Eating Disorders & Suicidality
Suicide in Individuals with Eating Disorders
Eating disorders are psychiatric disorders and involve emotional distress that can lead to severe mood imbalances resulting in self-harm, feeling out of control or suicidal thoughts or attempts. Patients may feel like their pain, hopelessness, depression or self-hated will never end and seek a way to escape overwhelming emotions.
The co-occurring psychiatric disorders, history offamily conflict, isolation, self-blame, lack of self-love and impulsivity characteristic of many individuals with eating disorder can compound the risk for suicide.1,2
Self-Injury, Suicidal Behavior & Suicidal Thoughts
Self-injury (or self-harm) refers to when a person intentionally hurts themselves. Self-injury can either be non-suicidal or suicidal.2,3
Non-suicidal self-injury (NSSI) is self-injurious behaviors with the absence of suicidal intent. NSSI includes behaviors like self-cutting, head banging, burning, self-hitting, scratching to the point of bleeding and interfering with wound healing.4
Suicidal self-injury are self-injurious behaviors used with the intent to end one’s life. Suicidal self-injury includes behaviors like hanging/strangulation, severe cutting and jumping from heights. Unlike suicidal self-injury, suicidal thoughts exclusively refer to thinking about or planning to engage in behaviors to end one's life (suicidal ideation or plan).1,5 Suicidal thoughts or ideation in isolation do not necessarily indicate intent to die by suicide.
Suicide continues to be a major concern in healthcare. Estimate from clinical samples estimate between 24-33% of adolescents and 35-40% of adults have reported a suicide attempt, however the number is much lower in community-based samples. Community-based samples suggest between 4-8% of adults and adolescents report making at least one suicide attempt.6
Suicidal behavior typically has an onset of late adolescent and studies indicate that adolescents report higher levels of suicidal ideation than other age groups, which coincides with the average age of onset for individuals with eating disorders.7 Middle aged adults are also at risk, with this age group having the highest rate of death by suicide.1,8 These findings suggest that although suicidal behavior may have its onset earlier in life, middle adulthood is the period of greatest risk for death by suicide.
Eating Disorders & Suicidal Behavior
Adults with a history of having an eating disorder are nearly 5-6 times more likely to attempt suicide compared to those who have never had an eating disorder.9,11 Suicide is the leading cause of death for those with anorexia nervosa and suicidal behavior is elevated in those with bulimia nervosa and binge eating disorder (BED).8
Anorexia Nervosa & Suicide
Suicide attempts in patients with anorexia nervosa are somewhat common, with lifetime estimates ranging between 3-29%. Attempts are typically serious and with an intention to die. Of those with AN who attempted suicide, 78% wanted to die during their attempt and 56% thought they would die. Those with anorexia nervosa binging and purging subtype (AN-BP) are at an increased risk of suicide compared to those with the restricting subtype (AN-R).8
Bulimia Nervosa & Suicide
Suicide attempts are also common in patients with bulimia, with 15-40% of individuals indicating a lifetime history of at least one suicide attempt. Of individuals with bulimia nervosa who attempt suicide, 34.1% had a “serious” or “extreme” first attempt, with attempts becoming more serious or extreme in subsequent attempts. Over 60% of individuals with bulimia nervosa were hospitalized because of their first suicide attempt, and 100% of those who utilized an “extreme” suicide attempt are hospitalized.10
Binge Eating Disorder & Suicide
BED have a similar risk level for suicidal thoughts, planning, and attempting as in those with anorexia and bulimia nervosa and adolescents with BED have been shown to have a higher level of suicide risk compared to their peers. The association between BED and suicide risk is significant, however there are far fewer studies covering BED and suicide risk because BED has only recently been considered a distinct diagnosis.11
Suicide Risk Factors
While eating disorders increase an individual’s risk of suicide, there are other risk factors that may compound the risk of suicide, including other co-occurring psychiatric disorders, gender, history of self-injury and LGBTQ+ identity.
Co-Occurring Psychiatric Disorders
Individuals with eating disorders are likely to have another co-occurring psychiatric disorder, which are strong predictors of suicide.12,13 Over 90% of patients who attempt suicide having a psychiatric disorder and 95% of patients who successfully commit suicide have a psychiatric diagnosis.14,15,16
Anxiety disorders, mood disorders, personality disorders and substance use disorder commonly co-occur with eating disorders and are also among the disorders most associated with suicide.17,18 Patients who have multiple psychiatric comorbidities appear to be an elevated risk compared to those with uncomplicated depression or an anxiety disorder.13
Research has consistently found that females are more likely to attempt suicide, but males are more likely to die by suicide in their lifespan.1,5,19 Common risk factors of suicidal behaviors for both genders are previous mental or substance abuse disorder and exposure to interpersonal violence.
There is more evidence to show that eating disorders contribute suicidality in females than in males. Risk factors for females include an eating disorder, post-traumatic stress disorder, bipolar disorder, being victim of dating violence, depressive symptoms and interpersonal factors.7
Risk factors for males include disruptive behavior/conduct problems, hopelessness, parental separation/divorce, friend’s suicidal behavior and access to means. Some male-specific risk factors for suicide death are drug abuse, externalizing disorders and access to means.7
Similar to how an eating disorder may manifest, NSSI also serves the purpose of emotional regulation and is a maladaptive coping mechanism.20,21,22 Up to 33% of individuals with eating disorders report engaging in NSSI at some point.23 Patients with eating disorders who also engaged in NSSI have a greater severity of disordered eating behavior, and the use of multiple methods of NSSI are associated with more severe eating disorder symptoms.24
Research suggests that NSSI is a risk factor for suicidal behavior. A prior history of self-injury being one is one of the strongest predictors of future suicide attempts and individuals receiving inpatient care who report a history of self-harm are at greater risk for death by suicide than those without a history of self-harm. However, it is unknown if this relationship is causal, as studies often do not differentiate between lethal or non-lethal intent, causing NSSI to be confounded with suicide attempts.4
LGBTQ+ young people experience significantly greater rates of both eating disorders and attempting suicide compared to their heterosexual and cisgender peers.25
Young people experience significantly greater rates of both eating disorders and attempting suicide compared to their heterosexual and cisgender peers. LGBTQ+ youth are more than four times as likely to attempt suicide than their peers, particularly if they are transgender or a member of a minority racial or ethnic group.26,27
Transgender and non-binary youth are at an elevated risk of suicide. Transgender and nonbinary youth are twice as likely to experience depressive symptoms, seriously consider suicide and attempt suicide compared to their cisgender LGBQ+ peers. LGBTQ+ youth of color also reported higher rates of attempting suicide than their white peers in the past year.28,29
LGBTQ-based discrimination, victimization and otherization can compound and produce negative mental health outcomes and increase suicide risk among LGBTQ+ individuals. Experiences of minority stress are associated with an increased risk of attempting suicide. LGBTQ+ youth who reported experiencing four types of minority stress (LGBTQ-based physical harm, discrimination, housing, etc.) were 12 times more likely to attempt suicide compared to those who experienced none.30,31
LGBTQ+ youth who have been diagnosed with an eating disorder are four times more likely to attempt suicide within the past year compared to those who have never suspected nor had an eating disorder diagnosis. Suicide risk is also higher among those who suspected they had an eating disorder, despite never being diagnosed, and are over twice as likely to suicide attempt within the last year compared to those who have never suspected they’ve had an eating disorder.32
According to the literature, the interpersonal psychological theory of suicide (IPTS) may provide insight into additional factors for suicidal risk.33 According to IPTS, suicidal behaviors occurs when an individual has a desire to commit suicide and an ability to do, often raising from unmet interpersonal needs.33,34 This can include thwarted belongingness, perceived burdensomeness, as well as having high acquired capability for suicide. For patients with severe eating disorders, they can often present with this high acquired capability via their engagement in unsafe disordered eating behaviors, including restriction and/or purging.35 This makes it ever more important for clinicians working with eating disorders to engage in ongoing assessment for patient’s interpersonal factors and risk for suicide.
Suicidality in Eating Disorder Treatment
If a patient is at an immediate risk of attempting suicide, a higher level of psychiatric care with 24/7 supervision is necessary.
If suicidal intent and planning is demonstrated in lower levels of eating disorder care, patients should be transferred to a facility that can provide appropriate intervention based on suicidal risks seen in the patient’s current presentation and history, such as history of past suicide attempts If demonstrating passive suicide and low levels of suicidality. These can be managed and assessed ongoingly while patient undergoes treatment for their eating disorder.
Patients who present with non-suicidal self-injury or engagement in parasuicidal or suicidal behaviors can also work with a DBT therapist to address these life-threatening behaviors that interfere with eating disorder treatment and recovery.
Not all self-injury or suicidal ideation indicates a high suicide risk level or being actively suicidal. Screening should be performed to determine the need for further assessment.
There are several initial suicide screening measures and scales to assess whether further assessment is necessary. While these tools cannot replace a complete clinical assessment, they can help determine next steps.
The Ask Suicide-Screening Questions Toolkit
The Ask Suicide-Screening Questions Toolkit (ASQ) is a set of four brief suicide screening questions designed to identify individuals that require further mental health/suicide safety assessment.36
Columbia-Suicide Severity Rating Scale (C-SSRS)
The Columbia-Suicide Severity Rating Scale (C-SSRS) is comprised of a series of six questions used to assess the severity and immediacy of a suicide risk. The C-SSRS has been validated in emergency setting and has some validation in the outpatient psychiatry setting.37
Linehan Risk Assessment and Management Protocol (LRAMP)
The Linehan Risk Assessment and Management Protocol (LRAMP) is an empirically supported risk assessment tool commonly utilized in Dialectical Behavior Therapy (DBT), and a helpful guide for therapists to assess, intervene and document suicidal behavior.38 LRAMP helps evaluate risks, as well as strategies, to intervene and consult or re-evaluate if needed, which is often helpful for providers in outpatient and community mental health settings.
Suicide Cognitions Scale
The Suicide Cognitions Scale (SCS) measures suicide-specific and identity-based hopelessness. SCS asks questions that refer to emotions that can render people vulnerable, such as unlovability, unbearability and unsolvability.39 Used in conjunction with the Patient Health Questionnaire-9 depression screener, the SCS has been shown to have improve the identification of patients most likely to progress to suicidal behavior in the next month.40
Managing Suicidality & Suicide Intervention
There are numerous programs that can help manage suicidal thoughts, including cognitive behavioral therapy, dialectical behavioral therapy and collaborative assessment and management of suicidality.
Dialectical Behavioral Therapy
DBT is a structured psychotherapy program designed to provide skills for managing intense emotions and negotiating social relationships. DBT aims to build skills related to mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation.
Although DBT was originally designed to treat borderline personality disorder, DBT has clinical use for a wide variety of psychiatric disorders, including eating disorders.41-47 DBT is also useful for those with a high risk of suicide. Suicide interventions that incorporate DBT skills training appear to be more effective at reducing suicidality than those without, and you receiving DBT were more likely to respond to treatment.48,49
Cognitive Behavioral Therapy for Suicide Prevention
Cognitive Behavioral Therapy (CBT) is a structured, goal-oriented psychotherapy program. CBT is versatile and used to manage a variety of psychiatric disorders and emotional concerns by identifying and changing unhelpful thought patterns. Cognitive behavioral therapy for suicide prevention (CBT-SP) is a specific group of therapies using a CBT approach to reduce risk of future suicidal behaviors. CBT has been shown to reduce suicidal behavior and suicide attempts.50,51
Collaborative Assessment and Management of Suicidality
The Collaborative Assessment and Management of Suicidality (CAMS) is a flexible therapeutic program during which patient and provider work together to assess the patient’s suicidal risk and use that information to plan and manage suicide-specific treatment. The framework fundamentally involves a participant’s engagement and cooperation in assessing and managing suicidal thoughts and behaviors and the therapist’s understanding of the patient’s suicidal thoughts, feelings and behaviors. CAMS has been shown to significantly reduce suicidal ideation, increase treatment acceptability and positively impact hopelessness.52
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