A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

May combine two claims.

The author experienced significant gaps in her treatment with respect to these identity and experiential intersections, and as a consequence, her treatment was often ineffective or harmful.

“I experienced significant gaps in my treatment with respect to these identity and experiential intersections, and as a consequence, my treatment was often ineffective or harmful.”

May combine two claims.

The author was repeatedly told by clinicians that she was 'beyond clinical help', that her AN would be fatal, and that her death was predicted within weeks, months, or a few years.

“Throughout my ED treatment in inpatient and outpatient services, I was repeatedly told by clinicians that I was ‘beyond clinical help’. I was told that my AN would be fatal, and that my death was predicted within weeks, months, or a few years.”

May combine two claims.

The author has lived experience of SE-AN, including inpatient and outpatient treatment and iatrogenic harm that impacted her engagement in treatment and compounded her illness course and suicidality.

“My personal lived experience includes inpatient and outpatient treatment, and iatrogenic harm that impacted my engagement in treatment and compounded my illness course and suicidality.”

May combine two claims.

Immediately after discharge, the author re-attempted suicide, which was thwarted by a stranger.

“Immediately after being discharged from hospital, I re-attempted suicide. This suicide attempt was thwarted by a brave stranger who intervened to save my life.”

May combine two claims.

After the treating team agreed the author was going to die and beyond help, her supervision was reduced from 24/7 to 10-min intervals; she attempted suicide, was revived, and was in a coma for 2 weeks.

“My supervision was reduced from 24/7 supervision to 10-min intervals; I attempted suicide, was found by staff members and revived through resuscitation and defibrillation, and was transported to another hospital where I remained in a coma for 2 weeks.”

May combine two claims.

In an inpatient ED unit, the treating team decided to treat the author's AN only as the 'primary threat to life' and not to treat her co-occurring trauma, psychosis, depression or suicidality.

“The treating team decided I was to be treated for my AN only as the ‘primary threat to life’, and I was not to be treated for my co-occurring trauma, psychosis, depression or suicidality.”

Classified as probably not a substantial claim.

Identity and experiential intersections (neurodivergence, LGBTIQ+ identity, trauma, co-occurring psychosocial/psychiatric disability, chronic medical issues secondary to SE-AN) have been important aspects of the author's illness prognosis and treatment engagement.

“Identity and experiential intersections have also been important aspects of my illness prognosis and treatment engagement (neurodivergence, LGBTIQ+ identity, trauma, co-occurring psychosocial/psychiatric disability, chronic medical issues as secondary to SE-AN).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In some of the author's experiences, suicidal drives or death wishes represented a need for rest and relief and for her sense of danger to end.

“In some of these experiences, suicidal drives or death wishes represented a need for rest and relief, and for my sense of danger to end.”

May combine two claims.

Using a harm-reduction approach, the author has been able to maintain a BMI between 12-14 and maintain some medical stability during the COVID-19 pandemic (2020-2022).

“Using the harm-reduction approach, I have been able to maintain a BMI between 12–14 and maintain some medical stability during the COVID-19 pandemic (2020–2022)”

May combine two claims.

Therapy was approached from a collaborative, trauma-informed, harm-reductive approach that affirmed the author's gender, sexuality and neurotype, and centred her strengths.

“Therapy was approached from a collaborative, trauma-informed, harm-reductive approach that affirmed my gender, sexuality and neurotype, and centred my strengths.”

Probably not a substantial claim: may not pass S3 (load-bearing).

During other experiences, the author felt she was communicating self-beliefs through emaciation, demonstrating she deserved to die.

“During others, I felt I was communicating my self-beliefs through my emaciation; my body was a vessel to demonstrate to others that I knew I was undeserving of breath, food, water, of occupying space in the world, and that I deserved to die.”

May combine two claims.

Through this work, the author regained a sense of self-connection, meaning in life, and was able to continue university study, casual work, and live independently.

“Through this work, I have regained a sense of self-connection, meaning in life, and was able to continue university study, casual work, and to live independently.”

May combine two claims.

The author's schizoaffective diagnosis was diagnosed as 'intractable' and 'incurable' after non-response to 8 anti-psychotic medications including clozapine and olanzapine; these messages of futility increased her sense of hopelessness, suicidality and led to treatment avoidance.

“My schizoaffective diagnosis was similarly diagnosed as ‘intractable’ and ‘incurable’, after non-response to 8 anti-psychotic medications including clozapine and olanzapine; these messages of futility increased my sense of hopelessness, suicidality and led to treatment avoidance.”

May combine two claims.

Inpatient hospitalisations often led to deterioration in the author's mental health and increased her suicidality.

“Inpatient hospitalisations often led to deterioration in my mental health and increased my suicidality.”

May combine two claims.

Traumatic experiences were etiological and maintaining factors in the author's AN development.

“These factors were significant, as traumatic experiences were etiological and maintaining factors in my AN development.”

May combine two claims. The quote only partly states this claim.

The author experienced numerous traumatic experiences in inpatient and outpatient ED care, including physical, mechanical, and chemical restraints and confinement, sexual harassment by professionals during medical procedures, discrimination/harassment/assault while bodily autonomy was compromised, and traumatic administration of medication.

“I experienced numerous traumatic experiences in inpatient and outpatient ED care, including: the use of physical, mechanical, and chemical restraints and confinement. I experienced sexual harassment by professionals during medical procedures such as ECGs, echocardiograms, medical exams.”

Probably not a substantial claim: may not pass S3 (load-bearing).

At other points, the author's death drive was grounded in self-hatred and trauma and a wish for her entire existence to be erased.

“At other points, I wished for my entire existence to be erased, and my death drive was grounded in self-hatred and trauma.”

May combine two claims.

Following work on untreated trauma and underlying beliefs driving psychosis, the author was able to engage with the same psychologist to work on her AN and reach a greater understanding of factors underlying her AN.

“Following work on the untreated trauma and underlying beliefs that were driving my psychosis, I was able to engage with the same psychologist to work on my AN, and was able to reach a greater understanding of factors underlying my AN.”

May combine two claims.

These experiences in inpatient and outpatient care compounded the author's trauma and ultimately maintained her AN.

“These experiences in inpatient and outpatient care compounded my trauma, and ultimately maintained my AN.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In other experiences, the author's death drive was related to retaining autonomy and control over her life and body and choosing the means of her suffering and death.

“In other experiences, my death drive was related to retaining autonomy and control over my life and body and choosing the means of my suffering and death rather than feeling victimised, including trying to put measures in place to control what happened to my body after death.”

May combine two claims.

Having another person truly believe that the author's future includes a fully realised recovered self has been a transformative experience and helped her remain engaged in harm reduction despite iatrogenic trauma and belief that she will die of SE-AN.

“By doing so, my psychologist’s belief has helped me to remain engaged in harm reduction despite my iatrogenic trauma and belief that I will die of my SE-AN.”

May combine two claims.

Despite this prognosis, the author has been in complete remission from psychosis over 5 years, without being on any of the anti-psychotic medications which previously led to severe side effects and loss of quality of life.

“Despite this prognosis, however, I have been in complete remission from psychosis over 5 years, without being on any of the anti-psychotic medications which previously led to severe side effects and loss of quality of life.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Alexithymia often created complexities in how the author expressed changes in her wish to engage/disengage from treatment, suicidality and illness perception.

“Alexithymia often created complexities in how I expressed (or did not express) changes in: my wish to engage/disengage from treatment, suicidality and illness perception.”

May combine two claims.

The author's ED treatment protocols were often dehumanising and degrading, which undermined the effects of nutritional restoration, and her AN was used as her primary coping strategy to increase her sense of safety and survival during and after treatment.

“However, the ED treatment protocols were often so dehumanising and degrading, these effects were undermined, and my AN would be used as my primary coping strategy to increase my sense of safety and survival during and after treatment.”

Classified as probably not a substantial claim. May combine two claims.

The author perceives SE-AN itself as a perpetual state of trauma, and both a suicidal and survival response.

“I perceive SE-AN itself as a perpetual state of trauma, and both a suicidal and survival response.”

Classified as probably not a substantial claim.

When recovery is made more possible, for example through hope, the author experiences a corresponding change in her sense of time, future, and space, which influences her felt connection and sense of agency for her medical reality and her motivation to address it.

“When recovery is made more ‘possible’ (e.g., through hope), as the inevitability of the threat of illness/death changes; I experience a corresponding change in my sense of time, future, and space. This influences my felt connection and sense of agency for my medical reality, and my motivation to address it.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The psychologist's commitment and different prognosis was life-altering for the author's quality of life.

“The psychologist that has committed to working with me has been one among many professionals throughout years of services that gave me a different prognosis, and this was life-altering for my quality of life.”

May combine two claims.

The author is still severely ill with multiple medical complications, still chronically avoids medical services, and may die before reaching functional recovery by clinical definitions.

“I am still severely ill with multiple medical complications, and still chronically avoid medical services. My healing is very gradual, and my medical complications may mean that I die before I reach a level of functional recovery by clinical definitions.”

May combine two claims.

The author's treatment protocols and deliveries were invalidating to her identity and experiences, and she experienced discrimination and trauma.

“It’s important to emphasise why I was refusing treatment and why continuing to live with AN became a ‘safer’ option to me: as previously stated, the treatment protocols and deliveries were invalidating to my identity and experiences and I experienced discrimination and trauma.”

May combine two claims.

In two involuntary admissions where the author received nutritional restoration via nasogastric and nasojejunal feeding, she was retrospectively grateful and recognised that her life had been in grave danger.

“In two involuntary admissions where I had received nutritional restoration via nasogastric and nasojejunal feeding, I was retrospectively grateful and recognised that my life had been in grave danger, aligning with reports in the literature [173].”

• cites [173] Guarda AS, Pinto AM, Coughlin JW, Hussain S, Haug NA, Heinberg LJ. Perceived coercion and change in perceived need for admission in patients hospitalized for eating disorders. Am J Psychiatry. 2007;164(1):108–14. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The author experienced clinicians refusing or ending treatment because they felt she was 'failure personified' or that it was 'ghoulish' to witness her 'living death'; a dietician refused to treat until she 'decided to commit to living'; a multidisciplinary team said her 'refusal to recover' was 'forcing us to participate in your suicide'.

“I have experienced clinicians refusing or ending treatment as they felt that I was: “failure personified in the chair across from me” or that it had become “ghoulish” to witness my “living death”. A dietician refused to treat me until I “decided to commit to living”, and a multidisciplinary team informed me that my “refusal to recover” was “forcing us to participate in your suicide”.”

May combine two claims.

The author found hospital ED protocols and conditions incompatible with her safety, so she avoided further inpatient hospitalisations and eventually stopped trying and accepted her SE-AN would not improve.

“I found the protocols and conditions within hospital ED programs incompatible with my safety. Therefore, I was persisting for improved quality of life whilst avoiding further inpatient hospitalisations. Eventually I stopped trying, and accepted that my SE-AN would not improve.”

May combine two claims.

After receiving 5 potassium IVs, the author felt her brain and muscles had 'come out of a trance, and come back online', felt stronger and more alive, less medically fragile and close to death, and had a spark of hope that her life could be saved.

“For example, after I had received 5 potassium IVs, I remember remarking to a nurse that I felt as though my brain and muscles had “come out of a trance, and come back online”. My mind and body felt stronger and more ‘alive’, and as I felt less medically fragile and close to death, and a spark of hope that my life could be saved.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

The author may not recover by the clinical curative definition and may still die from SE-AN, but she is healing.

“I may not recover by the clinical curative definition, I may still die from my SE-AN, but I am healing.”

May combine two claims.

Being turned away from treatments due to the belief that treatment was futile created harm, hopelessness and avoidance of medical care, resulting in further medical complications and disability.

“However, being turned away from treatments due to the belief that treatment was ‘futile’ also created harm, hopelessness and avoidance of medical care, resulting in further medical complications and disability.”

Classified as probably not a substantial claim.

When a clinician took the approach of valuing my humanity, wishes, quality and meaning of my life above a clinical recovery and further inpatient treatments (taking a harm-reductive approach), it had the effect of increasing my quality and meaning of life.

“My experience has been that when a clinician took the approach of valuing my humanity, wishes, quality and meaning of my life above a clinical recovery and further inpatient treatments (taking a harm-reductive approach), it had the effect of increasing my quality and meaning of life.”

Classified as probably not a substantial claim. May combine two claims.

Within my despair and life weariness, I also experienced ambivalence; within my wish for an end to my suffering was the hope for hope.

“However, within this despair and life weariness; I also experienced ambivalence. Within my wish for an end to my suffering was the hope for hope.”

Probably not a substantial claim: may not pass S2 (checkable).

Having someone holding hope with and for me that my life is worth fighting for and that we can find a way to do so created the possibility for a slow healing that has brought me greater freedom and peace.

“Having someone holding hope with and for me that my life is worth fighting for and that we can find a way to do so created the possibility for a slow healing that has brought me greater freedom and peace.”

Classified as probably not a substantial claim. May combine two claims.

Hearing that nothing could be done to help me eliminated this hope, and heightened the suffering of having those beliefs confirmed.

“Hearing that nothing could be done to help me eliminated this hope, and heightened the suffering of having those beliefs confirmed.”

Classified as probably not a substantial claim. May combine two claims.

I didn't wait to continue to starve to death, and acted immediately to take my life-being given that prognosis in that moment was a catalyst for suicide.

“I didn’t wait to continue to starve to death, and acted immediately to take my life—being given that prognosis in that moment was a catalyst for suicide.”

Classified as probably not a substantial claim.

These feelings change at different points according to how individuals conceptualise themselves and their illness at different times.

“However, these feelings change at different points according to how we may conceptualise ourselves and our illness at different times.”

May combine two claims.

Being told that there is no hope has been identified by individuals with SE-AN as a factor in maintaining the feeling that recovery is impossible, and part of the recovery phase of being unready or unable to change.

“Being told that there is no hope has been identified by individuals with SE-AN as a factor in maintaining the feeling that recovery is impossible, and part of the recovery phase of being unready or unable to change [7].”

• cites [7] Dawson L, Rhodes P, Touyz S. “Doing the impossible” the process of recovery from chronic anorexia nervosa. Qual Health Res. 2014;24(4):494–505. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

AN may be used as a form of embodied communication of unheard and unrecognised suffering, and diagnostic labelling has an important role in this relationship.

“AN may be used as a form of embodied communication of unheard and unrecognised suffering, and diagnostic labelling has an important role in this relationship.”

May combine two claims.

A 'terminal' diagnosis may trigger maladaptive schemas related to abandonment/rejection, dependence/incompetence, and self-sacrifice/burdensomeness, and influence engagement with future treatment if feelings change.

“We may be highly sensitive to social experiences that relate to perceived abandonment/rejection, dependence/incompetence, and self-sacrifice/burdensomeness, and a 'terminal' diagnosis may trigger these maladaptive schemas and influence the way we engage with others regarding re-engaging with future treatment if our feelings change (i.e., threat-related responses such as surrender) [20, 21].”

• cites [20] Damiano SR, Reece J, Reid S, Atkins L, Patton G. Maladaptive schemas in adolescent females with anorexia nervosa and implications for treatment. Eat Behav. 2015;16:64–71. sourceNot checked yet

  Not checked in the free run.

• cites [21] Meneguzzo P, Collantoni E, Bonello E, Busetto P, Tenconi E, Favaro A. The predictive value of the early maladaptive schemas in social situations in anorexia nervosa. Eur Eat Disord Rev. 2020;28(3):318–31. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Individuals with SE-AN may repeatedly experience severe medical crises and come close to death, and within these crises may experience world weariness and desire for death.

“Those of us with SE-AN may repeatedly experience severe medical crises and come close to death, and within these crises, we may experience world weariness, and desire for death.”

Classified as probably not a substantial claim. May combine two claims.

Gaudiani et al. recently proposed preliminary criteria for 'terminal' anorexia nervosa, with three cases used to illustrate the defining criteria.

“Preliminary criteria for ‘terminal’ anorexia nervosa (AN) was recently proposed by Gaudiani et al. [1], with three cases used to illustrate the defining criteria.”

• cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):1–14. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Hierarchies and stigma exist among ED diagnoses and diagnostic subtypes, which may lead to shame, distress, and treatment avoidance.

“Hierarchies and stigma are known to exist among ED diagnoses and diagnostic subtypes, which may lead to shame, distress, and treatment avoidance [8–11]”

• cites [8] Mortimer R. Pride before a fall: Shame, diagnostic crossover, and eating disorders. J Bioeth Inq. 2019;16(3):365–74. sourceNot checked yet

  Not checked in the free run.

• cites [9] Frey I. Anorexia’s failed little sisters: reflections on researching bulimia as a former bulimic. Soc Theory Health. 2020;18(2):138–51. sourceNot checked yet

  Not checked in the free run.

• cites [10] Eli K. Distinct and untamed: articulating bulimic identities. Cult Med Psychiatry. 2018;42(1):159–79. sourceNot checked yet

  Not checked in the free run.

• cites [11] Thomas JJ, Schaefer J. Almost anorexic: is my (or My Loved One’s) relationship with food a problem? Center City: Hazelden Publishing; 2013.Not checked yet

  Not checked in the free run.

May combine two claims.

Individuals with EDs face numerous barriers to accessing ED care and early intervention, and multiple issues influence treatment dropout.

“However, individuals with EDs face numerous barriers to accessing ED care and early intervention [29–32], and multiple issues influence treatment dropout.”

• cites [29] Harrop EN. 3201 Patient perceptions of healthcare provider interactions among higher-weight women with eating disorders: opportunities for earlier screening, improved referral, and increased clinician rapport. J Clin Transl Sci. 2019;3:151. sourceNot checked yet

  Not checked in the free run.

• cites [30] Cachelin FM, Striegel-Moore RH, Regan PC. Factors associated with treatment seeking in a community sample of European American and Mexican American women with eating disorders. Eur Eat Disord Rev. 2006;14(6):422–9. sourceNot checked yet

  Not checked in the free run.

• cites [31] Grammer AC, Shah J, Laboe AA, McGinnis CG, Balantekin KN, Graham AK, et al. Predictors of treatment seeking and uptake among respondents to a widely disseminated online eating disorders screen in the United States. Int J Eat Disord. 2022;55:1252–8. sourceNot checked yet

  Not checked in the free run.

• cites [32] Harrop E. “Maybe I Really Am Too Fat to Have an Eating Disorder”: A mixed methods study of weight stigma and healthcare experiences in a diverse sample of patients with atypical anorexia. [Doctoral dissertation]. 2020.Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

The proposed characteristics for 'terminal' AN include AN diagnosis, age over 30, prior persistent engagement in high-quality multidisciplinary eating disorders care, and decision-making capacity to understand further treatment is futile, the wish not to prolong life, and acceptance of death.

“The proposed characteristics for ‘terminal’ AN included: (1) AN diagnosis (2) Age over 30, (3) Prior persistent engagement in high-quality, multidisciplinary eating disorders care, and (4) decision-making capacity to understand further treatment is futile, the wish not to prolong life and acceptance of death [1].”

• cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):1–14. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Receiving a terminal diagnosis would have emotional and psychological impact on a person and their loved ones, and create a new experience in shaping how an individual thinks and relates to their experience, the feelings and responses of others, choices and outcomes.

“Receiving a terminal diagnosis would have emotional and psychological impact on a person and their loved ones, and create a new experience in shaping how an individual thinks and relates to their experience, the feelings and responses of others, choices and outcomes.”

May combine two claims.

Socio-cultural-political factors (e.g., gendered expectations, gender discrimination, sexual objectification, ableism) and traumatic experiences increase risk for ED development and influence treatment dropout.

“This gender and diagnostic skew is important as socio-cultural-political factors (i.e., gendered expectations, gender discrimination, sexual objectification, abelism) and traumatic experiences increase risk for ED development (e.g., [74–77]), and influence treatment dropout [78].”

• cites [74] Beccia AL, Austin SB, Baek J, Agénor M, Forrester S, Ding EY, et al. Cumulative exposure to state-level structural sexism and risk of disordered eating: results from a 20-year prospective cohort study. Soc Sci Med. 2022;301:114956. sourceNot checked yet

  Not checked in the free run.

• cites [75] Cheng H-L, Youngju KH. Racial and sexual objectification of Asian American Women: associations with trauma symptomatology, body image concerns, and disordered eating. Women Ther. 2018;41(3–4):237–60. sourceNot checked yet

  Not checked in the free run.

• cites [76] Mensinger JL, Granche JL, Cox SA, Henretty JR. Sexual and gender minority individuals report higher rates of abuse and more severe eating disorder symptoms than cisgender heterosexual individuals at admission to eating disorder treatment. Int J Eat Disord. 2020;53(4):541–54. sourceNot checked yet

  Not checked in the free run.

• cites [77] Beccia AL, Baek J, Austin SB, Jesdale WM, Lapane KL. Eating-related pathology at the intersection of gender identity and expression, sexual orientation, and weight status: an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) of the Growing Up Today Study cohorts. Soc Sci Med. 2021;281:114092. sourceNot checked yet

  Not checked in the free run.

• cites [78] Rodríguez M, Pérez V, García Y. Impact of traumatic experiences and violent acts upon response to treatment of a sample of colombian women with eating disorders. Int J Eat Disord. 2005;37(4):299–306. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Current evidence-based treatments for SE-AN are insufficient, and greater equity is needed for access to ED treatment.

“on the one hand, it may be recognised that current evidence-based treatments for SE-AN are insufficient, and greater equity is needed for access to ED treatment.”

May combine two claims.

In facilitating access to EAS for individuals with SE-AN, there is a significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism).

“we must also consider the significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism) [71–73].”

• cites [71] Dom G, Stoop H, Haekens A, Sterckx S. Euthanasia and assisted suicide in the context of psychiatric disorders: Sharing experiences from the Low Countries. Psychiatr Polska. 2020;54:661–72. sourceNot checked yet

  Not checked in the free run.

• cites [72] van Veen SM, Weerheim F, Mostert M, van Delden J. Euthanasia of Dutch patients with psychiatric disorders between 2015 and 2017. J Ethics Ment Health. 2018;10:1–15.Not checked yet

  Not checked in the free run.

• cites [73] Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiat. 2016;73(4):362–8. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

These factors influence whose lives may be associated with better prognosis and who may be considered beyond help.

“Ultimately, these factors influence whose lives may be associated with better prognosis and who may be considered beyond help.”

May combine two claims.

Problems with efficacy, quality, and access to existing treatments in AN highlight issues in defining what constitutes 'good quality' treatment, and therefore undermine any determination whether further treatment is 'futile'.

“Problems with efficacy, quality, and access to existing treatments in AN highlight issues in defining what constitutes ‘good quality’ treatment, and therefore undermines any determination whether further treatment is ‘futile’.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

When emotions are overwhelmingly painful, AN offers a way to anaesthetise pain and creates an illusion of a safe world to retreat into, which may include the pain and grief of being told one is beyond help.

“When our emotions are overwhelmingly painful, AN offers a way to anaesthetise our pain and creates the illusion of a safe world to retreat into—this may include the pain and grief of being told we are beyond help.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

When a small population of individuals with SE-AN become severely ill to a life-threatening degree, access to end-of-life care may alleviate profound suffering.

“When a small population of individuals with SE-AN become severely ill to a life-threatening degree, access to end-of-life care may alleviate profound suffering.”

Probably not a substantial claim: may not pass S3 (load-bearing).

People with SE-AN may experience internalised shame, blame and self-stigma in association with perpetual medical crises, which compounds difficulty expressing pain and fear of not being met with compassion.

“By living through SE-AN and its consequences, we may experience internalised shame, blame and self-stigma in association with our perpetual medical crises—which compounds the difficulty of expressing our pain and fear that we will not be met with compassion.”

Classified as probably not a substantial claim. May combine two claims.

As existing treatments for SE-AN are poor and many people lack equitable access, Yager et al. suggest this should not preclude individuals with severe illness from access to end-of-life care and a compassionate, dignified death if so wished.

“As existing treatments for SE-AN are poor and many people lack equitable access, Yager et al. [2] suggest that this should not preclude individuals with severe illness from access to end-of-life care and a compassionate, dignified death if so wished.”

• cites [2] Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord. 2022;10(1):1–11. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Alexithymia is correlated with greater severity of disordered eating and suicidality in individuals with EDs.

“Alexithymia is correlated with greater severity of disordered eating and suicidality in individuals with EDs [108, 109].”

• cites [108] Carano A, DeBerardis D, Campanella D, Serroni N, Ferri F, DiIorio G, et al. Alexithymia and suicide ideation in a sample of patients with binge eating disorder. J Psychiatr Pract®. 2012;18(1):5–11. sourceNot checked yet

  Not checked in the free run.

• cites [109] Alpaslan AH, Soylu N, Avci K, Coşkun KŞ, Kocak U, Taş HU. Disordered eating attitudes, alexithymia and suicide probability among Turkish high school girls. Psychiatry Res. 2015;226(1):224–9. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

There is a medical reality that a small population of individuals with severe SE-AN do not recover from their illness and die of medical complications.

“As argued by Yager et al. [2] of the proposed terminal AN diagnosis, there is a medical reality that a small population of individuals with severe SE-AN do not recover from their illness and die of medical complications.”

• cites [2] Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord. 2022;10(1):1–11. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Alexithymia and differences in conveying emotion in AN may be interlaced with atypical interoception and trauma survival, as well as autism-trauma intersections.

“Alexithymia and differences in conveying emotion in AN may also be interlaced with atypical interoception [96–99] and trauma survival, as well as autism-trauma intersections [100–104].”

• cites [96] Malecki J, Rhodes P, Ussher J. Childhood trauma and anorexia nervosa: from body image to embodiment. Health Care Women Int. 2018;39(8):936–51. sourceNot checked yet

  Not checked in the free run.

• cites [97] Kerr KL, Moseman SE, Avery JA, Bodurka J, Zucker NL, Simmons WK. Altered insula activity during visceral interoception in weight restored patients with anorexia nervosa. Neuropsychopharmacology. 2016;41(2):521–8. sourceNot checked yet

  Not checked in the free run.

• cites [98] Shah P, Hall R, Catmur C, Bird G. Alexithymia, not autism, is associated with impaired interoception. Cortex. 2016;81:215–20. sourceNot checked yet

  Not checked in the free run.

• cites [99] Datta N, Bidopia T, Datta S, Mittal G, Alphin F, Herbert BM, et al. Internal states and interoception along a spectrum of eating disorder symptomology. Physiol Behav. 2021;230:113307. sourceNot checked yet

  Not checked in the free run.

• cites [100] Hume R, Burgess H. “I’m Human After All”: autism, trauma, and affective empathy. Autism Adulthood. 2021;3(3):221–9. sourceNot checked yet

  Not checked in the free run.

• cites [101] Khan AN, Jaffee SR. Alexithymia in individuals maltreated as children and adolescents: a meta‐analysis. J Child Psychol Psychiatry. 2022. sourceNot checked yet

  Not checked in the free run.

• cites [102] Strodl E, Wylie L. Childhood trauma and disordered eating: exploring the role of alexithymia and beliefs about emotions. Appetite. 2020;154:104802. sourceNot checked yet

  Not checked in the free run.

• cites [103] Wooldridge T. Abjection, traumatic themes, and alexithymia in anorexia nervosa. Contemp Psychoanal. 2021;57(2):327–53. sourceNot checked yet

  Not checked in the free run.

• cites [104] Morgado Ramirez DZ. My autistic childhood and adult life: four stories of abuse and survival. Ought J Autistic Cult. 2022;3(2):14. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

People with AN may have difficulties identifying and expressing complex emotions, particularly when overwhelmed, and this may be intensified by starvation effects and relational dynamics including clinician-patient dynamics.

“We may have difficulties identifying and expressing complex emotions to others particularly when overwhelmed by them, a difficulty that may be intensified by starvation effects and relational dynamics, including those of clinician-patient.”

Classified as probably not a substantial claim. May combine two claims.

Mack and Stanton pointed out that in Gaudiani et al.'s case examples, patients' co-occurring conditions (depression, suicidality, OCD, anxiety) were not indicated as being appropriately treated, which may have profoundly impacted motivation, hope for recovery, and engagement in treatment.

“In response to Gaudiani et al.’s [1] case examples suggested to illustrate ‘terminal’ AN, Mack and Stanton [81] pointed out that the patients’ co-occurring conditions (i.e., depression, suicidality, obsessive compulsive disorder [OCD], anxiety) were not indicated as being appropriately treated, which may have profoundly impacted motivation, hope for recovery, and engagement in treatment.”

• cites [81] Mack RA, Stanton CE. Responding to “Terminal anorexia nervosa: three cases and proposed clinical characteristics.” J Eat Disord. 2022;10(1):1–4. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Self-stigma is associated with increased ED severity, decreased treatment-seeking behaviour, decreased psychological wellbeing, low self-esteem, shame, and delayed recovery.

“Self-stigma is associated with increased ED severity, decreased treatment-seeking behaviour, decreased psychological wellbeing, low self-esteem, shame, and delayed recovery [82–85].”

• cites [82] Brelet L, Flaudias V, Désert M, Guillaume S, Llorca P-M, Boirie Y. Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and binge eating disorder: a scoping review. Nutrients. 2021;13(8):2834. sourceNot checked yet

  Not checked in the free run.

• cites [83] Griffiths S, Mitchison D, Murray SB, Mond JM, Bastian BB. How might eating disorders stigmatization worsen eating disorders symptom severity? Evaluation of a stigma internalization model. Int J Eat Disord. 2018;51(8):1010–4. sourceNot checked yet

  Not checked in the free run.

• cites [84] Foran AM, O’Donnell AT, Muldoon OT. Stigma of eating disorders and recovery-related outcomes: a systematic review. Eur Eat Disord Rev. 2020;28(4):385–97. sourceNot checked yet

  Not checked in the free run.

• cites [85] Griffiths S, Mond JM, Li Z, Gunatilake S, Murray SB, Sheffield J, et al. Self-stigma of seeking treatment and being male predict an increased likelihood of having an undiagnosed eating disorder. Int J Eat Disord. 2015;48(6):775–8. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Many people with AN experience alexithymia and suppress emotions as an emotional coping strategy.

“Many of us with AN experience alexithymia [93, 94] and suppress our emotions as an emotional coping strategy [22, 95].”

• cites [93] Westwood H, Kerr-Gaffney J, Stahl D, Tchanturia K. Alexithymia in eating disorders: systematic review and meta-analyses of studies using the Toronto Alexithymia Scale. J Psychosom Res. 2017;99:66–81. sourceNot checked yet

  Not checked in the free run.

• cites [94] Gramaglia C, Gambaro E, Zeppegno P. Alexithymia and treatment outcome in anorexia nervosa: a scoping review of the literature. Front Psychiatry. 2020;10:991. sourceNot checked yet

  Not checked in the free run.

• cites [22] Bryant E, Aouad P, Hambleton A, Touyz S, Maguire S. ‘In an otherwise limitless world, I was sure of my limit’†. Experiencing Anorexia Nervosa: a phenomenological metasynthesis. Front Psychiatry. 2022;13:894178. sourceNot checked yet

  Not checked in the free run.

• cites [95] Ortiz S, Knauft K, Smith A, Kalia V. Expressive suppression mediates the relation between disordered eating and suicidal ideation. J Clin Psychol. 2019;75(10):1943–58. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

People with SE-AN may experience the receipt of compassion as painful, frightening, and untrustworthy, which may be related to histories of trauma and ruptured attachment.

“We may experience the receipt of compassion as painful, frightening, and untrustworthy [176, 177] which may be related to histories of trauma and ruptured attachment [178–180].”

• cites [176] Dias BS, Ferreira C, Trindade IA. Influence of fears of compassion on body image shame and disordered eating. Eat Weight Disord Stud Anorex Bulim Obes. 2020;25(1):99–106. sourceNot checked yet

  Not checked in the free run.

• cites [177] Mendes AL, Canavarro MC, Ferreira C. Affiliative interactions and body and eating-related difficulties in adolescent girls: the effects of fears of compassion and feelings of social safeness. Appetite. 2022;168:105715. sourceNot checked yet

  Not checked in the free run.

• cites [178] Silva C, Ferreira C, Mendes AL, Marta-Simões J. The relation of early positive emotional memories to women’s social safeness: the role of shame and fear of receiving compassion. Women Health. 2019;59(4):420–32. sourceNot checked yet

  Not checked in the free run.

• cites [179] Çevik Ö, Tanhan F. Fear of compassion: description, causes and prevention. Psikiyatr Guncel Yaklasimlar. 2020;12(3):342–51. sourceNot checked yet

  Not checked in the free run.

• cites [180] Matos M, Duarte J, Pinto-Gouveia J. The origins of fears of compassion: shame and lack of safeness memories, fears of compassion and psychopathology. J Psychol. 2017;151(8):804–19. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Within surviving chronic AN, people may be profoundly disconnected or desensitised to their ability to continue walking on a knife's edge, and may feel their suffering and perceived unrecoverable severity is deserved (self-stigma), and therefore believe they must accept their circumstances.

“Within the state of surviving chronic AN, we may be profoundly disconnected or desensitised to our ability to continue walking on a knife’s edge, and may feel that our suffering and the perceived unrecoverable severity of our condition is deserved (self-stigma), and therefore believe we must accept our circumstances.”

Classified as probably not a substantial claim.

People with SE-AN may at many points face imminent death or severe medical complications that result in seeking hospice or palliative care.

“However accessible recovery and healing is made and experienced, those of us with SE-AN may at many points be facing imminent death or severe medical complications that result in seeking out hospice or palliative care.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These feelings may be intensely felt when patients struggle to receive compassion and help, do not respond to treatment, and their suffering becomes chronic.

“These feelings may be intensely felt when we struggle to receive their compassion and help, do not respond to treatment, and our suffering becomes chronic [186].”

• cites [186] Thompson-Brenner H, Satir DA, Franko DL, Herzog DB. Clinician reactions to patients with eating disorders: a review of the literature. Psychiatr Serv. 2012;63(1):73–8. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Management of transference and countertransference are important features of how patients experience ED care and how clinicians respond, particularly in enduring EDs, and must be effectively managed to reduce iatrogenic harms in SE-AN treatment.

“Management of transference and countertransference are important features of how we experience ED care and how clinicians respond to us, particularly in enduring EDs, and must be effectively managed to reduce iatrogenic harms in treatment of SE-AN [175].”

• cites [175] Strober M. Managing the chronic, treatment-resistant patient with anorexia nervosa. Int J Eat Disord. 2004;36(3):245–55. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Lived experience recovery definitions centre a continuing process of personal transformation, reclamation of power, reconnection with the self and changing navigation of socio-cultural-political domains, in contrast to the medical definition of recovery as an endpoint.

“In contrast to the medical definition of recovery as an endpoint, lived experience recovery definitions centre a continuing process of personal transformation, reclamation of power, reconnection with the self and changing navigation of socio-cultural-political domains [124–128].”

• cites [124] Conti JE. Recovering identity from anorexia nervosa: Women’s constructions of their experiences of recovery from anorexia nervosa over 10 years. J Constr Psychol. 2018;31(1):72–94.Not checked yet

  Not checked in the free run.

• cites [125] Duncan TK, Sebar B, Lee J. Reclamation of power and self: a meta-synthesis exploring the process of recovery from anorexia nervosa. Adv Eat Disord. 2015;3(2):177–90. sourceNot checked yet

  Not checked in the free run.

• cites [126] Williams K, King J, Fox JR. Sense of self and anorexia nervosa: a grounded theory. Psychol Psychother Theory Res Pract. 2016;89(2):211–28. sourceNot checked yet

  Not checked in the free run.

• cites [127] Matusek JA, Knudson RM. Rethinking recovery from eating disorders: spiritual and political dimensions. Qual Health Res. 2009;19(5):697–707. sourceNot checked yet

  Not checked in the free run.

• cites [128] Venturo-Conerly K, Wasil A, Shingleton R, Weisz J. Recovery as an “Act of rebellion”: a qualitative study examining feminism as a motivating factor in eating disorder recovery. Eat Disord. 2020;28(3):265–71. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The perception of futility within the author's treatment may have shaped and created a clinical prognosis and reality, and interacted with schemas built on her trauma and maintaining her AN.

“The perception of futility within my treatment may have shaped and created a clinical prognosis and reality, and they also interacted with the schemas built on my trauma and maintaining my AN.”

May combine two claims.

People with SE-AN may find it difficult to develop trust in clinicians, reject and defend against receiving compassion, and reaffirm their belief and investment in AN as a safe harbour.

“We may therefore find it difficult to develop trust in clinicians [181], reject and defend against receiving compassion [182–184], and reaffirm our belief and investment in AN as a safe harbour.”

• cites [181] Kaplan AS, Garfinkel PE. Difficulties in treating patients with eating disorders: a review of patient and clinician variables. Can J Psychiatry. 1999;44(7):665–70. sourceNot checked yet

  Not checked in the free run.

• cites [182] Gilbert P, McEwan K, Gibbons L, Chotai S, Duarte J, Matos M. Fears of compassion and happiness in relation to alexithymia, mindfulness, and self-criticism. Psychol Psychother Theory Res Pract. 2012;85(4):374–90. sourceNot checked yet

  Not checked in the free run.

• cites [183] Duarte JA, Mendes AL, Marta-Simões J, Ferreira C. Striving as a paradoxical strategy to deal with fears of compassion: impact on disordered eating. Eat Weight Disord Stud Anorex Bulim Obes. 2020;25(4):983–90. sourceNot checked yet

  Not checked in the free run.

• cites [184] Oliveira VR, Ferreira C, Mendes AL, Marta-Simões J. Shame and eating psychopathology in Portuguese women: exploring the roles of self-judgment and fears of receiving compassion. Appetite. 2017;110:80–5. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

Wanting to survive and using AN to navigate the pain of existence, even when aware of risk to life, is different from being suicidal and using AN as a method of suicidal self-destruction.

“When I am experiencing my SE-AN as a survival response, it may appear to others as a suicidal, however wanting to survive and using AN to navigate the pain of my existence (even when aware of my risk to life) is different to being suicidal and using AN as a method of suicidal self-destruction.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Treatment approaches that centre recovery as an endpoint rather than an ongoing or lifelong process may lead to feelings of failure and hopelessness, and the perception of individuals with EDs and clinicians that treatment is futile.

“Treatment approaches that centre recovery as an endpoint (rather than an ongoing or lifelong process) may lead to feelings of failure and hopelessness, and the perception of individuals with EDs and clinicians that treatment is futile.”

Classified as probably not a substantial claim.

Clinicians treating SE-AN may be confronted with their own complex feelings regarding mortality and a wish to resolve patients' ambivalence and cognitive dissonance by prematurely ending treatment.

“In treating those of us with SE-AN, clinicians may be confronted with their own complex feelings regarding mortality, and a wish to ‘resolve’ our feelings of ambivalence and cognitive dissonance by prematurely ending treatment.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Person-centred recovery and harm-reduction approaches may be particularly beneficial for individuals with SE-AN, and recovery-model approaches for SE-AN may benefit both patients and clinicians.

“Person-centred recovery and harm-reduction approaches may be particularly beneficial, especially for individuals with SE-AN [140–142], and recovery-model approaches for SE-AN may benefit both patients and clinicians [143].”

• cites [140] Bianchi A, Stanley K, Sutandar K. The ethical defensibility of harm reduction and eating disorders. Am J Bioeth. 2021;21(7):46–56. sourceNot checked yet

  Not checked in the free run.

• cites [141] Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychol Med. 2013;43(12):2501–11. sourceNot checked yet

  Not checked in the free run.

• cites [142] Rempala K, Hornewer M, Roytman M, Samoska S, Meda R, Vukov J. Harm reduction models: roadmaps for transformative experiences. Am J Bioeth. 2021;21(7):63–5. sourceNot checked yet

  Not checked in the free run.

• cites [143] Webb H, Dalton B, Irish M, Mercado D, McCombie C, Peachey G, et al. Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings. J Eat Disord. 2022;10(1):1–13. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Some people with SE-AN may not find the right set of circumstances to heal, or if they do, they may find them late.

“Some of us may not find the right set of circumstances to heal, or if we do so, we may find them late.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

In the judgement of requests for EAS, a 'terminal' AN diagnosis is not needed to facilitate the process of EAS in countries where it is currently possible.

“In the judgement of requests for EAS, a ‘terminal’ AN diagnosis is not needed to facilitate the process of EAS in countries where it is currently possible.”

Classified as probably not a substantial claim. May combine two claims.

Moving from 'living to die' to 'dying to live' is fraught with challenges of developing a new skill set and a different understanding of what living entails, representing a first step in believing things could be different.

“if one has spent a good part of life ‘living to die’, moving towards ‘dying to live’ is fraught with challenges of developing a new skill set and a different understanding of what living entails. This represents a first step in believing that things could be different”

• cites [192, p. 139]Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Ambivalence is the dialectic holding of possibilities of living and dying at the same time, and within it is a kernel of hope that the person may not see or understand at the time.

“ambivalence is “the dialectic holding of possibilities of living and dying at the same time… within the sphere of ambivalence is a kernel of hope that the person may not see or understand at the time”.”

• cites [192, p. 139]Not checked yet

  Not checked in the free run.

May combine two claims.

In contrast, the option of EAS could lead to feelings of reassurance and encourage patients to refocus on treatment goals and to find relief from their suffering.

“In contrast, the option of EAS could lead to feelings of reassurance and encourage patients to refocus on treatment goals and to find relief from their suffering”

• cites [201] Verhofstadt M, Audenaert K, Mortier F, Deliens L, Liégeois A, Pardon K, et al. Concrete experiences and support needs regarding the euthanasia practice in adults with psychiatric conditions: a qualitative interview study among healthcare professionals and volunteers in Belgium. Front Psychiatry. 2022;13:859745. sourceNot checked yet

  Not checked in the free run.

• cites [202] Verhofstadt M, Chambaere K, Pardon K, Mortier F, Liégeois A, Deliens L, et al. The impact of the euthanasia assessment procedure: a qualitative interview study among adults with psychiatric conditions. BMC Psychiatry. 2022;22(1):1–15. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

A 'terminal AN' diagnosis may facilitate freedom of autonomy, liberation from suffering and a 'good death'.

“the alternative exists that a ‘terminal AN’ diagnosis may facilitate the freedom of autonomy, liberation from suffering and a ‘good death’”

May combine two claims.

Some individuals experience AN as a voice, person or alternate self, and externalisation may be an important step in dialogical connection with the 'healing/recovered' self.

“Some individuals experience AN as a voice, person or alternate self [196–198], and externalisation may be an important step in dialogical connection with the ‘healing/recovered’ self”

• cites [196] Pugh M. Understanding ‘Ed’: a theoretical and empirical review of the internal eating disorder ‘voice.’ BPS Psychother Sect Rev. 2020;65:12–23. sourceNot checked yet

  Not checked in the free run.

• cites [197] Mullins A. The experience of living with an anorexic voice: an interpretative phenomenological analysis. London: Metropolitan University; 2020.Not checked yet

  Not checked in the free run.

• cites [198] Ling NCY, Serpell L, Burnett-Stuart S, Pugh M. Interviewing anorexia: how do individuals given a diagnosis of anorexia nervosa experience Voice Dialogue with their eating disorder voice? A qualitative analysis. Clin Psychol Psychother. 2022;29(2):600–10. sourceNot checked yet

  Not checked in the free run.

• cites [7] Dawson L, Rhodes P, Touyz S. “Doing the impossible” the process of recovery from chronic anorexia nervosa. Qual Health Res. 2014;24(4):494–505. sourceNot checked yet

  Not checked in the free run.

• cites [199] Tokarska U, Ryżanowska D. Letters to anorexia. Narrative tools for working with anorectic patients in a Dialogical Self context. Psychiatr Pol. 2018;52(4):673–83. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Feelings of frustration, anger and helplessness toward AN patients may be mediated by clinicians' years of experience working with ED patients and caseload, indicating possible effects of stress and burnout.

“Feelings of frustration, anger and helplessness toward AN patients may be mediated by clinicians’ years of experience working with ED patients and caseload, indicating possible effects of stress and burnout [185, 186].”

• cites [185] Franko DL, Rolfe S. Countertransference in the treatment of patients with eating disorders. Psychiatry. 1996;59(1):108–16. sourceNot checked yet

  Not checked in the free run.

• cites [186] Thompson-Brenner H, Satir DA, Franko DL, Herzog DB. Clinician reactions to patients with eating disorders: a review of the literature. Psychiatr Serv. 2012;63(1):73–8. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Individuals with mental health concerns have experienced the option of EAS legislation as increasing their motivation for recovery and decreased suicidality.

“Individuals with mental health concerns have experienced the option of EAS legislation as increasing their motivation for recovery and decreased suicidality.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Ambivalence is inherent to the experience of AN, world-weariness and suicidality itself.

“I would argue that ambivalence is inherent to the experience of AN, world-weariness and suicidality itself”

May combine two claims.

The option of EAS could have the effect of closing windows of opportunity for recovery and tipping their most vulnerable patients into experiencing a tunnel vision toward death, feeling discouraged and demoralised toward the likelihood of treatment success, applying for EAS, and being swept into a 'death track'.

“The option of EAS could have the effect of closing windows of opportunity for recovery and tipping their most vulnerable patients into experiencing a tunnel vision toward death, feeling discouraged and demoralised toward the likelihood of treatment success, applying for EAS, and being swept into a ‘death track’”

• cites [201] Verhofstadt M, Audenaert K, Mortier F, Deliens L, Liégeois A, Pardon K, et al. Concrete experiences and support needs regarding the euthanasia practice in adults with psychiatric conditions: a qualitative interview study among healthcare professionals and volunteers in Belgium. Front Psychiatry. 2022;13:859745. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

EAS processes may also lead to experiences of ambivalence about death and a reduction in suffering through a sense of recognition and validation.

“EAS processes may also lead to experiences of ambivalence about death and a reduction in suffering through a sense of recognition and validation.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

A 'terminal AN' diagnosis may extinguish hope and the conceptualisation of the identity of a healing self.

“A ‘terminal AN’ diagnosis may extinguish hope and the conceptualisation of the identity of a healing self.”

• AssumptionRests on an assumption: Hope and belief in recovery are beneficial and should be preserved.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

For some, the 'terminal AN' diagnosis may erase these relational meanings of this narrative, and may construct the 'healthy' self that longs for survival as an 'unrecovered identity' that was unable to wrest power, identity, and meaning from AN as an external entity.

“For some, the ‘terminal AN’ diagnosis may erase these relational meanings of this narrative, and may construct the ‘healthy’ self that longs for survival as an ‘unrecovered identity’ that was unable to wrest power, identity, and meaning from AN as an external entity”

• cites [124] Conti JE. Recovering identity from anorexia nervosa: Women’s constructions of their experiences of recovery from anorexia nervosa over 10 years. J Constr Psychol. 2018;31(1):72–94.Not checked yet

  Not checked in the free run.

• cites [193] Neuman N. On anorexia nervosa and the embodied being-toward-death. Death matters. Berlin: Springer; 2019. p. 107–27.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

For others, the 'terminal AN' diagnosis may provide validation and freedoms; the diagnosis and reality of this encapsulates the ambivalences, contradictions and dualism within AN itself.

“For others, the ‘terminal AN’ diagnosis may provide validation and freedoms; the diagnosis and reality of this encapsulates the ambivalences, contradictions and dualism within AN itself.”

Probably not a substantial claim: may not pass S1 (asserted).

The proposed 'terminal' diagnosis has been suggested to amount to a facilitation of the capability to complete suicide when an individual with SE-AN is experiencing ambivalence toward death.

“The proposed ‘terminal’ diagnosis has been suggested to amount to a facilitation of the capability to complete suicide when an individual with SE-AN is experiencing ambivalence toward death”

• cites [81] Mack RA, Stanton CE. Responding to “Terminal anorexia nervosa: three cases and proposed clinical characteristics.” J Eat Disord. 2022;10(1):1–4. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Patients with SE-AN may have been repeatedly turned away from services and told further treatment will be futile while still uncertain whether further treatments may help or harm; these experiences can be harmful and shape a belief in futility of treatment.

“Those of us with SE-AN may have been repeatedly turned away from services and been told that further treatment for us will be futile while we are still uncertain about whether or not further treatments may help or harm us; these experiences can be harmful and can shape a belief in the futility of treatment.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

In ED treatment, it is rare for experiences of ambivalence to be understood as a self-protective and survival process, particularly for those with trauma histories, nor as representing an opportunity for reparation, restorative justice, healing and post-traumatic growth.

“In ED treatment, it is rare for experiences of ambivalence to be understood as a self-protective and survival process, particularly for those of us with trauma histories, nor as representing an opportunity for reparation and restorative justice, healing and post-traumatic growth, to create deeper relational bonds and re-connection to life.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

In clinical and research contexts, ambivalence is overwhelmingly framed in a negative light, and may contribute to feelings of shame, guilt and self-stigma.

“In clinical and research contexts, ambivalence is overwhelmingly framed in a negative light, and may contribute to our feelings of shame, guilt and self-stigma.”

May combine two claims.

Those with SE-AN may lose and regain hope for recovery, and experience suicidality, world-weariness and wish for reprieve through death at different points, and ambivalence within these states.

“Those of us with SE-AN may lose and regain hope for recovery, and experience suicidality, world-weariness and wish for reprieve from our suffering through death at different points throughout the course of our illness, and ambivalence within these states of being.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Diagnoses and prognoses have important impacts on our feelings about our illness, futures, engagement with treatment, and the reactions and responses of others to us.

“I argue that diagnoses and prognoses have important impacts on our feelings about our illness, futures, engagement with treatment, and the reactions and responses of others to us.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

AN may be experienced as the desire to exist without needs and without a body, to contain the self while simultaneously self-annihilating and existing in a state between 'being-and-not-being'.

“AN may be experienced as a the desire to exist without needs and without a body, to contain the self while simultaneously self-annihilating and existing in a state between ‘being-and-not-being’”

• cites [194] Dehler LC. Starvation as self-preservation: the paradoxical nature of anorexia nervosa through the lens of schizoid phenomena. New Brunswick: Rutgers The State University of New Jersey; 2012.Not checked yet

  Not checked in the free run.

May combine two claims.

Euthanasia and physician-assisted suicide is currently accessible for individuals with EDs in different countries, and in judgement of requests for EAS, an AN diagnosis has been sufficient to facilitate this process.

“Euthanasia and physician-assisted suicide (EAS) is currently accessible for individuals with EDs in different countries [72, 191], however in the judgement of requests for EAS, an AN diagnosis has been sufficient to facilitate this process [72, 191].”

• cites [72] van Veen SM, Weerheim F, Mostert M, van Delden J. Euthanasia of Dutch patients with psychiatric disorders between 2015 and 2017. J Ethics Ment Health. 2018;10:1–15.Not checked yet

  Not checked in the free run.

• cites [191] Dierickx S, Deliens L, Cohen J, Chambaere K. Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry. 2017;17(1):203. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

If the fourth criterion is applied appropriately and carefully, it should preclude individuals with SE-AN who experience ambivalence from accessing EAS.

“if the fourth criterion is applied appropriately and carefully, it should preclude individuals with SE-AN who experience ambivalence from accessing EAS.”

Classified as probably not a substantial claim. May combine two claims.

If my psychologist had oriented themselves toward a diagnosis of terminal AN, my death could have occurred through starvation, suicide, and were I residing in a country with greater access to psychiatric EAS, perhaps through physician-assisted means.

“If my psychologist had oriented themselves toward a diagnosis of terminal AN, my death could have occurred through starvation, suicide, and were I residing in a country with greater access to psychiatric EAS,5 perhaps through physician-assisted means”

• cites [204] Okninski ME. Meaningful protection or unacceptable risk? A critical analysis of undue influence as a safeguard in proposed voluntary assisted dying legislation in South Australia 2021.Not checked yet

  Not checked in the free run.

• cites [205] White BP, Del Villar K, Close E, Willmott L. Does the Voluntary Assisted Dying Act 2017 (VIC) reflect its states policy goals? UNSWLJ. 2020;43:417. sourceNot checked yet

  Not checked in the free run.

• cites [206] State of Victoria. Voluntary assisted dying model established ahead of vote in Parliament. [Media release]. 2017.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

The potential for harm exists from the proposed 'terminal AN' diagnosis, and great caution must be used if and how this diagnosis is to be used.

“I believe that the potential for harm exists, and great caution must be used if and how this diagnosis is to be used.”

• AssumptionRests on an assumption: The proposed 'terminal AN' diagnosis, if adopted, would be applied to individuals with SE-AN who experience ambivalence.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Ambivalence can be validated as a sign of hope and encourage motivation and belief in recovery.

“the experience of ambivalence can be validated as a sign of hope, and encourage motivation and belief in recovery.”

• cites [192] Bergmans Y, Rowe A, Dineen M, Johnson D. When despair and hope meet the stigma of “manipulation” and “ambivalence.” In: Critical suicidology: transforming suicide research and prevention for the 21st century; 2016, pp. 133–53. sourceNot checked yet

  Not checked in the free run.

• AssumptionRests on an assumption: Hope and belief in recovery are beneficial and should be preserved.

May combine two claims.

In one of the cases used by Gaudiani et al. to illustrate the proposed 'terminal' AN diagnosis, Jessica demonstrated repeated ambivalence about dying and the use of EAS, setting multiple dates to use medical aid in dying over a couple of months and changed her mind as the date got closer.

“In one of the cases used by Gaudiani et al. [1, p. 6] to illustrate the proposed ‘terminal’ AN diagnosis, Jessica demonstrated repeated ambivalence about dying and the use of EAS, setting “multiple dates to use [medical aid in dying] over a couple of months and changed her mind as the date got closer”.”

• cites [1, p. 6]Not checked yet

  Not checked in the free run.