Margaret talks to Raj Persaud about her frightening experience
of being admitted to a psychiatric hospital against her will with
no idea as to why this was happening. This interview was made
possible by 'Mind' - the mental health charity and particular
thanks go to Aimee Gee of 'Mind', for her assistance in making it
By Raj Persaud and Peter Bruggen
first published in The Huffington
Should Anorexics be force fed? The latest legal ruling could kill
the patient - but doing nothing might also condemn her to
Telegraph has reported that a leading judge who sits in
the Court of Protection, Mr Justice Peter Jackson, has ruled that a
former medical student suffering from severe anorexia nervosa, and
who is at a life-threatening low weight, should be force-fed
against her wishes by doctors.
Dr Evan Harris, the former Liberal Democrat MP and member of the
British Medical Association's ethics committee, is quoted by
Telegraph to have responded: "The implications of
force-feeding are really significant because she would need
restraining or sedation and the treatment would last a year... It
might not succeed and is itself life-threatening. To impose that on
a patient who might be competent in refusing treatment is a very
The 32-year-old woman is described as not having eaten solid food
for a year and her parents are reported by the Daily
Telegraph to have told the court: "It upsets us greatly
to advocate for our daughter's right to die... We feel she has
Mr Justice Jackson is reported by the newspaper to have conceded
the woman stood only a 20% chance of recovery even if she was put
on an invasive force-feeding programme that would last at least a
Is it really true that medical intervention can be as dangerous as
leaving people with an eating disorder to starve themselves to
death? And is it also true that it's pretty pointless anyway?
In a 2010 study by Dr Marie Vignaud from the University Hospital of
Clermont-Ferrand, France, all patients with Anorexia Nervosa
admitted to 11 Intensive Care Units in France between 2006-2008
were investigated, and of 68 admissions, seven died during the
The study published in the academic medical journal Critical Care,
found the commonest cause of death was 'Refeeding Syndrome'. This
is a potentially fatal shift in fluid and electrolyte levels
(minerals such as sodium, potassium and calcium which are
distributed around the body where the delicate balance across cell
membranes is vital for life) that may occur in the malnourished
receiving artificial nutrition.
Precisely because of the dangers of re-feeding, Dr Vignaud and
colleagues contend oral re-feeding is the best approach to weight
restoration. But faced with absolute refusal to eat, or in cases
with extreme malnutrition, feeding via a nasogastric tube may be
life-saving, the authors argue. In even more extreme cases, or when
the digestive tract itself is no longer functioning, intravenous
feeding should be used despite the risks, they believe.
Vignaud and colleagues point out the dangers of medical re-feeding
have to be balanced against the fact that Anorexia Nervosa is in
itself one of the most fatal psychiatric disorders, with a
mortality rate of almost 6% for every 10 years of having the
illness; 12 times the rate expected for similar age- and
It's perhaps sobering to realise in the light of these statistics
that rates of anorexia appear to have been going up since the
1930's. A 2007 study published in the American Journal of
Psychiatry by a group lead by Anna Keski-Rahkonen at the University
of Helsinki, Finland, found that up to 50% of Anorexia Nervosa
cases remain undetected by healthcare systems. Current estimates
are that lifetime prevalence rates for Anorexia Nervosa in
20-40-year-old women are estimated between 1.2% and 2.2%. The rates
for other milder eating disorders would be much higher.
In a study yet to be officially published, Daniel Rigaud and
colleagues from the Service d'Endocrinologie-Nutrition, in Dijon
France, followed up 41 severely malnourished anorexia nervosa
patients and compared them with 443 less malnourished Anorexia
Nervosa patients. The severely malnourished group of 41 had reached
an average seriously low weight of 26 kilograms (four stones 1.3
pounds) with an average height of 160 cm (5.2 feet) which
translates to an average Body Mass Index of 10 (bear in mind the
normal healthy range is roughly 20-25).
Body Mass Index is the measure nutritionists use to calculate
whether your weight is healthy as it takes into account your
height. The formula is your weight in kilograms divided by your
height in metres squared. A BMI lower than 10 kg/m2 in adults is
widely considered incompatible with life.
Rigaud's study, due to be published in the academic journal
'Clinical Nutrition', found that all of the 41 severely
malnourished anorexia patients received tube-refeeding: but during
the in-patient stay, one patient died, two others suffered from
myocardial infarction, two others from acute pancreatitis, and five
from mental confusion.
Compared with the other 443 less severe Anorexia Nervosa patients
(average weight in this less severe group was 40 kg or six stone
4.2 pounds), the 40 remaining patients (one died shortly after
admission) had a worse six year outcome: a further two died (7%
versus 1.2% in the 443 less ill group), and only 41% recovered
(versus 62% in the less ill group).
Rigaud and colleagues conclude that in Anorexia Nervosa patients
with a Body Mass Index of less than 11 kg/m2, prudent
tube-refeeding could avoid short-term mortality, but long-term, the
prognosis remains ominous.
Perhaps part of the problem lies in the very battle against the
fervent desire of the anorexic; perhaps something is being missed.
Jill Holm-Denoma and colleagues at the University of Vermont, USA,
in 2008 proposed a theory that the high death rate in anorexia
nervosa may be linked also to an especially high suicide
motivation, which may have been previously missed by clinicians and
relatives. Their study is based on previous research which finds
the risk of death by suicide among anorexic women is approximately
57 times the expected rate.
The study, published in the 'Journal of Affective Disorders',
considered the suicides of nine women with Anorexia Nervosa. They
were found to be more likely to use highly lethal methods, with low
rescue potential, that would likely kill anyone. Three died by
throwing themselves in front of a train, and two more died by
Another reason courts may have to intervene against the wishes of
severely anorexic patients, doctors argue, is their brains are
likely to be incapable of reasoning rationally because the mind
itself begins to be affected by the malnutrition. Brain imaging
studies find reduced cerebral volume and the greater and faster the
weight loss, the smaller the total brain volume. Refeeding, if it
leads to weight gain, can largely reverse this brain shrinkage.
The latest study to report this kind of finding was conducted by a
group lead by Boris Suchana from the Institute of Cognitive
Neuroscience, Ruhr-University Bochum, Germany, in a study published
in the journal 'Behavioural Brain Research' in 2010. This
intriguing brain imaging study found a particular reduction in gray
matter density with anorexia sufferers in a specific part of the
brain associated with body size misjudgement. This raises the
possibility that sufferers from anorexia get caught in a vicious
cycle whereby losing weight might produce brain changes which in
turn alter perception, and thus encourage more weight loss.
Anorexia Nervosa is a serious and complex disorder for which
treatment must be tailored to the needs of the individual, but
where 'the system' seldom allows this. Life saving intervention is
required more than in most other psychiatric disorders.
Patrick Keown from Queen Elizabeth Hospital, Gateshead, and
colleagues, published in the British Medical Journal in July 2011
an analysis on the impact of the dramatic reduction in UK NHS
psychiatric hospital beds between 1988-2008 - a period when
alternatives to hospital admission in the form of community care
was supposed to be provided.
Keown and colleagues found the rate of involuntary admissions
(being 'sectioned' under the Mental Health Act) per year in the NHS
increased by more than 60%, while the provision of mental illness
beds decreased by more than 60% over the same period. The authors
calculated the closure of two mental illness beds contributes to an
additional involuntary admission in the subsequent year. This data
referred to all of psychiatry - not just eating disorders - but it
might also contribute to our understanding of why anorexia has
ended up in the courts, and in the news now.
A dramatic rise in the use of compulsory admissions over the last
two decades does not mean that psychiatric disorders have in their
nature got worse, but that the prospects for those who have them
seem more bleak.
This is because a progressively starved, more disorganised NHS is
less effectively caring.
Those desperately trying to look after patients who've reached the
end of this road, are therefore forced to seek help from sources
outside the health service.
So now we dispense with the doctors, and retain the lawyers.
Raj Persaud is a Consultant Psychiatrist in Private Practice in
Harley Street, London UK and author of several best-selling books
including ‘The Mind: A Users Guide’ published by Bantam
Raj Persaud is joint podcast editor for the Royal College of
Psychiatrists and also now has a free app on iTunes and google play
store entitled ‘Raj Persaud in conversation’, which includes a lot
of free information on the latest research findings in mental
health, plus interviews with top experts from around the world.