Criteria for Involuntary Admission in Severe Anorexia Nervosa
Patients with anorexia nervosa should be considered for involuntary hospital admission when they have a BMI <16 kg/m², longer illness duration (>10 years), alcohol abuse, poor social adjustment, or when their life is at immediate risk despite less invasive interventions. 1, 2
Primary Criteria for Involuntary Admission
- BMI <16 kg/m² represents a critical threshold requiring immediate intervention to prevent mortality 1
- Presence of medical complications that pose immediate threat to life, including:
- Severe electrolyte abnormalities
- Cardiac complications (bradycardia, hypotension, ECG abnormalities)
- Hypothermia 3
- Failure of less restrictive treatment approaches 4
- Inability to make informed decisions about treatment due to the severity of malnutrition affecting cognitive function 5
Risk Factors Associated with Higher Mortality
- Illness duration exceeding 10 years 1, 2
- BMI below 16 kg/m² 1
- Comorbid alcohol abuse 1, 2
- Poor social adjustment 1
- Presence of personality disorders 2
- History of multiple previous hospitalizations 5
- History of treatment discontinuation 2
Legal and Ethical Considerations
- Involuntary treatment is considered a medical decision that must be in the patient's best interest 1
- The decision should be made by the primary physician after consultation with a multidisciplinary team 1, 3
- The physician must always prioritize the patient's health and safety above all other considerations 1
- Involuntary admission does not necessarily require forced feeding but allows for more stringent supervision and prevents premature discharge 5
Implementation Process
- Comprehensive medical and psychiatric evaluation must document:
- Current weight and BMI
- Medical complications
- Psychiatric comorbidities
- Previous treatment history 3
- Consultation with a multidisciplinary team including psychiatrists, medical specialists, and nutritionists 3
- Clear documentation of why less restrictive alternatives are insufficient 4, 6
- Regular reassessment of the need for continued involuntary status 6
Expected Outcomes and Follow-up
- Short-term benefits typically include weight restoration and medical stabilization 4, 5
- Long-term observation is essential due to high mortality rates among patients who required involuntary admission 5
- Transition to voluntary specialized treatment should be the goal once medical stability is achieved 7
- Contrary to common concerns, involuntary treatment often does not damage the therapeutic relationship and may even strengthen it by demonstrating the seriousness of the condition 5
Important Caveats
- Patients with severe anorexia often show ambivalence toward treatment, which should not be confused with complete treatment refusal 4
- The contextual sphere of the patient (family support, living situation) should be considered in decision-making 6
- Patients who have required involuntary admission remain at high risk and require intensive follow-up care 2, 5