Should palliative psychiatry be considered for anorexia?

A few days later, no longer near death, Naomi announced she was going home and the hospital responded by putting her on mental health hold for 72 hours. Doctors then obtained what Colorado calls a short-term certification, which required, by court order, that Naomi be detained and treated, if appropriate, until she reached what doctors determined was 80 percent of her “ ideal body weight. In Colorado, as in most states, a patient can be treated against her will if she is mentally ill and is deemed incapable of making informed decisions. That day, Naomi was transferred to a residential program at the Eating Recovery Center (ERC) in Denver.

“I’m so angry, I’m so angry,” Naomi said in another video message, her voice dull and impassive. “They completely disrespected me. “They tricked me.” Naomi could sense that her mind was diminished (she was too slow, too relaxed), but she discovered that she could think straight. She could reason. So why did doctors claim otherwise? By then, she had been in and out of hospitals, psychiatric wards, and eating disorder programs, including the ERC, more times than she could remember. Was it really that irrational of her to assume that trying the same treatment for the hundredth time would be useless?

As a teenager, Naomi believed that treatment programs could save her. She ate supervised meals and attended group therapy sessions where, among other things, patients discussed the origins and possible psychic functions of their eating disorders. Sometimes, Naomi told the story of how she stopped eating because she thought it would make her a faster swimmer. Or that she just wanted to be special, like her older brother was special because he was so smart. Other times she would tell the story of the day her grandfather died and her whole family went to eat at a restaurant. Naomi rebelled at seeing everyone feeding their bodies with something as carnal as food when they should have been flooded with pain. Years later, it was hard to know if any of these origin stories mattered. With each hospital admission, Naomi gained weight. Each time, her extra weight became unbearable and she lost it shortly after discharge.

As the years went by, Naomi found it more difficult to “stick” to standard treatment. She refused to participate in group sessions. He or she became disengaged during therapy, which he or she found childish and unhelpful. She sometimes manipulated her IVs because it was too horrible to see those plastic bags of liquid calories empty into her body. During some admissions, Naomi forced herself to gain weight so she could be discharged. Other times, she would disconnect against medical advice. Later, Naomi began binge eating and purging. She would excuse herself after eating and go out to the backyard to vomit into plastic bags that she would throw into the neighbor’s yard, so that no one would see her. She vomited and vomited until the stomach acid burned the enamel on her teeth and she had to spend $22,000 to replace them.

Between treatment programs and emergency hospitalizations, 18-year-old Naomi went to college. She wanted to study psychology, but the only thing she could really do was exercise for hours a day while eating almost nothing, maybe an apple. In her senior year, she dropped out. She later found jobs that interested her (a certified nursing assistant who did home health assessments, a patient coordinator at a hospital), but they were often interrupted by another medical entry.

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