Wednesday, 8 December 2010

Anorexia, the Mental Health Act – and Kayleigh

Anorexia Nervosa is a fairly common mental disorder; the most common age of onset is 10-19 years of age; nine out of ten patients are female. Anorexia is also a mental disorder that can be fatal: chronic starvation can lead to a range of life threatening conditions, including heart problems and kidney failure. Indeed, it is estimated that as many as one in five of patients with anorexia will die each year.

So there shouldn’t be any problem using the powers of treatment in the Mental Health Act with people with anorexia, should there?

That certainly wasn’t the case in the 1990’s. Some mental health professionals did not like the idea of compelling someone with a mental disorder to receive physical treatment (for example, tube feeding or rehydration), and often the MHA was not used, even when a person’s life was at risk.

I could never understand this. As far as I was concerned, anorexia nervosa was a mental disorder within the meaning of the Act, both then and now, and if someone’s life was in danger as a result of this disorder, then I had no ethical problem in using detention under Sec.3 to ensure that they received appropriate treatment. Over the years I have detained several people with anorexia under the MHA, simply in order to save their lives.

Then in 1996 there was the case of Nikki Hughes. Nikki Hughes was a young woman who had suffered from anorexia since her teens, who died in January 1996 as a result of starving herself. The doctors treating her had sought legal advice regarding feeding her without her consent, and they were told that this could lead to charges of assault against the doctors and the hospital. She was therefore allowed to die.

In response to this case the Mental Health Act Commission issued guidance in 1997, stating in part that some patients "may not be able to make an informed choice as their capacity to consent may be compromised by fears of obesity or denial of the consequences of their actions". The Care Quality Commission issued updated guidance in 2008 (Guidance on the treatment of anorexia nervosa under the Mental Health Act 1983). While the CQC believes “that it is only in its most severe manifestations that anorexia nervosa may be considered to require compulsory admission” they advise that detention is justified “in rare cases of serious threat to health, where compulsory feeding may be necessary to combat both the physical complications and the underlying mental disorder.”

However, there have continued to be cases where people with anorexia have died, when use of the MHA may have prevented it. In 2004 Samantha Price died from heart failure at the age of 22. Her family maintained that she should have been detained under the MHA, but the South West London and St George's Mental Health NHS Trust said that “forcing patients to come into hospital for treatment against their will simply does not work with patients like Samantha”.

As recently as this year Jonathan Edwards died of complications arising from his anorexia. Newspaper reports of the inquest (Swindon Advertiser, 29th June 2010) stated that his mother had told the coroner “that her son’s only hope of survival was to be sectioned and forced to eat by trained eating disorder specialists.” Despite the CQC and other guidance, it was still stated at the inquest as fact that “as Jonathan acknowledged his condition and periodically asked for help, to section and force feed him would have been illegal.”

I recently received a request from the Charwood Child and Adolescent Mental Health Service (CAMHS) to assess Kayleigh for detention under the MHA for treatment. She was just 17, and had a 2½ year history of anorexia nervosa. During that time, she had had two informal admissions to the regional children’s anorexia unit. Two weeks before referral, she had had an acute medical admission with a severe infection, as a result of poor nutrition, and had nearly died. She had also suffered damage to her heart because of the anorexia, but persisted in playing in the local basketball team, even though she had been warned that such exertion could be dangerous.

A couple of days before I saw Kayleigh, her care coordinator had calculated her Body Mass Index as less than 14 (20-25 is normal), and her blood pressure was dangerously low. Even though there was evidence that her very poor physical condition was putting her life at imminent risk, she remained in denial that she was not feeding herself adequately, and there was evidence that she was “water-loading” when she knew she was going to be weighed in order to deceive her workers.

A further concern was that her mother, with whom she lived, was colluding in some way with Kayleigh, and was herself in denial of the seriousness of her daughter’s condition.

Her CAMHS consultant, another Sec.12 doctor and I went to see Kayleigh at home. We expressed our concerns about her current condition, and the fact that she was still losing weight, despite her recent medical admission. However, she was not prepared to consider a hospital admission.

“I am all right, you know,” she said. “I’ll be fine as long as I can have therapy and treatment at home.”

“But therapy clearly hasn’t been working for you,” I said. “You nearly died a couple of weeks ago, but you still don’t seem to think there’s a problem. Do you want to die?”

“No, of course not. I enjoy life. I like playing basketball.”

I noticed that her knuckles were grazed. “What happened to your hand?” I asked her.

“Oh, just had an argument with a wall. I punched it out, that’s all. It’s nothing.”

This eventually led in to an admission that she had been cutting herself over the last few days. She also admitted that she had told her care co-ordinator that she had been feeling suicidal, and was also afraid that her mother might kill herself if Kayleigh wasn't there to keep an eye on her. There was obviously a lot going on.

Despite all this, she didn’t come across as being clinically depressed. But there was overwhelming evidence that her anorexia was controlling her. If it continued, she might very soon, within a matter of days, reach a point at which her body would not be able to recover from the damage that had been done. We concurred that she was unable or unwilling to consider that her behaviour was placing her at grave risk, and that she was powerless to modify her behaviour or recognise the risks. As she undoubtedly had a mental disorder within the meaning of the Mental Health Act, and it was clear that the only way she was going to receive necessary care and treatment was through admission to hospital, we completed an application for her to be detained under the MHA.

Of course, that was only half the problem. Once the decision to detain had been made, I knew that the specialist unit where she had been before had no beds, and the only bed that had been identified was in a private hospital with a child and adolescent ward over 70 miles away. And I would have to get her there. This is a common problem with children and adolescents. Young people under the age of 18 cannot be admitted to an adult psychiatric ward, and there are no suitable beds at all in the county in which I work.

We also had to inform Kayleigh’s mother of the decision. As we anticipated, she was not pleased. I informed her of her rights as nearest relative, which include the right to apply to the hospital for the discharge of her daughter, and she informed me of her intention to exert her rights at the soonest available moment. Kayleigh also expressed her intention to appeal against her detention.

Since the consultant had indicated to me that there were no imminent medical reasons why she needed to be transported in an ambulance, I offered to take Kayleigh, with her mother, to the hospital. I knew from bitter experience that the local ambulance service would be less than keen to transport a patient to a hospital so far away, and would therefore delay it until the shift change. I could foresee a delay of 5 or 6 hours before an ambulance would arrive, which would not be in the interests of the patient, who would just get more and more wound up waiting – and I confess it would not be in my interests, as I could see that I would not get home until late evening.

Kayleigh’s mother somewhat reluctantly agreed to this. I suggested that we went straight away (it was about 1pm), but mother asked for an hour to get things ready and to have some lunch. I agreed to this, although later on wondered quite how much of a lunch Kayleigh was going to have, and when I returned to the house I half expected the two of them to have disappeared.

But they were both present and ready to go, and by now more resigned to the inevitability of the admission. I took them to the hospital without incident.

And Kayleigh’s still alive.


  1. From personal experience MHA & anorexia might work so long as the hospital is a specialist ED one. My ED started when i was sectioned on an acute MH ward & the staff there did nothing at all, barely acknowledged my weight loss. Of course my agreement to eat once i got home didn't mean my weight increased however 6 months later i went to my GP & was refered to an ED nurse specialist who has been wonderful.

    However i have no doubt that when my BMI was 12 & an admission was mentioned that they would have had no trouble finding grounds to section me with a history of 3 previous section 3's. Do you think that a previous history of MH issues would have an impact on the sectioning of a person with an eating disorder?

    Fortunately the thought of hospital (a hospital that wouldn't be local this time) and being told i wasn't allowed to work by my boss encouraged me to gain weight. It just a shame that although i have a BMI of 23, people don't understand that the battle is far from over.

  2. I have written a letter stating that if my weight loss ever becomes life-threatening again and I am refusing treatment, I want to be sectioned. I don't know how much legal power such a letter would have, but at least it makes my wishes known.

    I'm currently at a healthy weight and able to think more or less clearly. I know that if I relapse my reasoning skills will become more and more impaired, and my delusion of being fat will mushroom out of control. This is why enforced refeeding can work for patients with anorexia, providing it is done appropriately: it gets your brain to the point where you have a half-chance of thinking sensibly again.

  3. Hi Susie
    Certainly the previous mental health history of someone would have a bearing on making decisions about whether or not to detain under the MHA. Knowledge of the outcome of such actions in the past can inform your decisons as an AMHP.
    Hi Vicky
    From an AMHP point on view, it is helpful to know the advance wishes of a patient. I have known one or two people with psychosis who recognise that they do things when they are unwell that they later regret, and have stated that they would wish to be sectioned when their capacity goes.
    Believe it or not, I have even had patients who have thanked me for sectioning them when they have recovered!

  4. This is really interesting. I remember reading on a forum not so long ago about someone concerned that they would be detained under section because of their eating disorder.

    Is it purely based on physical health risks or their BMI that means the MHA could be used? I know the two are generally linked, but a friend of mine mentioned that their friend in hospital died from a heart attack caused by her ED when she wasn't particularly underweight.

    I know you cannot commment on individual cases, but the line between what poses a risk & what doesn't interests me..

    Brilliant post, as ever :)

    outwardly x

  5. Detention under the MHA would only be considered as a last resort. I know that our local Eating Disorders Services tries its hardest to avoid using compulsion, on the basis that it is better to develop a cooperative realtionship with the patient than to use coercion. It is not just BMI that is of concern -- it is more the overall health of the person and their capacity to understand the risk to which they have put their health and life. Most people with anorexia do not actually want to die -- it's just that they no longer know how to keep themselves alive and healthy.

  6. Hi, just a question re conveying people who are detained and not going in on an informal basis. All LA's have a conveying policy, usually we do not convey patients that are detained. What was your policy?

    Also, i take it you detained using a 2 by the fact there is no mentioned of the mother objecting which it appears she was doing?



  7. She was detained under Sec.2. In accordance with the Code of Practice, our local conveying policy says that you should use an ambulance. However, the AMHP hass the discretion to convey in any manner they see fit taking into account the circumstances. There was no risk identified in her being transported in my car, and I discussed this option with her consultant. In view of the distance of the hospital (70 odd miles), and therefore the likelihood that I would be waiting a long long time for an ambulance, I took the decision to transport her myself, with her mother as escort. This turned out to be a good decision, and I was able to establish a useful rapport with her mother. I am still actually working with Kayleigh and I am now her care coordinator. That involvement back then was useful. I would never recommend that an AMHP transports a patient -- it's a matter of individual judgment.

  8. Hi, are you still able to answer questions on this issue please?

    1. Yes I am. Fire away, or email me directly (email address somewhere on the right hand side of the blog).

  9. Would/could someone ever be sectioned if bmi is fine at bmi 18 but over exercising and eating no more 200 cals a day and continuing to reduce?

    1. Sorry, I lost your email. Would not usually consider admission above bmi 13, but crash dieting as you describe could lead to very rapid weight loss and potential serious issues with hydration, electrolytes etc. Also depends on previous history and patterns of admission etc.

  10. Cool thank you. its driven by ocd and can't go against ocd number rules for eating and exercise. No previous afmissions around eating, one brief admission last year with severe depression.

    1. Just to add, been restricting/over exercising for eight months but heavy restricting more recently

  11. My friend has been in hospital and similar settings for the past 10 years with various issues.
    He now 24 was sectioned on a 3 last july and diagnosed with severe anorexia,which the first time time this diagnosis had been formally made.
    he is now in recovery, His section has now been formally lifted and is living in the hospital as an informal patient awaiting discharge (due to happen in next 2-3 weeks)
    Today he spoke to a manager of his ward and asked her if he was to become ill again would he be able to make an advanced decision that he should not not be tube fed if relapse was to occur.
    He told me that the ward manager had said that he would need to be assessed for capacity but she is not sure of the ins and outs of whether the request would even be considered should relapse occur.
    Just wondering if you could shed any light on the subject? Thanks.
    He also has a diagnosis of Aspergers syndrome.

  12. I'm 34 and have anorexia for over 20years. My BMI is just above 14, recently I'm struggling more ..if I eat I just purge as I can't keep anything down... I ignored my appointments with ED team for over 2 months . Can I be sectioned??? I just worry one day they will come to get me ...I used to be sectioned in the past x

    1. If your weight is at a dangerous level, which it is, and you are not engaging with a treatment plan, then you are indeed at risk of being detained under the MHA. You recognise you have a problem, so please get help from services to reduce your risks.

    2. Thank u. I don't think my weight is low, and I don't want to gain any more..and they know I don't but still they pushing me to. And I explained so many times to the team that I'm better by myself as I'm not stress about getting weight when I don't see them and I can just manipulate the weight by myself. I'm working full time andthey know I was much lower BMI and still worked. I don't think it's an illness any more in my case it's more my life style as I won't change ... By any chance I'm in position to discharge myself from services even they don't want to discharge me ?? Just want to avoid any not nice situations. Thank u

    3. A healthy BMI is 19 - 25, as I'm sure you know. Your BMI is at a dangerously low level, and mental health services would not consider self discharge to be an option.

  13. If you voluntarily go into hospital at a bmi of 13 and want to better your physical health to get to around 14 bmi , with the plan of not pushing yourself to bigger goals in an aim of getting to bmi 15 so you have more independence , able to drive and work again. Even though you have osteo. Could you be sectioned for self discharging at a bmi of 14 with the goals of moving forward but in time as you're not willing to do recover any further at that point ?

    1. As an AMHP I would be very concerned if a patient with anorexia wanted to discharge themselves with a BMI below 17. The reality is that many people with anorexia are in denial about the seriousness of their condition and its associated physical health problems, including death. They will make promises that they have no intention of keeping. The point of BMI is to describe a healthy weight based on the ratio of height to weight. "Normal" BMI is defined as 20-25, so a BMI below 19 would be considered to be as unhealthy as a BMI much above 27.

  14. Hello, I suffer with EUPD (emotionally unstable personality disorder) and have had 4 inpatient admissions due to being a risk to myself, I was formally diagnosed in February and was assessed under the mental health act at bmi 19.3 as my blood sugars dropped due to not eating for 2 weeks. In just over 3 weeks I've lost from a bmi of 22 to 19, I've not eaten in 3 days have abused laxatives, my blood sugars have dropped to 2.8 and I've fainted twice. I have an appointment with my gp today, am I a risk of being detained under section due to my history of long periods of fasting (3 1/2 weeks this time last year and 2 1/2 weeks in January and 5 days refusing food and fluid as well as deliberate self harm and suicide attempts) is there a risk of being detained today?

    1. I really can't tell you what might happen with your GP. If you are not prepared to work with professionals to modify your eating patterns, it is possible your GP may ask for an assessment under the MHA. However, a BMI of 19 is not actually low; I wouldn't normally be considering use of the MHA unless someone had a BMI of 13-14 or less.

  15. Hi - I have had 3 admissions, 2 of which I was sectioned under section 3, for anorexia, in the last 4 years, and was first diagnosed when I was 9 (I'm 17 now). I have never had a period, have severe osteoporosis, etc. Since my last admission in December, things were okay, but then in the last couple of weeks, I began struggling and lost a lot of weight (BMI now 13/14). I completely understand I am very underweight and I do really want to gain; I have come up with a meal plan and have been following it and slowly increasing so I can get back to what I was eating. My pulse is in the 40s and my blood pressure is VERY low (70s/30s). I am happy to go to my local general hospital every day for checks, etc, but my mum and I both feel another admission just won't help me, and that we CAN do it at home. My team don't agree and I have a mental health act assessment soon. Do you think it is likely I will be sectioned? On what grounds? I would at least like a couple of weeks to prove I can do it.

  16. Hi if your still answering questions on this blog could i have your email please as I can't find it anywhere and would like some advice on how to approach my care coordinator. My BMI is 15.4 and keeps falling. In a way I know I could do with some extra support but I dont know exactly what would happen as I refused impatient admission in 2014 but my BMI was a little higher then. Also been inpatient on mental health wards for suicidal ideation ect and have diagnosis of emotionally unstable personality disorder and anorexia. My email is if you could reply to my email instead. Thanks if you can