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In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN.

BackgroundMental capacity to consent to treatment in anorexia nervosa is a neglected area in clinical decision-making.AimsTo examine clinical and neuropsychological parameters associated with diminished mental capacity in anorexia nervosa.MethodAn explorative study was conducted in 70 adult female patients with severe anorexia nervosa. Mental capacity to consent to treatment was assessed by experienced psychiatrists. Further measurements included the MacCAT-T (to assess mental capacity status), a range of clinical measures (body mass index (BMI) and comorbidity) and neuropsychological tests assessing decision-making, central coherence and set-shifting capacity.ResultsDiminished mental capacity occurs in a third of patients with severe anorexia nervosa and is associated with a low BMI, less appreciation of illness and treatment, previous treatment for anorexia nervosa, low social functioning and poor set shifting.ConclusionsAssessment of diminished mental capacity in anorexia nervosa requires careful evaluation of not only BMI, but also the degree of appreciation of illness and treatment, history and the tendency to have a rigid thinking style.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Severe and Enduring Anorexia Nervosa (SE-AN) is a chronic eating disorder characterized by long-term starvation and its physical and psychological sequelae, and severe loss of quality of life. Interactions between neurobiological changes caused by starvation, vulnerability (personality) traits, and eating behaviors play a role. Several other factors, such as increased fear and decreased social cognition, have also been found in relation to SE-AN. With this in mind, we aim to add to the understanding of SE-AN by introducing the concept of mental capacity (MC), which refers to the ability to understand and process information—both on a cognitive and an emotional level—and then make a well-informed choice. MC may be an important construct within the context of SE-AN. Furthermore, we will argue how impaired decision-making processes may underlie, fuel, or contribute to limited MC in SE-AN. We will speculate on the importance of dysfunctional emotion processing and anxiety-related processes (e.g., a high intolerance of uncertainty) and their potential interaction with decision-making. Lastly, we will propose how these aspects, which to our knowledge have previously received little attention, may advise research and treatment or help in dealing with the “want but cannot” situation of life-threatening AN.

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