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SAN FRANCISCO – The patient at a Florida eating disorder clinic said she was eating plenty even though she acknowledged purging once a week. But her vitals told a different story: Her body mass index (BMI) was 12.2, down from 14.8 a couple of years before – a dangerously low value.
While the woman agreed that she needed to gain weight, she refused advice to pursue residential or inpatient treatment. This left her team with a big dilemma: Should they force her into care because she wouldn’t eat? Was that even possible under the law? Did she have the capacity to make decisions about her future? What other alternatives were there?
Determining the best course of action in cases like this is anything but simple, Dr. Cacodcar said. To make matters more complicated, .
“At least in my state of Florida, we know that it can be very, very hard to get patients expert care,” said Dr. Cacodcar. And, she said, it can be even tougher for certain types of patients, such as those that are LGBTQ and those who have severe illness but don’t meet the criteria.
As Dr. Cacodcar noted, the APA released new practice guidelines regarding eating disorders earlier this year, marking their first update since 2006. The guidelines highlight research that suggests nearly 1% – 0.8% – of the U.S. population will develop AN over their lifetimes. Recent studies also suggest that eating disorder numbers rose during the pandemic, with one analysis finding that patients under inpatient care doubled in 2020.
“Mortality rates are high for anorexia nervosa, up to 10 times higher than matched controls,” Dr. Cacodcar said. “It has the highest mortality rate of the psychiatric diseases with the exception of opioid use disorder.”
As for outcomes, she pointed to a 2019 study that surveyed 387 parents who had children with eating disorders, mostly AN. Only 20% made a full recovery. “The farther you get out from the onset of anorexia, the less likely you are to achieve recovery,” Dr. Cacodcar said. “A lot of the control behaviors become very automatic.”
Determining capacity
In some cases of AN, psychiatrists must determine whether they have the capacity to make decisions about treatment, said Gabriel Jerkins, MD, a chief resident of psychiatry at the University of Florida. At issue is “the ability of the individual to comprehend the information being disclosed in regard to their condition, as well as the nature and potential risks and benefits of the proposed treatment alternatives. They include of course, no treatment at all.”
“We know psychiatric conditions can limit one’s ability to appreciate consequence,” he said.
One option is to seek to institutionalize patients with severe AN because they are a danger to themselves. Clinicians opted to not do this in the case of the patient profiled by Dr. Cacodcar, the one with the BMI of 12.2 who didn’t want inpatient or residential care. (A 5-foot-8 person with a BMI of 12.2 would weigh 80 pounds.)
“The main reason we did not hospitalize her is because an appropriate level of care was not going to be readily available,” Dr. Cacodcar said, and her treatment would have been substandard.
Fortunately, the woman did return after a couple of months and accept residential care. No facility in Florida was willing to accept her because of her low BMI, but she did find one in North Carolina, where she stayed for 2 months. She’s doing well, and her BMI is now 21, Dr. Cacodcar said.
The patient’s story shows that involuntary hospitalization “is not necessarily the best course of action,” Dr. Cacodcar said. “It wasn’t necessarily going to be in the patient’s best interest.”
In another case, a 22-year-old woman had severe AN. She had been a gymnast and dancer, Dr. Jerkins said, “and I include that here only because of how commonly we see that kind of demographic information in patients with anorexia nervosa.”
Her BMI was 17.5, and clinicians discussed feeding her through a feeding tube. She still had “no insight that her symptoms were related to an underlying eating disorder,” Dr. Jerkins said, raising questions about her capacity. “Is it sufficient that the patient understand that she’s underweight?”
Ultimately, he said, she received a feeding tube at a time when her BMI had dropped to 16.3. She suffered from an infection but ultimately she improved and has stabilized at a BMI of around 19, he said.
“I do wonder if allowing her to have some control of how to pursue treatment in this case was therapeutic in a way,” he said, especially since matters of control are deeply ingrained in AN.
A former physical trainer, the patient had a BMI of 17.6. The University of Florida’s eating disorder clinic sent her to an out-of-state residential program, but she was discharged when her blood glucose dipped dangerously low as she compulsively exercised. Her BMI dipped to 16.2.
Dr. Schmidt had the patient involuntarily committed upon her return, but she went home after 12 days with no change in her weight. Ultimately, the patient was referred to an eating disorder center in Colorado for medical stabilization where she was given a feeding tube. But her medical situation was so dire that she was discharged to her home, where she went on hospice and died.
“I’m not arguing for or against the term ‘terminal anorexia.’ But this case does make me think about it,” said Dr. Schmidt. She was referring to a controversial term used by some clinicians to refer to patients who face inevitable death from AN. “Unfortunately,” wrote the authors of a recent report proposing a clinical definition, “these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa.”
SAN FRANCISCO – The patient at a Florida eating disorder clinic said she was eating plenty even though she acknowledged purging once a week. But her vitals told a different story: Her body mass index (BMI) was 12.2, down from 14.8 a couple of years before – a dangerously low value.
While the woman agreed that she needed to gain weight, she refused advice to pursue residential or inpatient treatment. This left her team with a big dilemma: Should they force her into care because she wouldn’t eat? Was that even possible under the law? Did she have the capacity to make decisions about her future? What other alternatives were there?
Determining the best course of action in cases like this is anything but simple, Dr. Cacodcar said. To make matters more complicated, .
“At least in my state of Florida, we know that it can be very, very hard to get patients expert care,” said Dr. Cacodcar. And, she said, it can be even tougher for certain types of patients, such as those that are LGBTQ and those who have severe illness but don’t meet the criteria.
As Dr. Cacodcar noted, the APA released new practice guidelines regarding eating disorders earlier this year, marking their first update since 2006. The guidelines highlight research that suggests nearly 1% – 0.8% – of the U.S. population will develop AN over their lifetimes. Recent studies also suggest that eating disorder numbers rose during the pandemic, with one analysis finding that patients under inpatient care doubled in 2020.
“Mortality rates are high for anorexia nervosa, up to 10 times higher than matched controls,” Dr. Cacodcar said. “It has the highest mortality rate of the psychiatric diseases with the exception of opioid use disorder.”
As for outcomes, she pointed to a 2019 study that surveyed 387 parents who had children with eating disorders, mostly AN. Only 20% made a full recovery. “The farther you get out from the onset of anorexia, the less likely you are to achieve recovery,” Dr. Cacodcar said. “A lot of the control behaviors become very automatic.”
Determining capacity
In some cases of AN, psychiatrists must determine whether they have the capacity to make decisions about treatment, said Gabriel Jerkins, MD, a chief resident of psychiatry at the University of Florida. At issue is “the ability of the individual to comprehend the information being disclosed in regard to their condition, as well as the nature and potential risks and benefits of the proposed treatment alternatives. They include of course, no treatment at all.”
“We know psychiatric conditions can limit one’s ability to appreciate consequence,” he said.
One option is to seek to institutionalize patients with severe AN because they are a danger to themselves. Clinicians opted to not do this in the case of the patient profiled by Dr. Cacodcar, the one with the BMI of 12.2 who didn’t want inpatient or residential care. (A 5-foot-8 person with a BMI of 12.2 would weigh 80 pounds.)
“The main reason we did not hospitalize her is because an appropriate level of care was not going to be readily available,” Dr. Cacodcar said, and her treatment would have been substandard.
Fortunately, the woman did return after a couple of months and accept residential care. No facility in Florida was willing to accept her because of her low BMI, but she did find one in North Carolina, where she stayed for 2 months. She’s doing well, and her BMI is now 21, Dr. Cacodcar said.
The patient’s story shows that involuntary hospitalization “is not necessarily the best course of action,” Dr. Cacodcar said. “It wasn’t necessarily going to be in the patient’s best interest.”
In another case, a 22-year-old woman had severe AN. She had been a gymnast and dancer, Dr. Jerkins said, “and I include that here only because of how commonly we see that kind of demographic information in patients with anorexia nervosa.”
Her BMI was 17.5, and clinicians discussed feeding her through a feeding tube. She still had “no insight that her symptoms were related to an underlying eating disorder,” Dr. Jerkins said, raising questions about her capacity. “Is it sufficient that the patient understand that she’s underweight?”
Ultimately, he said, she received a feeding tube at a time when her BMI had dropped to 16.3. She suffered from an infection but ultimately she improved and has stabilized at a BMI of around 19, he said.
“I do wonder if allowing her to have some control of how to pursue treatment in this case was therapeutic in a way,” he said, especially since matters of control are deeply ingrained in AN.
A former physical trainer, the patient had a BMI of 17.6. The University of Florida’s eating disorder clinic sent her to an out-of-state residential program, but she was discharged when her blood glucose dipped dangerously low as she compulsively exercised. Her BMI dipped to 16.2.
Dr. Schmidt had the patient involuntarily committed upon her return, but she went home after 12 days with no change in her weight. Ultimately, the patient was referred to an eating disorder center in Colorado for medical stabilization where she was given a feeding tube. But her medical situation was so dire that she was discharged to her home, where she went on hospice and died.
“I’m not arguing for or against the term ‘terminal anorexia.’ But this case does make me think about it,” said Dr. Schmidt. She was referring to a controversial term used by some clinicians to refer to patients who face inevitable death from AN. “Unfortunately,” wrote the authors of a recent report proposing a clinical definition, “these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa.”
SAN FRANCISCO – The patient at a Florida eating disorder clinic said she was eating plenty even though she acknowledged purging once a week. But her vitals told a different story: Her body mass index (BMI) was 12.2, down from 14.8 a couple of years before – a dangerously low value.
While the woman agreed that she needed to gain weight, she refused advice to pursue residential or inpatient treatment. This left her team with a big dilemma: Should they force her into care because she wouldn’t eat? Was that even possible under the law? Did she have the capacity to make decisions about her future? What other alternatives were there?
Determining the best course of action in cases like this is anything but simple, Dr. Cacodcar said. To make matters more complicated, .
“At least in my state of Florida, we know that it can be very, very hard to get patients expert care,” said Dr. Cacodcar. And, she said, it can be even tougher for certain types of patients, such as those that are LGBTQ and those who have severe illness but don’t meet the criteria.
As Dr. Cacodcar noted, the APA released new practice guidelines regarding eating disorders earlier this year, marking their first update since 2006. The guidelines highlight research that suggests nearly 1% – 0.8% – of the U.S. population will develop AN over their lifetimes. Recent studies also suggest that eating disorder numbers rose during the pandemic, with one analysis finding that patients under inpatient care doubled in 2020.
“Mortality rates are high for anorexia nervosa, up to 10 times higher than matched controls,” Dr. Cacodcar said. “It has the highest mortality rate of the psychiatric diseases with the exception of opioid use disorder.”
As for outcomes, she pointed to a 2019 study that surveyed 387 parents who had children with eating disorders, mostly AN. Only 20% made a full recovery. “The farther you get out from the onset of anorexia, the less likely you are to achieve recovery,” Dr. Cacodcar said. “A lot of the control behaviors become very automatic.”
Determining capacity
In some cases of AN, psychiatrists must determine whether they have the capacity to make decisions about treatment, said Gabriel Jerkins, MD, a chief resident of psychiatry at the University of Florida. At issue is “the ability of the individual to comprehend the information being disclosed in regard to their condition, as well as the nature and potential risks and benefits of the proposed treatment alternatives. They include of course, no treatment at all.”
“We know psychiatric conditions can limit one’s ability to appreciate consequence,” he said.
One option is to seek to institutionalize patients with severe AN because they are a danger to themselves. Clinicians opted to not do this in the case of the patient profiled by Dr. Cacodcar, the one with the BMI of 12.2 who didn’t want inpatient or residential care. (A 5-foot-8 person with a BMI of 12.2 would weigh 80 pounds.)
“The main reason we did not hospitalize her is because an appropriate level of care was not going to be readily available,” Dr. Cacodcar said, and her treatment would have been substandard.
Fortunately, the woman did return after a couple of months and accept residential care. No facility in Florida was willing to accept her because of her low BMI, but she did find one in North Carolina, where she stayed for 2 months. She’s doing well, and her BMI is now 21, Dr. Cacodcar said.
The patient’s story shows that involuntary hospitalization “is not necessarily the best course of action,” Dr. Cacodcar said. “It wasn’t necessarily going to be in the patient’s best interest.”
In another case, a 22-year-old woman had severe AN. She had been a gymnast and dancer, Dr. Jerkins said, “and I include that here only because of how commonly we see that kind of demographic information in patients with anorexia nervosa.”
Her BMI was 17.5, and clinicians discussed feeding her through a feeding tube. She still had “no insight that her symptoms were related to an underlying eating disorder,” Dr. Jerkins said, raising questions about her capacity. “Is it sufficient that the patient understand that she’s underweight?”
Ultimately, he said, she received a feeding tube at a time when her BMI had dropped to 16.3. She suffered from an infection but ultimately she improved and has stabilized at a BMI of around 19, he said.
“I do wonder if allowing her to have some control of how to pursue treatment in this case was therapeutic in a way,” he said, especially since matters of control are deeply ingrained in AN.
A former physical trainer, the patient had a BMI of 17.6. The University of Florida’s eating disorder clinic sent her to an out-of-state residential program, but she was discharged when her blood glucose dipped dangerously low as she compulsively exercised. Her BMI dipped to 16.2.
Dr. Schmidt had the patient involuntarily committed upon her return, but she went home after 12 days with no change in her weight. Ultimately, the patient was referred to an eating disorder center in Colorado for medical stabilization where she was given a feeding tube. But her medical situation was so dire that she was discharged to her home, where she went on hospice and died.
“I’m not arguing for or against the term ‘terminal anorexia.’ But this case does make me think about it,” said Dr. Schmidt. She was referring to a controversial term used by some clinicians to refer to patients who face inevitable death from AN. “Unfortunately,” wrote the authors of a recent report proposing a clinical definition, “these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa.”
AT APA 2023