Involuntary admission criteria for anorexia w/ purging behavior

[annoyedpsychiatrist]

Patient with a BMI of 11. Hasnt had labs in 6 months, outpatient setting. Any updates on involuntary admission criteria? Seems like this is a bit of murky situation. has ben severely underweight for years.

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[calvnandhobbs68]

Entirely depends on the state commitment laws if it's an adult. In my old state where I did fellowship, super easy to get admitted involuntary for something like this. In my current state, I haven't had to do it but seems a little more difficult, there is a provision where you can involuntarily admit someone who basically can't care for themselves as a result of a mental illness (which you'd be saying they have from the anorexia diagnosis).

Either way it's usually gonna be a mess of an admission I remember consulting on these in residency on the med floor. Your problem on the outpatient side is going to be getting them to the ER in the first place....usually these came from the ER when they presented after passing out or something.

 

[comp1]

Totally, 100%, state specific. If you give your state, people from there might be able to help with advice. Involuntary is always a legal (state specific) consideration. Clinically, of course they could benefit and it could be life saving.

 

[Merovinge]

How did you ascertain this information? Did they come into the office? I am so lucky I only see adolescents so it's straight to the ED where anything resembling that comes in.

I would be looking real hard at what you can do in your state and also likely reach out to anyone in risk/your malpractice insurance as this patient's mortality rate in the near future is sky high.

I saw a BMI 12 severe/psychotic orthorexia case in medical school. He was brought in by EMS unable to move but somehow managed to type 911 after days without movement/food, they re-nourished and rehabbed him enough to be able to move but he then left AMA and I heard he passed away shortly thereafter. Actually a really pleasant young man when we were rounding on him on consults.

 

[mistafab]

In many states this can be construed as "imminent danger to self" or "grave disability." Some states do not allow grave disability involuntary admissions. Some states won't allow this for imminent danger to self. Risk of mortality is very high and these patients tend to require involuntary medical admission for stabilization with psychiatry as consultants.

 

[nexus73]

If lacking capacity, consent for medical admission could be obtained from surrogate decision maker.

 

[splik]

If the patient is stable, which it sounds like they are (even though they are clearly very unwell), they won't qualify for involuntary treatment. Further, I only know of one place that will even accept and properly treat adult patients like this (much easier for children and adolescents). Very few inpatient psych units would accept an adult patient like this and most hospital medicine services don't want patients like this. For hospitalization, evidence of severe bradycardia, hypotension, hypoglycemia, other metabolic derangements (e.g. hypokalemia, hypomagnesemia needing IV intervention) or end organ failure/dysfunction. Interestingly, most patients do agree to treatment when they feel very sick but as they rapidly feel better they want to be discharged. I saw quite a few severe AN pts over the years in the medical setting. In general, the patients were treated without a psychiatric hold (though risk management did allow the patients to be detained when there was an imminent danger even without the hold and they were too weak to leave). The problem is that the medical teams did not want these patients, so sometimes we would have to place a psychiatric hold to prevent the medical teams discharging them due to hateful countertransference.

Also remember the treatment of severe anorexia nervosa is food. It is not inpatient psychiatry. Though superficially cognitively intact and with superficial decision making capacity, these patients (especially with a BMI of 11) tend to have significant neuropsychological impairments. Refeeding is necessary to nourish their brains enough to benefit from treatment.

It is controversial, but some of these patients do have an end stage disease and would benefit more from a palliative medicine approach as championed by Joel Yager (RIP).

 

[clausewitz2]

If the patient is stable, which it sounds like they are (even though they are clearly very unwell), they won't qualify for involuntary treatment. Further, I only know of one place that will even accept and properly treat adult patients like this (much easier for children and adolescents). Very few inpatient psych units would accept an adult patient like this and most hospital medicine services don't want patients like this. For hospitalization, evidence of severe bradycardia, hypotension, hypoglycemia, other metabolic derangements (e.g. hypokalemia, hypomagnesemia needing IV intervention) or end organ failure/dysfunction. Interestingly, most patients do agree to treatment when they feel very sick but as they rapidly feel better they want to be discharged. I saw quite a few severe AN pts over the years in the medical setting. In general, the patients were treated without a psychiatric hold (though risk management did allow the patients to be detained when there was an imminent danger even without the hold and they were too weak to leave). The problem is that the medical teams did not want these patients, so sometimes we would have to place a psychiatric hold to prevent the medical teams discharging them due to hateful countertransference.

Also remember the treatment of severe anorexia nervosa is food. It is not inpatient psychiatry. Though superficially cognitively intact and with superficial decision making capacity, these patients (especially with a BMI of 11) tend to have significant neuropsychological impairments. Refeeding is necessary to nourish their brains enough to benefit from treatment.

It is controversial, but some of these patients do have an end stage disease and would benefit more from a palliative medicine approach as championed by Joel Yager (RIP).

Have to push back on them not qualifying for involuntary treatment. In my state at that BMI they absolutely could be hospitalized involuntarily. Where I trained was unusual but we did have a dedicated inpatient eating disorders unit that would accept patients like this, which is how I know it is possible for adults in these parts to be hospitalized against their will strictly on the basis of a sufficiently low BMI (IBW actually but at BMI 12 it's going to be plenty low too).

Agree with everything else for the most part.

 

[annoyedpsychiatrist]

If the patient is stable, which it sounds like they are (even though they are clearly very unwell), they won't qualify for involuntary treatment. Further, I only know of one place that will even accept and properly treat adult patients like this (much easier for children and adolescents). Very few inpatient psych units would accept an adult patient like this and most hospital medicine services don't want patients like this. For hospitalization, evidence of severe bradycardia, hypotension, hypoglycemia, other metabolic derangements (e.g. hypokalemia, hypomagnesemia needing IV intervention) or end organ failure/dysfunction. Interestingly, most patients do agree to treatment when they feel very sick but as they rapidly feel better they want to be discharged. I saw quite a few severe AN pts over the years in the medical setting. In general, the patients were treated without a psychiatric hold (though risk management did allow the patients to be detained when there was an imminent danger even without the hold and they were too weak to leave). The problem is that the medical teams did not want these patients, so sometimes we would have to place a psychiatric hold to prevent the medical teams discharging them due to hateful countertransference.

Also remember the treatment of severe anorexia nervosa is food. It is not inpatient psychiatry. Though superficially cognitively intact and with superficial decision making capacity, these patients (especially with a BMI of 11) tend to have significant neuropsychological impairments. Refeeding is necessary to nourish their brains enough to benefit from treatment.

It is controversial, but some of these patients do have an end stage disease and would benefit more from a palliative medicine approach as championed by Joel Yager (RIP).

This is my thought process. 1

1. Patient has been at current BMI for at least a few years. Previously she was maybe 10 pounds heavier? But that was over two years ago per records i see.

2. She went to inpatient medical hospital in september, corrected all electrolyte abnormalities. Only residual thing i see is mild hyponatremia. I do not have any updated labs since then however.

3. Last available EKG to me no qtc prolongation, nothing that shows risk of arythmia/acute.

4. Appears shes following with neprohlogy in regards to her electrolye abnormalities, and they are monitoring it/prescribing appropriate medications.


My state, the guidelines are very vague on this and I could not find any official guidelines on this. I combed different sources. Uptodate gives some criteria on involuntary but does note that if the only issue is the low BMI and they are coherent and refuse admission, they dont necessarily meet criteria (assuming theres no urgent medical disturbances that are life or death).


Im thinking that based on available data, its hard to say she is an urgent/immediate threat to herself (though obviously at a much higher, chronic, future risk).

However, if she presents with significant bradycardia and other physical symptoms, then that would likely change my assessment.

 

[comp1]

People have some good general advice above (presumably based on their own states), but this is still a legal question because the clinical treatment required is going to be driven by the community standard which is going to be forced to vary based on the state law. If you're finding the state law unclear, name the state so that people can help clarify it for you. For all you know, there may be case law in your state.

 

[Merovinge]

This is my thought process. 1

1. Patient has been at current BMI for at least a few years. Previously she was maybe 10 pounds heavier? But that was over two years ago per records i see.

2. She went to inpatient medical hospital in september, corrected all electrolyte abnormalities. Only residual thing i see is mild hyponatremia. I do not have any updated labs since then however.

3. Last available EKG to me no qtc prolongation, nothing that shows risk of arythmia/acute.

4. Appears shes following with neprohlogy in regards to her electrolye abnormalities, and they are monitoring it/prescribing appropriate medications.


My state, the guidelines are very vague on this and I could not find any official guidelines on this. I combed different sources. Uptodate gives some criteria on involuntary but does note that if the only issue is the low BMI and they are coherent and refuse admission, they dont necessarily meet criteria (assuming theres no urgent medical disturbances that are life or death).


Im thinking that based on available data, its hard to say she is an urgent/immediate threat to herself (though obviously at a much higher, chronic, future risk).

However, if she presents with significant bradycardia and other physical symptoms, then that would likely change my assessment.

So you have demonstrated knowledge that she required IP admission to correct electrolyte abnormalities in the past 6 months. I wouldn't touch this patient in an outpatient psychiatry dept with a 100 foot pole unless there was a documented palliative consult/approach. Pt clearly needs IP to RTC to PHP to IOP and then multiple rounds of failures with those elevated HLoC to consider for palliation. If you can talk her into starting the process, Denver Acute would be the #1 place in the US to start the work.

 

[calvnandhobbs68]

So you have demonstrated knowledge that she required IP admission to correct electrolyte abnormalities in the past 6 months. I wouldn't touch this patient in an outpatient psychiatry dept with a 100 foot pole unless there was a documented palliative consult/approach. Pt clearly needs IP to RTC to PHP to IOP and then multiple rounds of failures with those elevated HLoC to consider for palliation. If you can talk her into starting the process, Denver Acute would be the #1 place in the US to start the work.

Yeah my thinking here would be was she actually stepped down to you from RTC to PHP/IOP who then clearly demonstrated she wasn't progressing and moved her out of the program or did they just d/c her from the hospital and said "good luck find a psychiatrist"?

A major problem here is you're gonna get stuck with a bunch of liability possibly without any good routes for treatment. General outpatient psych isn't the place for treatment here, especially with a clearly severely undertreated eating disorder. Any "psych" complaints you're gonna get are likely secondary to the lack of nutrition.

Outside of the whole involuntary inpatient thing, this is someone I'd consider just ending treatment right off the bat if they aren't willing to go right into an eating disorder program right now and not come back until the eating d/o program says it's appropriate. It's what's honestly best for the patient too, you're very limited in what you can actually "treat" here on your own.

 

[Merovinge]

Yeah my thinking here would be was she actually stepped down to you from RTC to PHP/IOP who then clearly demonstrated she wasn't progressing and moved her out of the program or did they just d/c her from the hospital and said "good luck find a psychiatrist"?

A major problem here is you're gonna get stuck with a bunch of liability possibly without any good routes for treatment. General outpatient psych isn't the place for treatment here, especially with a clearly severely undertreated eating disorder. Any "psych" complaints you're gonna get are likely secondary to the lack of nutrition.

Outside of the whole involuntary inpatient thing, this is someone I'd consider just ending treatment right off the bat if they aren't willing to go right into an eating disorder program right now and not come back until the eating d/o program says it's appropriate. It's what's honestly best for the patient too, you're very limited in what you can actually "treat" here on your own.

If you are a trainee or not familiar with eating disorders, please read this post and sear it into your brain. You can thank us later.

 

[hamstergang]

4. Appears shes following with neprohlogy in regards to her electrolye abnormalities, and they are monitoring it/prescribing appropriate medications.

The only appropriate treatment for her electrolytes is food and fluids (unless something else is going on). Giving meds to mask the problem is doing her a disservice.

 

[annoyedpsychiatrist]

Yeah my thinking here would be was she actually stepped down to you from RTC to PHP/IOP who then clearly demonstrated she wasn't progressing and moved her out of the program or did they just d/c her from the hospital and said "good luck find a psychiatrist"?

A major problem here is you're gonna get stuck with a bunch of liability possibly without any good routes for treatment. General outpatient psych isn't the place for treatment here, especially with a clearly severely undertreated eating disorder. Any "psych" complaints you're gonna get are likely secondary to the lack of nutrition.

Outside of the whole involuntary inpatient thing, this is someone I'd consider just ending treatment right off the bat if they aren't willing to go right into an eating disorder program right now and not come back until the eating d/o program says it's appropriate. It's what's honestly best for the patient too, you're very limited in what you can actually "treat" here on your own.

I work for a hospital based system so im a clinic affiliated with the hospital and her PCP is pushing for me to see her. Im being forced to see her. Now i dont have to agree to take her on as a patient, and TBH there is no way I will take her as a patient, because obviously theres no medication i can give to rectify this, and from what ive gathered, the patient does seem to inclined to even work on her eating disroder. But im forced to at least "evaluate" the patient. So yeah, under no circumstance will i take the patient on/prescribe meds, im just under the question of if they do present to me, enacting an involuntary hold or not. Which again, i feel like information out there for this is murky unless they have obvious/urgent signs of imminent decompensation.

 

[annoyedpsychiatrist]

The only appropriate treatment for her electrolytes is food and fluids (unless something else is going on). Giving meds to mask the problem is doing her a disservice.

I agree that it is masking the issue, but if someone isnt willing to work on the issue and they do not correct these, then she will likely die regardless. I would argue better to mask the issue then die.

I understand what youre saying and no ill intent, i just think its an ethical situation where the treatment is obvious, but if she doesnt engage in the treatment, and things arent done to keep her "relatively stable" then risk of death is high.

Again, i have no intent to prescribe/accept her as a patient, but i am forced to at least "evaluate" her essentially which of course my recommendation will be inpatient/residential eating disorder facility/anything but outpatient/etc. Im just trying to ascertain if i simply provide the information, document capacity, offer the information, send her on her way, or if it will turn into me initiating involuntary hold given how low her BMI is (but still ultimately wont follow with her post hospitlization)

 

[Mad Jack]

Patient with a BMI of 11. Hasnt had labs in 6 months, outpatient setting. Any updates on involuntary admission criteria? Seems like this is a bit of murky situation. has ben severely underweight for years.

In my state that is clear medical risk and would be an admit to the med floors for refeeding, wouldn't even go to psych until more stable due to the monitoring required. Wouldn't even need a commitment until such time as they were medically stable, and everything prior to that would be handled through the capacity process

 

[hamstergang]

I agree that it is masking the issue, but if someone isnt willing to work on the issue and they do not correct these, then she will likely die regardless. I would argue better to mask the issue then die.

I understand what youre saying and no ill intent, i just think its an ethical situation where the treatment is obvious, but if she doesnt engage in the treatment, and things arent done to keep her "relatively stable" then risk of death is high.

This is essentially enabling. It allows her to more easily believe that she isn't in fact too sick, which removes some of the motivation to get better.

Have you run this situation by your hospital's risk management yet? That should 1) give you the correct legal answer for your state, and 2) give you some legal protection when things go south.

 

[mistafab]

Have you run this situation by your hospital's risk management yet? That should 1) give you the correct legal answer for your state, and 2) give you some legal protection when things go south.

This is great advice.

 

[annoyedpsychiatrist]

This is essentially enabling. It allows her to more easily believe that she isn't in fact too sick, which removes some of the motivation to get better.

Have you run this situation by your hospital's risk management yet? That should 1) give you the correct legal answer for your state, and 2) give you some legal protection when things go south.

i plan on running by legal next week just to see what they say, ideally get their responses in writing as well.

Im just very annoyed that this patient is on my schedule, to be frank. I dont even think it makes any sense at all her coming in, and i already know shes not appropriate to treat in the outpatient psychiatry setting. Its completely futile.

 

[michaelrack]

I work for a hospital based system so im a clinic affiliated with the hospital and her PCP is pushing for me to see her. Im being forced to see her. Now i dont have to agree to take her on as a patient, and TBH there is no way I will take her as a patient, because obviously theres no medication i can give to rectify this, and from what ive gathered, the patient does seem to inclined to even work on her eating disroder. But im forced to at least "evaluate" the patient. So yeah, under no circumstance will i take the patient on/prescribe meds, im just under the question of if they do present to me, enacting an involuntary hold or not. Which again, i feel like information out there for this is murky unless they have obvious/urgent signs of imminent decompensation.

Here is how I would approach it:

I would (by chart review and patient interview) confirm the diagnosis and try to give a precise DSM diagnosis (such as Anorexia Nervosa, restricting type). If anything seems off, I would recommend (to the referring doc) appropriate medical work up (for example GI eval if you feel there might be a medical cause of her symptoms).

I would recommend (to the referring doc) any needed labs, such as comp metabolic panel, ekg etc to evaluate for medical stability.

Next I would look at vitamins. Is the patient taking an MVI? Consider recommending to the referrer a couple of weeks of thiamine 100 daily along with possibly a B1 level if there are prominent neurocog symptoms.

Next, I would let the referring doc know about any specialized eating d/o programs that might be available in the area/state.

The above is how I would structure a letter to the referring doctor. At the end of the interview with the patient, I would give her a breif overview of my diagnosis and recs (not getting too specific about needed labs). I would tell the patient that she needs to see the referrer in 5-10 days and get that letter out (presumably via the EMR) within the next 12 hours.

Of course, if there are complicating factors (such as suicidality, severe psych comorbity), that might change what I do.

 

[comp1]

I'll be intrigued to see what a hospital legal department might say about this. Obviously they'd be preferable over us who still don't know the state the OP is in, but I haven't met a lot of hospital legal departments who are extremely familiar with their own state's commitment laws, but I guess they'll be the ones defending the hospital when it gets roped into any lawsuits, so checking is always good idea.

 

[Merovinge]

I'll be intrigued to see what a hospital legal department might say about this. Obviously they'd be preferable over us who still don't know the state the OP is in, but I haven't met a lot of hospital legal departments who are extremely familiar with their own state's commitment laws, but I guess they'll be the ones defending the hospital when it gets roped into any lawsuits, so checking is always good idea.

Huge variability there. The legal team where I did residency at was on point and had an extremely strong grasp on the laws around commitment and involuntary treatment. Of course our attendings did too, but on the rare instance they were involved it was pretty clear that they were well educated white collar professionals that were looking out for the doctors (and of course also the hospital).

I then stayed within the same state but moved to a rural area and I'm not sure those lawyers even knew what a mental health law was that seemed to have gotten their JD from an online school.

 

[annoyedpsychiatrist]

The wording of involuntary hold that applies in this setting:

"He or she is incapable of surviving alone or with the help of willing, able, and responsible family or friends, including available alternative services, and, without treatment, is likely to suffer from neglect or refuse to care for himself or herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; or"

The way i interpret that is in the moment of the evaluation, their current self neglect poses a significant risk of injury to themselves. While anorexia certainly increases the risk of mortality, if their vital signs are within normal limits, shes not falling over/oriented, and theres no labs to support to severe electrolyte abnormalities/EKG/ETC during that time frame, its hard to justify that her threat to herself is current, rather than in the future/near future.

 

[comp1]

Finally, we got a state! It's Florida. Now hopefully some Florida psychiatrists can weigh in.

 

[Ceke2002]

If the patient is stable, which it sounds like they are (even though they are clearly very unwell), they won't qualify for involuntary treatment. Further, I only know of one place that will even accept and properly treat adult patients like this (much easier for children and adolescents). Very few inpatient psych units would accept an adult patient like this and most hospital medicine services don't want patients like this. For hospitalization, evidence of severe bradycardia, hypotension, hypoglycemia, other metabolic derangements (e.g. hypokalemia, hypomagnesemia needing IV intervention) or end organ failure/dysfunction. Interestingly, most patients do agree to treatment when they feel very sick but as they rapidly feel better they want to be discharged. I saw quite a few severe AN pts over the years in the medical setting. In general, the patients were treated without a psychiatric hold (though risk management did allow the patients to be detained when there was an imminent danger even without the hold and they were too weak to leave). The problem is that the medical teams did not want these patients, so sometimes we would have to place a psychiatric hold to prevent the medical teams discharging them due to hateful countertransference.

Also remember the treatment of severe anorexia nervosa is food. It is not inpatient psychiatry. Though superficially cognitively intact and with superficial decision making capacity, these patients (especially with a BMI of 11) tend to have significant neuropsychological impairments. Refeeding is necessary to nourish their brains enough to benefit from treatment.

It is controversial, but some of these patients do have an end stage disease and would benefit more from a palliative medicine approach as championed by Joel Yager (RIP).

A thousand times yes to the bolded part! I spent an inordinate amount of time when I was sick reading and viewing as much Eating Disorder material as I could possibly get my hands on, trying to find "The Cure". I read all of the classics, Bruch, Crisp, Woodman, Levenkron, etc, etc, I still have a VHS collection of old eating disorder documentaries and films from the 70s and 80s, I attended public lectures, and sat in on weekly IRL support groups in the mid 1980s, and all that time I thought if I just could unlock the inner reason why I was anorexic then everything would just fall into place, I'd gain weight and I'd be recovered. And no, no it didn't work that way. The absolute best thing I decided to do, after nearly 25 years of basically navel gazing levels of faffing about, was to prioritise nutritional and weight restoration before anything else.

Also agree with palliative care in certain cases. I know one person who was moved to palliative care after years of involuntary admissions, and not only have they stayed out of the hospital, they've actually improved their quality of life and life expectancy being on palliative care. Not sure if they're still receiving palliative care now, just that they're still alive and palliative care really helped them. I also lost a good friend to a suicidal overdose after they'd battled severe anorexia for over 12 years (regularly hitting BMIs in the 8s and 9s, and getting carried into hospital with risk of imminent death). It sucks to lose someone to this illness, especially someone you know and love and admire greatly because they're an amazing person, but part of me does still wonder occasionally if she would have been better off being offered palliative care rather than spending the last year of her life suffering mentally and physically.

 

[psycho-matic]

I once had a young teen with a dangerously low BMI. I contacted child protective services. I don't regret that decision.

 

[calvnandhobbs68]

I once had a young teen with a dangerously low BMI. I contacted child protective services. I don't regret that decision.

Cool story but that has nothing to do with OPs situation with an adult. Also not sure why your step would be contacting CPS unless there's some significant issue with the parents but that's not an option for OP.

 

[futureapppsy2]

If the patient is stable, which it sounds like they are (even though they are clearly very unwell), they won't qualify for involuntary treatment. Further, I only know of one place that will even accept and properly treat adult patients like this (much easier for children and adolescents). Very few inpatient psych units would accept an adult patient like this and most hospital medicine services don't want patients like this. For hospitalization, evidence of severe bradycardia, hypotension, hypoglycemia, other metabolic derangements (e.g. hypokalemia, hypomagnesemia needing IV intervention) or end organ failure/dysfunction. Interestingly, most patients do agree to treatment when they feel very sick but as they rapidly feel better they want to be discharged. I saw quite a few severe AN pts over the years in the medical setting. In general, the patients were treated without a psychiatric hold (though risk management did allow the patients to be detained when there was an imminent danger even without the hold and they were too weak to leave). The problem is that the medical teams did not want these patients, so sometimes we would have to place a psychiatric hold to prevent the medical teams discharging them due to hateful countertransference.

Also remember the treatment of severe anorexia nervosa is food. It is not inpatient psychiatry. Though superficially cognitively intact and with superficial decision making capacity, these patients (especially with a BMI of 11) tend to have significant neuropsychological impairments. Refeeding is necessary to nourish their brains enough to benefit from treatment.

It is controversial, but some of these patients do have an end stage disease and would benefit more from a palliative medicine approach as championed by Joel Yager (RIP).

In addition, refeeding/weight and nutrition restoration not only addresses the malnutrition (and the neuropsychological and physical effects thereof), but it also serves as great exposure therapy towards food (a significant part of AN/restrictive EDs is very much like a specific phobia or OCD around food/exercise). I really doubt someone's ED competence when they say that EDs, especially AN, are "not about food," because they really, really are and without refeeding, none of the other work can be effective.

 

[clausewitz2]

In addition, refeeding/weight and nutrition restoration not only addresses the malnutrition (and the neuropsychological and physical effects thereof), but it also serves as great exposure therapy towards food (a significant part of AN/restrictive EDs is very much like a specific phobia or OCD around food/exercise). I really doubt someone's ED competence when they say that EDs, especially AN, are "not about food," because they really, really are and without refeeding, none of the other work can be effective.

I absolutely agree and am just of sick of hearing this. I acknowledge that there's a lot of people at various stages of AN who don't seem to be mostly motivated by concerns about weight or fatness, but food and eating are always issue #1.

 

[clozareal]

I read this AAPL article during residency which I thought did a great job discussing the different ethical considerations related to involuntary treatment for anorexia nervosa patients in addition to having court case examples.

Involuntary Treatment of Patients With Life-Threatening Anorexia Nervosa

Anorexia nervosa has the highest mortality rate of any psychiatric illness. Predictors of mortality include chronicity of the illness, critically low body weight, and binging and purging behavior. Delusional beliefs body image, coupled with impaired judgment and cognition caused by starvation...

jaapl.org

 

[Crayola227]

Cool story but that has nothing to do with OPs situation with an adult. Also not sure why your step would be contacting CPS unless there's some significant issue with the parents but that's not an option for OP.

In kindness, I would take the point to be, that the least we can do for any patient is reach out anywhere we might find purchase to help a patient. Which, OP reached out to SDN and that's as unlikely a place to get help as any 😅 I kid but really that's commendable they did.

Possibly some of these centers we're discussing may know of more local providers in the area with experience? There's always "people who do this kind of thing" and that's generally a good place to look. If it is Florida I suspect there is someone in Florida who is sort of a go-to person for this?

In fact, I just remembered my relative who battles AN went to a really nice facility (voluntary) in Florida from out of state, and this is the type of person who gets the best care available. So something exists in Florida. I would probably call those places. There must be someone in the state with some insight.

 

[calvnandhobbs68]

In kindness, I would take the point to be, that the least we can do for any patient is reach out anywhere we might find purchase to help a patient. Which, OP reached out to SDN and that's as unlikely a place to get help as any 😅 I kid but really that's commendable they did.

Possibly some of these centers we're discussing may know of more local providers in the area with experience? There's always "people who do this kind of thing" and that's generally a good place to look. If it is Florida I suspect there is someone in Florida who is sort of a go-to person for this?

In fact, I just remembered my relative who battles AN went to a really nice facility (voluntary) in Florida from out of state, and this is the type of person who gets the best care available. So something exists in Florida. I would probably call those places. There must be someone in the state with some insight.

Do you know what CPS is? It’s Child Protective Services.

I’m not sure what you’re trying to say here but calling CPS for a patient with anorexia unless there is a significant concern about child abuse or neglect is inappropriate.

 

[Crayola227]

Do you know what CPS is? It’s Child Protective Services.

I’m not sure what you’re trying to say here but calling CPS for a patient with anorexia unless there is a significant concern about child abuse or neglect is inappropriate.

How do you know that there is not child abuse or neglect occurring in a child with anorexia? Maybe that's the only outward sign the child is showing of abuse. I agree this would make more sense with context beyond just the diagnosis to support that action, but in general we should err on the side of CPS than not. Yes you're a psychiatrist and you talk to the patient and get collateral, but you cannot do a whole investigation like they can.

In any case, I assumed the psychiatrist that made the statement had what seemed to them good reason to call CPS besides just the diagnosis itself in the chart - when they said they did and did not regret it, I took that as saying, don't let "guilt" over going over someone's head to authorities or taking it out of their hands stop you from trying to protect someone.

I might be wrong and you might be right, but this was how I took it.

 

[calvnandhobbs68]

How do you know that there is not child abuse or neglect occurring in a child with anorexia? Maybe that's the only outward sign the child is showing of abuse. I agree this would make more sense with context beyond just the diagnosis to support that action, but in general we should err on the side of CPS than not. Yes you're a psychiatrist and you talk to the patient and get collateral, but you cannot do a whole investigation like they can.

In any case, I assumed the psychiatrist that made the statement had what seemed to them good reason to call CPS besides just the diagnosis itself in the chart - when they said they did and did not regret it, I took that as saying, don't let "guilt" over going over someone's head to authorities or taking it out of their hands stop you from trying to protect someone.

I might be wrong and you might be right, but this was how I took it.

That person is an NP.
But anyway, with no detail it's not clear what the heck was going on there and it had nothing to do with the original question.

If you're somehow implying it's appropriate to call CPS solely because a kid has anorexia or a low body weight, I would strongly disagree with this, as someone who's well versed with CPS reporting in 4 different states.

 

[Merovinge]

That person is an NP.
But anyway, with no detail it's not clear what the heck was going on there and it had nothing to do with the original question.

If you're somehow implying it's appropriate to call CPS solely because a kid has anorexia or a low body weight, I would strongly disagree with this, as someone who's well versed with CPS reporting in 4 different states.

Right, you have to call if a parent is refusing treatment for AN that has an imminent risk of harm to the child. I have had to do that before (teenager with BMI <13 and bradycardiac on exam, parent refusing to take kid to ED). The overwhelming majority of parents who have kids that have eating disorders are just trying to the best they can and CPS would not have any involvement.