When would you involuntary commit someone

[Slevin]

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I am wondering when you would involuntary commit someone

Two test choices where:
When they stop taking their antipsychotic medications which causes them to stop taking their insulin because they have diabetes

or

When they intentionally burn themselves

According to the professor the correct answer is because they are off their meds and stop taking their insulin because they're in danger of hurting themselves but diabetes has long term consequences and isn't an immediate threat to their health whereas an individual who burns themselves is at a more immediate threat of harming themselves or am I wrong here.

Thanks for the help

 

[whopper]

When they stop taking their antipsychotic medications which causes them to stop taking their insulin because they have diabetes

or

When they intentionally burn themselves

This is not enough information. Were these the exact answer choices? If so, I don't like the question.

Burn--well if the person knew what they were doing, and they burn themselves for reasons not due to severe mental illness, they can't be held for commitment. Problem is that the choice doesn't specify.

Stop the meds? This too, I feel, is a poor choice because several patients can not be compliant with their medications and still be fine for several months, if not years. Most commitment laws are for the intention of committing someone who is immediately dangerous, not for harm that will likely be experienced months to years down the road.


The real answer (which is likely more than you need to know) is it depends on the laws of the state. Commitment laws have some variability between states, though in general, they are very similar.
In most states, the doctor has to have enough evidence (clear and convincing legal standard, which means there has to be enough evidence to the point where it's true by about 75% or more), that due to a severe mental illness, that the person is dangerous to him/herself, others, or cannot care for him/herself in the community.

(Emphasis on severe: e.g. psychotic disorder, bipolar, major depression).

Wisconson has the criteria that the evidence must be beyond reasonable doubt. That's a smoking gun level which is very difficult to clinically obtain.

NJ has the added criteria that the person can be committed if the person due to mental illness, destroys property.

Ohio has the criteria that a commitable patiant has to have to a disorder of thought, mood, memory, or perception, to the degree that person is dangerous to him/herself, others, cannot care for him/herself, or...and this is important, due to mental illness will significantly hurt the rights of him/herself or others, or is in need of treatment.


Under the Ohio criteria, you can commit a borderline patient who self-mutilates (though I still know several psychiatrists that would not hold a person for commitment simply because that person is a borderline who self-mutilates). Borderline is not a mood disorder? Yes--to us psychiatrists. The words in the law are based on their use in English, not in psychiatry. Borderline PD is characterized by unstable mood--hence in real English it can be considered a mood disorder.

 

[Slevin]

This is not enough information. Were these the exact answer choices? If so, I don't like the question.

they named the specific medication but I don't remember that, but that was really all there was to the question.

When would you involuntary commit someone

Patient intentionally burned themselves
Pt stopped taking their antipsychotic medication which then caused them to stop taking their insulin

There were three other choices but these were the most viable ones

 

[whopper]

You question brings back traumatic memories of why I hated medical school. I remember several questions I got wrong where I knew the material, but the question was poorly worded.

 

[Slevin]

You question brings back traumatic memories of why I hated medical school. I remember several questions I got wrong where I knew the material, but the question was poorly worded.

I'm trying to come up with a vaild argument that will get the question dropped because it's all I need to pass the class because I know the question isn't worded very well.

But here is the applicaple passage in the notes regarding this sitution

Persons who may be subject to involuntary emergency examination and treatment

(a) Persons Subject.-- any person who is severely mentally disabled and in need of immediate treatment may be made subject to involuntary emergency examination and treatment, if they refuse voluntary treatment and meet certain statute criteria.

A person is severely mentally disabled when, as a result of mental illness, his capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself.

(b) Determination of Clear and Present Danger.—

Clear and present danger shall be shown by establishing that within the
past 30 days:

(i) Harm to self or others (due to a mental disorder or disability) - within the past 30 days the person has inflicted or attempted to inflict serious bodily harm on another and that there is a reasonable probability that such conduct will be repeated. If a person threatened or caused harm to another that is not due to a mental disorder or disability, the individual should be processed through the criminal justice system,
or

(ii) Self Protection and Safety – (due to a mental disorder or disability) has acted in such manner as to evidence that he would be unable, without care, supervision and the continued assistance of others, to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety, and that there is a reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded under this act;
or

(iii) Suicidal the person has attempted suicide and that there is the reasonable probability of suicide unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger may be demonstrated by the proof that the person has made threats to commit suicide and has committed acts which are in furtherance of the threat to commit suicide;
or

(iv) Self Mutilation - the person has substantially mutilated himself or attempted to mutilate himself substantially and that there is the reasonable probability of mutilation unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger shall be established by proof that the person has made threats to commit mutilation and has committed acts which are in furtherance of the threat to commit mutilation.

Thanks for your help

 

[whopper]

Sorry, don't think I can help much other than what I wrote above. Unless there's something you missed, I don't think there's enough information in the wording of the questions.

People can burn themselves for reasons not due to mental illness although it's rare. E.g. some fraternities brand their members. Some people voluntarily brand themselves as part of some type of sadomasochistic act. You can't just hold someone for involuntarily commit for an intentional burn. There has to be more to it than that...e.g. the person burned himself because he heard auditory hallucinations telling him to do so.

As for the diabetes question, it's only a clear and present danger if the person's diabetes is advanced to the point where missing their insulin would cause acute problems.

They way the questions are worded, we don't have that information.

 

[Doctor Bagel]

It looks like the two relevant portions of the statute you posted are b(ii) and b(iv). However, I'm with whopper -- the correct answer depends on the wording. The key with the diabetes and insulin thing would be the reasonable probability of death or serious injury within 30 days if the pt is not taking insulin. With a type I diabetic, I think maybe that's true, especially if they already have a history of being in DKA. With a type II diabetic, most could probably not take their insulin for a long time and just suffer long term (possibly deadly) consequences, so they probably wouldn't fit in that 30 days timeframe. Lots of type II diabetics walk around with ridiculous blood sugars for a long time without treatment and without any obvious, immediate side effects.

As for the burning, the key word there seems to be "substantial." If the person is seriously hurting herself and has threatened to continue to do so, I think they would fit the criteria until b(iv). If the burns are minor, it wouldn't meet the criteria.

So both the answers could be correct under the right circumstances.

 

[billypilgrim37]

Based on what you posted, I think I know what state you're in. 😉

The part that isn't clear is what level of threat to him not taking the insulin represents. If not taking his insulin has a high likelihood of creating a medical emergency, then he can be committed. He lacks capacity due to a mental illness to tend to his ADLs at an acceptable (non-life threatening) level. If not taking his insulin means his A1c is going up to 7.2, then that would be very weak grounds for commitment.

There is really no gray area on the self-burning. That is the best answer.

You could argue that the consequences of not taking the insulin are not clear in the question. But of course, we can't see the question, so maybe it was.

 

[NJWxMan]

I usually commit if I simply don't like him/her.

 

[Slevin]

How does this sound?

You reasoned for the choice of the individual who stopped taking their medications which caused them to stop taking their insulin would cause the individual harm is valid but it doesn't meet the criteria for a clear and present danger. I cite from the assigned reading

"A person is severely mentally disabled when, as a result of mental illness, his capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself...Self Protection and Safety – (due to a mental disorder or disability) has acted in such manner as to evidence that he would be unable, without care, supervision and the continued assistance of others, to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety, and that there is a reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded under this act"

The individual who stopped taking their insulin may cause harm to themselves but the dependent on how the answer choice is interpreted there is not a reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded under this act. If not taking the patients insulin represented a high likelihood of creating a medical emergency that would be grounds for commitment but without knowing the type of diabetes the patient suffers from there is no way to determine that they would cause a medical emergency within the next 30 days to warrant their commitment. There are various forms of diabetes and patients with type I diabetes would most defiantly be at risk of death without insulin within the 30 day time period especially if they have a prior history of suffering from DKA, however type II diabetics can survive for long periods of time without taking their insulin and not knowing the type of diabetes the patient is suffering from makes it a poor question because the test taker would have to infer what type of diabetes the patient was suffering from to decide that that was the correct answer. So I argue that this question should have been dropped because it wasn't clear that the answer choices didn't clearly distinguish between the most dangerous condition to the individual or others

 

[whopper]

There is really no gray area on the self-burning. That is the best answer.

In several subcultures, burning oneself occurs. It's certainly not normal behavior, but per DSM guidelines, we are supposed to be open to such behaviors. It does create an argument that it's the better answer, but IMHO that too is a grey area. I've encountered brittle diabetics a handful of times a year, I encountered self-burners on the order of the same frequency.

In urban-areas, and in areas with African-American fraternities and sororities, the act of branding as a voluntary phenomenon occurs. It also occurs among some borderlines, goths, and gang-members trying to prove their tough-guys.

In rare circumstances, people have burned themselves as form of protest. These people were not mentally ill in a DSM-IV sense of the word.

http://en.wikipedia.org/wiki/Self-immolation

If these are the only answer choices, and if the descriptions did them justice, this really is a poor question. I can think of 3 highly experienced and nationally renowned forensic psychiatrists that would likely not agree on the answer.

 

[masterofmonkeys]

Clearly the answer is the second choice.

Because if a patient stops taking their antipsychotic (I'm assumign atypical here), their diabetes will reverse itself as the metabolic syndrome and direct insulin resistance driven by the medication will slowly fade away...

 

[kugel]

Two test choices where:
A) When they stop taking their antipsychotic medications which causes them to stop taking their insulin because they have diabetes

or

B) When they intentionally burn themselves

In the four states where I've worked,
both could be committed under the right circumstances;
both might well not be committed under the right circumstances.

Simply not enough information.

However, if I have to pick and answer,
When stopping antipsychotics causes one to lose understanding of the consequences of diabetes - that is pretty clear evidence that the mental illness is causing the self harm (stopping insulin)

Burning oneself is most often NOT a suicide attempt, and the consequences of burning are not commonly misunderstood even by psychotics.

So my answer is (A) because it contains both the major elements of commitment:
1) danger to self/others
2) the danger is due to a mental illness

In addition, it contains the element not always explicitly stated in the laws:
a condition treatable by psychiatric hospitalization, i.e. psychiatric medication.
This element sometimes comes into play when questioning whether to commit someone with antisocial PD, since this is not typically "treatable" by psychiatric hospitalization. And it sometimes used as part of the argument against involuntary psych admission for behaviors related to Mental ******ation or Dementia , i.e. these conditions will not be significantly affected by acute psych admission.

 

[Encephalopathy]

I think you guys are answering this on a forensics attending level, and while it is a greatly informative discussion, is beyond what the OP needs answered. On an MS3 level, this question is trying to illustrate the difference between acute harm to self by commission (burning) vs distant potential for harm by omission (insulin). I'm pretty sure the answer is burning. I highly doubt anyone on this forum has ever committed anyone for having poorly controlled DM.

 

[notdeadyet]

I think you guys are answering this on a forensics attending level, and while it is a greatly informative discussion, is beyond what the OP needs answered. On an MS3 level, this question is trying to illustrate the difference between acute harm to self by commission (burning) vs distant potential for harm by omission (insulin). I'm pretty sure the answer is burning.

I couldn't agree with this more.

A great technique to get hammered on a 3rd year medical school shelf is to over-think the questions. If you stare at some of the questions long enough, you start questioning how many angels can dance on the head of a pin.

On a multiple choice test, go with the right-est. A willful act of self harm is much more likely to lead to an involuntary commitment than medication non-compliance. Tattoos/branding/etc vs metabolic syndrome/etc. is interesting theoretical discussion, but for the sake of the exam, peeling back so many layers of the onion only leads to tears.

 

[whopper]

I highly doubt anyone on this forum has ever committed anyone for having poorly controlled DM.

You are right on an important point.........

I do think that some, like myself, took it to a level that medstudents won't need to know for the purposes of an exam.

But yes, I have committed people who didn't take their insulin as a result of mental illness. It all depends on how "brittle" the diabetic is. A brittle diabetic would need insulin. If they didn't take their metformin, that would highly suggest the danger is not acute since metformin can stabilize diabetes that is not yet far advanced.

So it boils down to this...


Possible acute or long term danger (we don't know which) due to lack of care due to mental illness.

Or...

Acute danger, though we don't know if it's due to mental illness.

I remember being in student government and having to look at the professor mentioning that on behalf of the students, I didn't think some of the questions were fair. The professor would look me squarely in the eye and said there was nothing wrong with the question when even other professors said there was. Several of these professors I felt weren't even willing to listen. They're response masked their true intent which was something to the effect of, "When I was in medical school, we didn't even have the right to question our professor, so you shouldn't either."

What we need to know to answer the question...

1) Is the diabetic a brittle one?
2) Why would the person burn him/herself? How much of the body does that person intend to burn, and to what degree? (A brand?, cigarette burn to impress his friends he's a tough guy?)

If the professor pulled some BS response to the effect of "of course no one would burn themselves in their right mind, so that's the right answer" then this guy obviously doesn't understand the concept that we are supposed to consider that several behaviors may be within a cultural norm (even if from a subculture) that we don't agree with, or has no exposure to some situations several of his med-students may possibly face. If you work in an ER in a poor urban area, you're going to commonly see people brand themselves, stick potatoes on gaping holes more than an inch large (thinking it'll heal it), smoke cocaine to the point where defecating on oneself is common, and sell their underage siblings for sex.

If he were to argue "well I just wanted the best answer", he only has a leg to stand on if he can prove that the frequency of encountering a brittle diabetic is more or less (depending on the right answer) vs the frequency of seeing someone who wanted to intentionally burn himself in a manner not due to mental illness. As far as I'm aware, there's no data on the latter.

 

[nancysinatra]

When they stop taking their antipsychotic medications which causes them to stop taking their insulin because they have diabetes

or

When they intentionally burn themselves

With no other information, even at an MS3 (shelf exam) level, I would choose answer A. It includes the two elements needed for commitment that are always required: 1) Danger to self or others and 2) Mental illness. You don't know if the person who burned themselves has a mental illness. There are reasons why people might try to harm themselves besides having a mental illness, and these people do not meet commitment criteria.

However the person who stopped taking their antipsychotics very likely does have a mental illness, since stopping the antipsychotics led to their stopping insulin.

I admit DM is not a very compelling form of self harm but nonetheless... Like many a shelf question it's the better answer because it adequately fulfills all criteria, not because it's the finest example ever made.

It would be better if it said if they're a Type I or II diabetic, how high their blood sugar is, or if they are anywhere near DKA. People off antipsychotics do all sorts of unwise things, obviously, and they're often not committed. However, I have gone to court with an attending and seen patients be committed because they can't care for themselves while off antipsychotics--for example because they aren't eating properly or their house is extremely filthy.

On a different note, once the patient's committed, then (at least in my current state), then you can apply to the courts to mandate that they take antipsychotics. However, you can't just "mandate" that they take insulin. I suppose you could apply capacity reasoning. If it's an emergency we probably would. But the attendings I've seen usually let the psychotic patients decline whatever medical medications they please, as long as it's not urgent. Medical capacity and psychotropic medication over objection run through different channels and some attendings don't like to do both at once I guess. So you see patients getting committed because they can't care for themselves, but then we don't force that care upon them either, we just restart antipsychotics, and hope they'll become more rational soon.

We've actually had patients committed because they were off their antipsychotics and stopped their antihypertensives or other medical meds. It's pretty common. They become delusional about all medications. But someone with NO mental illness who intentionally harmed themselves for a different type of reason--never.

The fact that it's burning too--that implies it could be something other than a suicide attempt. I agree though, there's a lack of information.

 

[Doctor Bagel]

I think the burning and the suicide issue is not really relevant here because apparently this state allows people to be involuntarily committed for self-mutilation without suicidal ideation or attempts. That's why burning in and of itself is more compelling than it would be in other states. Of course, the burning option doesn't mention a mental illness, but I'm assuming the test writer wrote the question based on the assumption that both people were mentally ill. So to me, based on the statute, the bigger issue with the burning is how severe it is. I'm also assuming the test writer wrote the question with the assumption that the diabetic was a type I and could very likely suffer immediate consequences from not taking her insulin.

Anyway, good luck getting the question thrown out. At my school, our human behavior professors were entirely unwilling to ever throw anything out, probably both because our grades were high, and they thought we didn't respect their class.

 

[nancysinatra]

I'm assuming the test writer wrote the question based on the assumption that both people were mentally ill. So to me, based on the statute, the bigger issue with the burning is how severe it is. I'm also assuming the test writer wrote the question with the assumption that the diabetic was a type I and could very likely suffer immediate consequences from not taking her insulin.

That is a lot of assumptions. Looking at the statutes, you need to meet A) the Persons Subject criteria and B) the Clear and Present Danger criteria. Why assume that they are meeting A? Why assume anything about the type of diabetes or the severity of the burn? It could go either way--a slight burn is less harmful than ketoacidosis in a Type I diabetic, but 90% third degree burns are worse than missing one day's dose of short acting insulin. The questions seems purposefully vague.

The only information that can be gleaned from the question is the number of criteria met. In the diabetic answer, both criteria are met. In the burn answer, only 1 criteria is met. This to me seems clear.

In any case, I hope everyone realizes, if they already burned themselves and you consider it severe, this discussion won't be happening, because they're not going to the psych ward at all. They're going to the burn unit.

 

[nancysinatra]

On a multiple choice test, go with the right-est. A willful act of self harm is much more likely to lead to an involuntary commitment than medication non-compliance. Tattoos/branding/etc vs metabolic syndrome/etc. is interesting theoretical discussion, but for the sake of the exam, peeling back so many layers of the onion only leads to tears.

This isn't always true. If you look at homicidal ideation, especially, it is totally not true. We involuntarily commit people for homicidal ideation that is very low level when they have a mental illness such as a psychotic disorder and are having auditory hallucinations to harm someone even rather slightly. On the other hand, they can be in a murderous rage and about to stab or kill someone, but if it's because of antisocial PD, we don't commit them. Those people either control themselves on their own, or they go to jail. There is a parallel with self harm, but it is much harder to give examples because most self harm does connect to mental illness. But in any case, severity of the intention or act is not the only criteria. They mental illness criteria is necessary.

I agree that choosing the rightest answer is a good test strategy. But it will be more rightest if it is fulfills both the criteria.

 

[whopper]

Add to the confusion...

On the other hand, they can be in a murderous rage and about to stab or kill someone, but if it's because of antisocial PD, we don't commit them.

Several doctors actually would hold such a patient for commitment under the argument that perhaps the person is bipolar or psychotic, but would need to observe the patient for 72 hrs. to figure it out.

And some doctors would hold anyone who burned themselves, even if not due to mental illness.

Some doctors would never hold a patient who stops insulin because it's quite common for patients to not comply with controlling their blood sugars, unless the person were a brittle diabetic. (Even then, I've seen some that would not because they were clueless).

 

[kugel]

Add to the confusion...



Several doctors actually would hold such a patient for commitment under the argument that perhaps the person is bipolar or psychotic, but would need to observe the patient for 72 hrs. to figure it out.

And some doctors would hold anyone who burned themselves, even if not due to mental illness.

Some doctors would never hold a patient who stops insulin because it's quite common for patients to not comply with controlling their blood sugars, unless the person were a brittle diabetic. (Even then, I've seen some that would not because they were clueless).

Well, yes.
There are docs who will admit anyone who is even remotely dangerous because they are mostly concerned with making sure they never get blamed for anything and "we can just let the inpatient team figure that out." In other words, they don't bother doing their job and just pass it off onto the next guy.

There are also docs who, as you say, don't have a clue what they are doing psychiatrically and don't know the laws of their state. Unfortunately, there is essentially NO oversight of this whole involuntary admission process.

But neither of those is where we're going to turn to answer this question on a test or in real life.

 

[Slevin]

An update to all of you, first thanks for giving me ideas on how to argue this vague question.

The released revised final grades and a question was dropped allowing me to pass. Now I don't know if it was the email I sent to the professor over the weekend describing how vague the question could be or something else but a question was dropped boosting me over the line and I was able to pass the class. I'm so relieved at this you can't believe. This is a weight off my shoulders.

Again thanks for all your help

 

[Shikima]

The down and ugly of it is that I have committed people on similar occasions and have gone so far as to get JC/Court orders for mandatory treatment. Using the erroneous logic that they're not capable in taking care of themselves, I am expected to step in to save them from themselves.

It's ugly. Hard to argue the question during medical school. Ends up being a debate in opinion which is fruitless at best. Sometimes you have to end up eating crow and moving on with hate in your heart.😀

 

[whopper]

Using the erroneous logic that they're not capable in taking care of themselves, I am expected to step in to save them from themselves.

In most states this is a perfectly acceptable option if the person cannot take care of themselves to the point where they cannot care for basic needs (food, shelter, water) in the community.

If the person, for example, is homeless and is doing quite well living in the homeless shelter, then you don't have to hold for commitment. If the person is doing fine panhandling, then you don't have to hold for commitment. If the person is eating garbage, shows up to the hospital with enteritis as a result of eating garbage, that's different.

 

[mooshika]

Someone can't be committed just because they stopped taking their psych meds and they have a Hx of then stopping insulin, etc. They have to be actually refusing treatment ie. insulin either intentionally or due to evidenced and documented psychosis/delusions or other MI.

A person burning themselves could have a variety of reasons for doing so, if it is established as intentional self-harm (ie. cutting) they can be put on IVC immediately, particularly if there are current SI or a history of SA. It may seem like a stupid idea but you can't commit someone for being stupid otherwise we all would be locked up.