorexia nervosa (AN) are such that involuntary treatment might be required to preserve life. Although the peer-reviewed literature generally accepts that AN is a serious biologically based disorder (Klump, Bulik, Kaye, Treasure, & Tyson, 2009), there is a proanorexia argument that eating disorders are a lifestyle choice (Fox, Ward, & O'Rourke, 2005; Overbeke, 2008). The ethical decision-making process outlined in the Companion Manual to the Canadian Code of Ethics for Psychologists (Sinclair & Pettifor, 2001) is useful for a psychologist to substantiate lower thresholds for involuntary treatment for adolescents with AN.
Keywords: anorexia nervosa, proana, adolescent, Canadian Code of Ethics for Psychologists, involuntary treatment
There is little professional conflict about the need for life-saving intervention or involuntary commitment for serious psychiatric disorders, such as a patient with major depressive disorder with suicidal intentions or a patient with schizophrenia with hallucinations commanding them to harm others (Andersen, 2007). In these cases, it is fairly clear that the patient may be admitted to hospital and treated, whether or not he or she feels the process to be coercive. In the past, individuals with eating disorders (EDs) were helped by clinical psychologists or psychiatrists; they are now being treated in a variety of settings and by a variety of professionals, including counselling psychologists (Werth, Wright, Archambault, & Bardash, 2003). A psychologist's assumptions about the need for involuntary treatment could depend on whether or not the psychologist has had experience with the more severe range of the spectrum of EDs (Andersen, 2007).
The adolescent with disordered eating symptoms, who has not necessarily reached the age of majority, presents a special case with respect to diagnosis and treatment. In this article, I explore the unique aspects of diagnosing anorexia nervosa (AN) in adolescents, consider the proanorexia stance that AN is a lifestyle that one has the right to pursue against the current understanding in peer-reviewed literature, and engage in an ethical decision-making process, weighing the ethical principles in conflict and exploring relevant literature, with respect to a hypothetical case of an adolescent presenting with eating-disordered symptoms. Despite the proanorexia argument that EDs are a lifestyle choice rather than a disorder, given the prevalence, severity and mortality of AN, the psychologist, with adherence to the Canadian Code of Ethics for Psychologists (2000), ought to consider involuntary treatment for the adolescent at a lower threshold than the adult.
In this article, I focus on AN rather than bulimia nervosa (BN) for several reasons, including the fact that there are fewer physical risks and lower lethality for pure BN as opposed to AN (Herzog et al., 2000). Also, given that there may be a core shared psychopathology for all EDs, the "overvaluation of the benefits of and need for weight loss or shape change" (Andersen, 2007, p. 10), much of the content of this article may be applicable to extreme cases of BN. In a similar token, my focus remains on adolescent females; although males can and do suffer from AN, the majority of those diagnosed with AN are female; only 10% of individuals with any ED are men (Health Canada, 2002). For the purposes of this article, I focus on the adolescent female's experience of AN and use the feminine pronoun when appropriate.
Anorexia Nervosa in Adolescents, the Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994), AN is characterised by the individual's refusal to maintain at least a minimally normal body weight, an intense fear of gaining weight or becoming fat, a disturbance in the way one's body weight or shape is perceived, and amenorrhea (the absence of at least three consecutive menstrual cycles). …