Thursday, May 23

Should Palliative Psychiatry Be Considered for Anorexia?

A few days later, when she was not imminently dying anymore, Naomi announced that she was going home — and the hospital responded by placing her on a 72-hour mental-health hold. Clinicians then obtained what Colorado calls a short-term certification, which required, by judicial order, that Naomi be detained and treated, in her case until she reached what physicians determined to be 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 found incapable of making informed decisions. That day, Naomi was transferred to a residential program at Denver’s Eating Recovery Center (E.R.C.).

“I’m so mad, I’m so mad,” Naomi said in another video message, her voice dull and impassive. “I was completely disrespected. I was tricked.” Naomi could feel that her mind was diminished — it was too slow, too slack — but she found that she could think in a straight line. She could reason. So why did the doctors claim otherwise? By then, she had been in and out of hospitals and psychiatric wards and eating-disorder programs, including the E.R.C., more times than she could recall. Was it really so irrational for her to assume that trying the same treatment for the hundredth time would be futile?

When she was a teenager, Naomi believed that treatment programs might 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 the one about how she just wanted to be special, like her eldest brother was special because he was so smart. Other times, she told the story about the day her grandfather died and the whole family went to eat at a restaurant. Naomi was revolted watching everyone nourish their bodies with something as carnal as food when they should have been awash in grief. Years later, it was hard to tell if any of these origin stories mattered. With each inpatient admission, Naomi gained weight. Each time, the extra weight felt unbearable, and she lost it soon after discharge.

As the years passed, Naomi found it harder to be “compliant” with standard treatment. She refused to participate in group sessions. Or she disengaged during therapy, which she found infantile and pointless. She sometimes tampered with her intravenous lines, because it was too awful to watch those plastic bags of liquid calories empty into her body. During some admissions, Naomi forced herself to gain weight so that she could be discharged. Other times, she signed herself out against medical advice. Later, Naomi started bingeing and purging. She would excuse herself after meals and step into the backyard to vomit into plastic bags that she would throw into the neighbor’s yard, so that nobody would see. She vomited and vomited until stomach acid burned through the enamel of her teeth and she had to spend $22,000 to replace them.

In between treatment programs and emergency hospitalizations, Naomi, at 18, went to college. She wanted to study psychology, but all she could really do was exercise for hours a day after eating almost nothing, maybe an apple. In her final year, she dropped out. Later she found jobs that she cared about — a certified nursing assistant who did home health assessments, a patient coordinator at a hospital — but they were often interrupted by yet another medical admission.