When should a patient with anxiety, potential neurological or psychiatric disorders, and a history of psychiatric conditions be hospitalized?

Hospitalization Criteria for Patients with Anorexia Nervosa

Patients with anorexia nervosa require hospitalization when they present with severe medical instability, including abnormal vital signs (bradycardia, hypotension, hypothermia, orthostatic changes), severe malnutrition with rapid weight loss, cardiac arrhythmias, electrolyte disturbances, acute psychiatric crisis with active suicidal ideation or inability to engage in safety planning, or when outpatient treatment has failed to prevent continued deterioration. 1

Medical Instability Requiring Admission

Cardiovascular and vital sign abnormalities are critical indicators for hospitalization:

• Bradycardia, hypotension, hypothermia, or significant orthostatic blood pressure changes warrant immediate admission 1
• ECG abnormalities suggesting arrhythmic risk, including prolonged QT interval, require inpatient cardiac monitoring 1
• Syncope occurring with exercise, causing severe injury, or in the supine position necessitates hospitalization for diagnostic evaluation 1

Metabolic and laboratory derangements indicating need for admission:

• Severe electrolyte abnormalities (hyponatremia, hypocalcemia, hypoglycemia, hypokalemia) require inpatient correction 1
• Evidence of end-organ damage from malnutrition, including cardiac dysfunction or renal impairment 1
• Acute medical complications such as seizures, stroke, or focal neurologic deficits 1

Psychiatric Criteria for Hospitalization

High-risk psychiatric presentations requiring inpatient admission include 1:

• Continued endorsement of desire to die or active suicidal ideation with plan
• Severe hopelessness or inability to engage in safety planning discussions
• High-lethality suicide attempt or attempt with clear expectation of death
• Severe agitation that cannot be managed in outpatient setting
• Inadequate support system or inability to be monitored at home

Psychiatric assessment is specifically recommended in patients with frequent recurrent syncope who have multiple other somatic complaints when initial evaluation raises concerns for stress, anxiety, and possible other psychiatric disorders 1. This is particularly relevant in anorexia nervosa where psychiatric and medical complications frequently overlap.

Nutritional Status Requiring Admission

Severe malnutrition indicators necessitating hospitalization:

• Rapid or severe weight loss (>75% ideal body weight or rapid decline)
• Inability to maintain adequate oral intake
• Evidence of refeeding syndrome risk with severe chronic malnutrition 1

Evaluation Priorities During Hospitalization

Comprehensive medical assessment must include 1, 2:

• Careful assessment of abnormal vital signs with particular attention to cardiac and neurologic systems
• Complete physical examination looking for signs of self-injury, malnutrition stigmata, and end-organ effects
• Baseline neurologic evaluation and mental status examination
• ECG to assess for conduction abnormalities and QT prolongation 1

Laboratory testing should be targeted rather than routine 1:

• Basic laboratory tests are only indicated if syncope may be due to loss of circulating volume or if a metabolic cause is suspected 1
• Electrolytes, complete metabolic panel including magnesium and phosphorus, complete blood count, and coagulation profiles 1
• Routine urine drug testing has limited utility and should not be performed routinely 1

Common Pitfalls to Avoid

Do not rely solely on patient self-report of symptom severity, as patients with anorexia nervosa frequently minimize symptoms 1. Collateral information from family members has significant clinical utility 1.

Do not assume psychiatric symptoms are purely functional without ruling out medical causes 1. Medical conditions including neurologic disease, metabolic disturbances, endocrine disorders, and cardiac abnormalities can present as psychiatric or behavioral problems 1.

Do not discharge patients who cannot be adequately monitored or who lack adequate support systems, even if they appear medically stable at the moment of evaluation 1.

Disposition Planning

Patients who do not meet criteria for medical hospitalization but have ongoing psychiatric risk may be candidates for 1:

• Inpatient psychiatric facility admission once medically cleared
• Partial hospital programs or intensive outpatient services where available
• In-home treatment or crisis stabilization interventions

Safety planning before discharge must include identification of warning signs, coping strategies, healthy distraction activities, social supports, professional contact information, and means restriction counseling 1.