Suicidality & Self-Harm in Eating Disorders

Self-harm, suicide and eating disorders are often interconnected, as individuals may use disordered eating or self-injury as ways to cope with emotional pain or distress. Both eating disorders and self-harm can be expressions of deeper mental health struggles. Addressing these issues in treatment requires a comprehensive approach, focusing on emotional regulation and coping strategies.

Suicide, Self-Harm & 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. Those living with an eating disorder may feel like their pain or hopelessness will never end and seek a way to escape overwhelming emotions.

Co-occurring psychiatric disorders, history of family conflict, isolation, self-blame, lack of self-love and impulsivity found in many individuals with eating disorder can compound the risk for suicide.^1,2

What are the differences between suicidal ideation, self-injury & suicide?

Suicidal thoughts, self-injury and suicide are elevated in individuals with eating disorders.³ Even though non-suicidal self-injury (NSSI) features no suicidal intent, it often precedes suicidal ideation and behavior.

Suicidal ideation

Suicidal ideation exclusively refers to thinking about or planning to engage in behaviors to end one's life. Suicidal thoughts or ideation in isolation do not necessarily indicate intent to die by suicide. About 51% of individuals with eating disorders experience suicidal thoughts at some point in their life.³

Self-injury

Non-suicidal self-injury (NSSI) is inflicting intentional harm to one’s body without the intent to die. Self-injury is a maladaptive coping mechanism that frequently occurs alongside an eating disorder, with up to 33% of individuals with eating disorders report engaging in NSSI at some point.⁴

NSSI is associated with higher levels of impulsivity and emotional reactivity in patients with eating disorders, which are both higher in patients with bulimia nervosa than those with anorexia nervosa.^5,6 NSSI are used to alleviate overwhelming negative emotions, which serves a similar purpose for many of those who suffer from an eating disorder. NSSI can include:

• Cutting
• Burning
• Scratching
• Banging
• Hitting
• Intentionally preventing wound healing

Many of those who utilize NSSI use multiple methods.

Suicide

Suicide is a common cause of death for individuals with eating disorders and varies by disorder. Compared to gender and age-matched peers, individuals with anorexia nervosa are 18 times more likely to die by suicide, and individuals with bulimia nervosa are seven times more likely to die by suicide.⁷ Suicidal self-injury includes self-injurious behaviors used with the intent to end one’s life. There are fewer studies covering suicidality in those with binge eating disorder (BED), but it is suggested that those with BED experience suicidal ideation, planning and attempts at similar rates to other eating disorders.⁸

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. ^8,9

Suicide attempts are also common in patients with anorexia nervosa and bulimia nervosa, with lifetime history of up to 30% for those with anorexia nervosa and up to 40% of individuals with bulimia nervosa.¹⁰ Research is mixed on the role of eating disorder subtypes on suicide attempts, with some studies suggesting higher prevalence in anorexia nervosa, others suggesting rates are higher in those with bulimia nervosa and some suggesting no difference.¹⁰

Intent to die

Suicide is the second leading cause of death for those with anorexia nervosa. Suicide attempts are typically serious and with an intention to die. Of those with anorexia nervosa who attempted suicide, 78% wanted to die during their attempt and 56% thought they would die.¹⁰

Seriousness of attempt

Of individuals with bulimia nervosa who attempt suicide, 34% had a “serious” or “extreme” first attempt, with attempts becoming more serious over time.¹⁰ 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

Emerging research

Individuals with BED have a similar risk level for suicidal thoughts, planning and attempting as those with anorexia nervosa and bulimia nervosa. Adolescents with BED have been shown to have a higher level of suicide risk compared to their peers.⁸ 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.⁸

Suicide Risk Factors

Suicide continues to be a major concern in healthcare. Estimates from clinical samples indicate up to 33% of adolescents and up to 40% of adults have reported a suicide attempt, however the number is much lower in community-based samples.¹¹ Community-based samples suggest up to 8% of adults and adolescents report making at least one suicide attempt.¹¹

Suicidal behavior typically has an onset of late adolescence 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.¹² Middle aged adults are also at risk, with this age group having the highest rate of death by suicide.^1,13 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.

Co-occurring psychiatric disorders

Individuals with eating disorders are likely to have another co-occurring psychiatric disorder, which are strong predictors of suicide. Over 90% of patients who attempt suicide having a psychiatric disorder and 95% of patients who successfully commit suicide have a psychiatric diagnosis.^14-16

Anxiety disorders, mood disorders, personality disorders and substance use disorders 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.^19,20Over 80% of individuals with anorexia nervosa who attempted suicide reporting that their worst or only attempt occurred during an active episode of major depressive disorder.¹⁰

Gender

Research has consistently found that females are more likely to attempt suicide, but males are more likely to die by suicide in their lifetime.^1,21,22 Common risk factors of suicidal behaviors for both genders are previous mental or substance abuse disorder and exposure to interpersonal violence.²²

There is more evidence to show that eating disorders contribute to 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.²²

Risk factors for males include disruptive behavior/conduct problems, hopelessness, parental separation/divorce, friend’s suicidal behavior and access to means.²² Some male-specific risk factors for suicide death are drug abuse, externalizing disorders and access to means.²²

Non-suicidal self-injury

Similar to how an eating disorder may manifest, NSSI also serves the purpose of emotional regulation and is a maladaptive coping mechanism. Up to 33% of individuals with eating disorders report engaging in NSSI at some point.⁴ 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.²³

Research suggests that NSSI is a risk factor for suicidal behavior. A prior history of self-injury being 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.⁵ 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.

LGBTQ+ identity

Young LGBTQ+ 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 experience minority stress. LGBTQ+ youth who reported experiencing four types of minority stress were 12 times more likely to attempt suicide compared to those who experienced none.^24-27

Eating disorder diagnosis

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.²⁸ Suicide risk is also higher among those who suspected they had an eating disorder, despite never being diagnosed.²⁸ These individuals are over twice as likely to attempt suicide within the last year compared to those who have never suspected they’ve had an eating disorder.²⁸

Transgender & nonbinary identity

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.²⁹ LGBTQ+ youth of color also reported higher rates of attempting suicide than their White peers in the past year.³⁰

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.

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.

Assessing Suicidality

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.

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.³¹

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. 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. 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.³²

Suicide Intervention

Dialectical behavioral therapy

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. 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 those receiving DBT are more likely to respond to treatment.^33,34

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 techniques using a CBT approach to reduce risk of future suicidal behaviors. CBT has been shown to reduce suicidal behavior and suicide attempts.^35,36

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.³⁷

Get Help for an Eating Disorder

Struggling with thoughts of suicide and ean eating disorder can feel especially overwhelming, but you don’t have to navigate it alone. Integrated care that addresses both conditions at the same time is essential for lasting recovery. With the right support team and evidence-based treatment, recovery is possible.

References

1. Koutek, J., Kocourková, J., & Dudova, I. (2016). Suicidal behavior and self-harm in girls with eating disorders. Neuropsychiatric Disease and Treatment, 787. https://doi.org/10.2147/ndt.s103015
2. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S., Caldwell, B., Calvert, S., Carroll, B., Castle, D., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
3. Amiri, S., & Khan, M. A. (2023). Prevalence of non-suicidal self-injury, suicidal ideation, suicide attempts, suicide mortality in eating disorders: a systematic review and meta-analysis. Eating Disorders, 31(5), 487–525. https://doi.org/10.1080/10640266.2023.2196492
4. Pérez, S., Marco, J. H., & Cañabate, M. (2018). Non-suicidal self-injury in patients with eating disorders: prevalence, forms, functions, and body image correlates. Comprehensive Psychiatry, 84, 32–38. https://doi.org/10.1016/j.comppsych.2018.04.003
5. Smith, K. E., Hayes, N. A., Styer, D. M., & Washburn, J. J. (2017). Emotional reactivity in a clinical sample of patients with eating disorders and nonsuicidal self-injury. Psychiatry Research, 257, 519–525. https://doi.org/10.1016/j.psychres.2017.08.014
6. Cass, K. (2025, March). Impulsivity in Patients with Eating Disorders. acute.org. https://www.acute.org/resources/impulsivity-patients-eating-disorders
7. Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal Self-Injury: What we know, and what we need to know. The Canadian Journal of Psychiatry, 59(11), 565–568. https://doi.org/10.1177/070674371405901101
8. Conti, C., Lanzara, R., Scipioni, M., Iasenza, M., Guagnano, M. T., & Fulcheri, M. (2017). The Relationship between Binge Eating Disorder and Suicidality: A Systematic Review. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.02125
9. Udo, T., Bitley, S., & Grilo, C. M. (2019). Suicide attempts in US adults with lifetime DSM-5 eating disorders. BMC Medicine, 17(1). https://doi.org/10.1186/s12916-019-1352-3
10. Pisetsky, E. M., Thornton, L. M., Lichtenstein, P., Pedersen, N. L., & Bulik, C. M. (2013). Suicide attempts in women with eating disorders. Journal of Abnormal Psychology, 122(4), 1042–1056. https://doi.org/10.1037/a0034902
11. Hamza, C. A., Stewart, S. L., & Willoughby, T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32(6), 482–495. https://doi.org/10.1016/j.cpr.2012.05.003
12. Volpe, U., Tortorella, A., Manchia, M., Monteleone, A. M., Albert, U., & Monteleone, P. (2016). Eating disorders: What age at onset? Psychiatry Research-neuroimaging, 238, 225–227. https://doi.org/10.1016/j.psychres.2016.02.048
13. World Health Organization. (2002). World report on violence and health. www.who.int. https://www.who.int/publications/i/item/9241545615
14. Bostwick, J., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100. https://doi.org/10.1176/appi.ajp.2016.15070854
15. Hirschfeld, R. M. A., & Russell, J. M. (1997). Assessment and treatment of suicidal patients. The New England Journal of Medicine, 337(13), 910–915. https://doi.org/10.1056/nejm199709253371307
16. Mościcki E. K. (1995). Epidemiology of suicide. International psychogeriatrics, 7(2), 137–148.
17. Schreiber, J., & Culpepper, L. (n.d.). Suicidal ideation and behavior in adults. UpToDate. https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults
18. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S., Caldwell, B., Calvert, S., Carroll, B., Castle, D., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022b). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
19. Tidemalm, D., Långström, N., Lichtenstein, P., & Runeson, B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ, 337(nov18 3), a2205. https://doi.org/10.1136/bmj.a2205
20. Haukka, J., Suominen, K., Partonen, T., & Lönnqvist, J. (2008). Determinants and outcomes of serious Attempted suicide: a nationwide study in Finland, 1996-2003. American Journal of Epidemiology, 167(10), 1155–1163. https://doi.org/10.1093/aje/kwn017
21. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133–154. https://doi.org/10.1093/epirev/mxn002
22. Miranda-Mendizabal, A., Castellví, P., Parés-Badell, O., Alayo, I., Almenara, J., Alonso, I., Blasco, M. J., Cebria, A., Gabilondo, A., Gili, M., Lagares-Franco, C., Rodríguez, J. a. P., Rodríguez-Jiménez, T., Marín, J. R., Roca, M., Soto-Sanz, V., Vilagut, G., & Alonso, J. (2019). Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. International Journal of Public Health, 64(2), 265–283. https://doi.org/10.1007/s00038-018-1196-1
23. Vieira, A. I., Ramalho, S., Brandão, I., Saraiva, J., & Gonçalves, S. (2016). Adversity, emotion regulation, and non-suicidal self-injury in eating disorders. Eating Disorders, 24(5), 440–452. https://doi.org/10.1080/10640266.2016.1198205
24. Green, A. E., Price-Feeney, M., & Dorison, S. H. (2021). Cumulative minority stress and suicide risk among LGBTQ youth. American Journal of Community Psychology, 69(1–2), 157–168. https://doi.org/10.1002/ajcp.12553
25. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
26. Johns, M. M., Lowry, R., Andrzejewski, J., Barrios, L. C., Demissie, Z., McManus, T., Rasberry, C. N., Robin, L., & Underwood, J. M. (2019). Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk Behaviors among high school students — 19 states and large urban school districts, 2017. Morbidity and Mortality Weekly Report, 68(3), 67–71. https://doi.org/10.15585/mmwr.mm6803a3
27. Johns, M. M., Lowry, R., Haderxhanaj, L. T., Rasberry, C. N., Robin, L., Scales, L., Stone, D. M., & Suarez, N. A. (2020). Trends in violence Victimization and suicide risk by sexual identity among high school students — Youth Risk Behavior Survey, United States, 2015–2019. MMWR Supplements, 69(1), 19–27. https://doi.org/10.15585/mmwr.su6901a3
28. The Trevor Project. (2022, February 22). Eating Disorders among LGBTQ Youth. https://www.thetrevorproject.org/research-briefs/eating-disorders-among-lgbtq-youth-feb-2022/
29. Price-Feeney, M., Green, A. E., & Dorison, S. H. (2020). Understanding the mental health of transgender and nonbinary youth. Journal of Adolescent Health, 66(6), 684–690. https://doi.org/10.1016/j.jadohealth.2019.11.314
30. 2022 National Survey  on LGBTQ Youth  Mental Health. (2023). The Trevor Project. https://www.thetrevorproject.org/survey-2022/
31. Salvi, J. (2019, May 5). Columbia-Suicide Severity Rating Scale (C-SSRS). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7974826/
32. Bryan, C. J., Allen, M., Thomsen, C. J., May, A. M., Baker, J. C., Bryan, A. O., Harris, J. F., Cunningham, C. A., Taylor, K. B., Wine, M. D., Young, J., Williams, S., White, K., Smith, L. M., Lawson, W., Hope, T., Russell, W. H., Hinkson, K. D., Cheney, T., & Arne, K. (2021). Improving suicide risk screening to identify the highest risk patients: results from the PRIMary Care Screening Methods (PRISM) study. Annals of Family Medicine, 19(6), 492–498. https://doi.org/10.1370/afm.2729
33. Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R., Lungu, A., Neacsiu, A. D., McDavid, J., Comtois, K. A., & Murray-Gregory, A. M. (2015). Dialectical Behavior therapy for high suicide risk in individuals with borderline personality disorder. JAMA Psychiatry, 72(5), 475. https://doi.org/10.1001/jamapsychiatry.2014.3039
34. McCauley, E., Berk, M., Asarnow, J. R., Adrian, M., Cohen, J. A., Korslund, K., Avina, C., Hughes, J. L., Harned, M. S., Gallop, R., & Linehan, M. M. (2018). Efficacy of Dialectical behavior therapy for adolescents at high risk for suicide. JAMA Psychiatry, 75(8), 777. https://doi.org/10.1001/jamapsychiatry.2018.1109
35. Tarrier, N. (2008). Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK75709/
36. Wu, H., Liu, L., Qian, Y., Jin, X., Yu, H., Du, L., Fu, X., Chen, H., & Zhu, B. (2022). The significance of cognitive-behavioral therapy on suicide: An umbrella review. Journal of Affective Disorders, 317, 142–148. https://doi.org/10.1016/j.jad.2022.08.067
37. Swift, J. K., Trusty, W. T., & Penix, E. A. (2021). The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta‐analysis. Suicide and Life Threatening Behavior, 51(5), 882–896. https://doi.org/10.1111/sltb.12765