Reflections on Coercion in the Treatment of Severe Anorexia Nervosa
Carney, Terry, Wakefield, Alison, Tait, David, Touyz, Stephen, The Israel Journal of Psychiatry and Related Sciences
Abstract: Background: The high mortality of severe anorexia nervosa causes clinicians to consider any legal avenues for coercing acutely-ill patients to remain in treatment or refeeding programs, such as mental health laws or adult guardianship laws. Method: Review of pattern of laws for coercing treatment in various jurisdictions and retrospective file analysis over 4.7 years for a specialist anorexia unit in the State of New South Wales, Australia, to isolate attributes associated with resort to two different avenues of legal coercion. Results: Coercion is most likely indicated for patients with more chronic histories (prior AN admissions), already known to the unit, where they present with other psychiatric illnesses and a low BMI. Compared to voluntary admissions, coerced patients were significantly more likely to experience the refeeding syndrome (an indicator of being seriously medically compromised). They were more likely to be tube fed and placed on a locked unit. Limitations: Sample size, limited variables and retrospective analysis method. Conclusions: The study suggests that, where available, clinicians will use legal coercion to help treat severe medical crisis situations, or manage behaviors such as vomiting, excessive exercise/sit-ups, or of absconding to no fixed abode when patients are very young.
From a medico-legal perspective it is not the incidence of severe anorexia, but its characteristics and consequences, which distinguish it from other DSM-IV(R) eating disorders like bulimia nervosa (1). Experienced by up to one percent of young women (and occasionally young men) (2), anorexia nervosa differs precisely because it is such a serious, life-threatening condition (3). This feature tests the ethical limits of medicine, the state and the law in deciding whether to coerce patients into treatment (4). It is compounded by questions about whether anorexia is a traditional illness rather than a "syndrome" (5), and whether law should facilitate treatment interventions (6, 7).
In some jurisdictions - such as Israel and, until recently, also the State of New South Wales (NSW) in Australia - anorexia does not qualify as a mental illness warranting involuntary mental health admission and treatment. This outcome mainly hinges on the drafting "model" adopted to express the gateway definition of mental illness, rather than on medical differences of opinion about the condition. There are three main definitional forms (8):
* A "non-definition" (or circular definition) model, where the meaning of "mental illness" is defined by the judiciary. In 1986 the New South Wales Supreme Court ruled that under the then definition in section 4 of its Mental Health Act 1958 anorexia was not a mental illness because this "syndrome" lacked the sharp "diagnostic criteria" of, for instance, a psychosis (5, 9,10).
* A "disorder of function" or consequence-based model, such as that now contained in the NSW Mental Health Act 1990, that defines mental illness as a condition which temporarily or permanently impairs a person's "mental functioning" and which is accompanied by "symptoms" such as delusions, hallucinations, serious disorders of thought form, a severe disturbance of mood, or sustained or repeated irrational behavior. This is a test which covers rather than excludes anorexia (Matter of Ms CS, 1999).
* The third model, like that in the neighboring Australian state of Victoria, combining a functional test with a list of certain conditions, also catches anorexia because mental illness is interpreted to cover a "medical condition characterised by a significant disturbance of thought, mood, perception or memory" (10,11).
The availability of legal coercion hinges not only on the way the law is written, but also its institutions and procedures. When courts decide about mental health committal (as in the U.S.A.) it is utilized less frequently than in Britain, for instance, where medical practitioners make the initial admission subject to tribunal review (12). …