Suicidality in eating disorders: Occurrence, correlates, and clinical implications

Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, MA 02115-5000, USA.
Clinical Psychology Review (Impact Factor: 7.18). 11/2006; 26(6):769-82. DOI: 10.1016/j.cpr.2006.04.001
Source: PubMed

ABSTRACT This review summarizes the published studies on suicide and suicide attempts in individuals with eating disorders, highlighting rates of occurrence, clinical correlates, and implications for practitioners. Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3-20% of patients with anorexia nervosa and in 25-35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms.

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    • "Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in interpersonal relationships, selfimage , and affect (APA, 2013) and is marked by impulsivity and recurrent suicidal and self-mutilating behavior. Suicidal behavior and self-harm also occur among patients with Bulimia nervosa (BN; Corcos et al., 2002; Crow et al., 2009; Franko & Keel, 2006; Preti, Rocchi, Sisti, Camboni, & Miotto, 2011) and a robust and differential pattern of comorbidity has been found between BPD and BN in clinical samples of mixed personality disorder (PD; Reas, Rø, Karterud, Hummelen, & Pedersen, 2013). Significant associations have also been found between purging behavior, personality traits, and self-injury or suicidality in women with eating disorders (ED) (Paul, Schroeter, Dahme, & Nutzinger, 2002) and adolescent psychiatric inpatients (Zaitsoff & Grilo, 2010), consistent with clinical observations linking BN with impulsivity and dysregulation. "
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    ABSTRACT: Objective: Few studies have investigated whether a diagnosis of Bulimia nervosa (BN) confers additional risk of life-threatening behaviors such as self-harm and suicidal behavior in borderline personality disorder (BPD). Method: Participants were 483 treatment-seeking women diagnosed with BPD according to the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997; Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; APA, 1994) and admitted to the Norwegian Network of Psychotherapeutic Day Hospitals between 1996 and 2009. Of these, 57 (11.8%) women met DSM-IV diagnostic criteria for BN according to the Mini-International Neuropsychiatric Interview (M.I.N.I.; Sheehan et al., 1998) and they were compared with women with BPD and other Axis I disorders. Results: We found that comorbid BN is uniquely and significantly associated with increased risk of suicidal behavior among women being treated for BPD. Findings underscore the importance of routinely screening for BN among women seeking treatment for BPD, as co-occurring bulimia appears to be a significant marker for immediate life-threatening behaviors in this already high-risk population, which is a significant public health issue. A significantly greater proportion of women with BPD-BN reported suicidal ideation at intake (past 7 days), engaged in self-harm behavior during treatment, and attempted suicide during treatment. All bivariate associations remained significant in the logistic regression models after controlling for mood, anxiety, and substance-related disorders. Conclusion: The presence of a concurrent diagnosis of BN among women with BPD is significantly and uniquely associated with recent suicidal ideation, and self-harm behavior and suicide attempts during treatment after controlling for major classes of mental disorders. Co-occurring BN appears to represent a significant marker for immediate life-threatening behaviors in women seeking treatment for BPD. Extra vigilance and careful monitoring of suicidal behavior during treatment is important for these individuals, and routine screening for BN is warranted. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
    Journal of Consulting and Clinical Psychology 12/2014; 83(3). DOI:10.1037/ccp0000014 · 4.85 Impact Factor
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    • "Whether the risk of suicide attempts across ED subtypes differs remains a matter of some disagreement, with some studies reporting no difference in the prevalence of attempts (Bulik et al., 1999; Herzog et al., 1999; Milos et al., 2004), some reporting higher prevalence of suicide attempts in individuals with BN than in those with AN (Favaro & Santonastaso, 1996, 1997), and others reporting higher prevalence of suicide attempts in individuals with AN than in those with BN (Franko et al., 2004). The differences are likely attributable to differences in subtyping diagnostics, although one fairly consistent finding is higher risk among the binge-purge subtype of AN than individuals with the restricting subtype (Bulik et al., 2008; Favaro, Tenconi, & Santonastaso, 2006; Franko & Keel, 2006). However, most of the research has focused on differences in prevalence of suicide attempts across AN subtypes and BN. "
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    ABSTRACT: We evaluated whether the prevalence of lifetime suicide attempts/completions was higher in women with a lifetime history of an eating disorder than in women with no eating disorder and assessed whether eating disorder features, comorbid psychopathology, and personality characteristics were associated with suicide attempts in women with anorexia nervosa, restricting subtype (ANR), anorexia nervosa, binge-purge subtype (ANBP), lifetime history of both anorexia nervosa and bulimia nervosa (ANBN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD). Participants were part of the Swedish Twin study of Adults: Genes and Environment (N = 13,035) cohort. Lifetime suicide attempts were identified using diagnoses from the Swedish National Patient and Cause of Death Registers. General linear models were applied to evaluate whether eating disorder category (ANR, ANBP, ANBN, BN, BED, PD, or no eating disorder [no ED]) was associated with suicide attempts and to identify factors associated with suicide attempts. Relative to women with no ED, lifetime suicide attempts were significantly more common in women with all types of eating disorder. None of the eating disorder features or personality variables was significantly associated with suicide attempts. In the ANBP and ANBN groups, the prevalence of comorbid psychiatric conditions was higher in individuals with than without a lifetime suicide attempt. The odds of suicide were highest in presentations that included purging behavior (ANBN, ANBN, BN, and PD), but were elevated in all eating disorders. To improve outcomes and decrease mortality, it is critical to be vigilant for suicide and identify indices for those who are at greatest risk. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
    Journal of Abnormal Psychology 11/2013; 122(4):1042-56. DOI:10.1037/a0034902 · 4.86 Impact Factor
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    • "Provocative behaviors (e.g., binging, purging, self-injury, substance use), however, linked AN-binge/purge subtype to suicidal behavior. To our knowledge, no study has tested constructs of the IPTS in a sample of people with symptoms of BN, despite the fact that individuals with BN display increased rates of suicidal behavior compared to the general population (Bulik et al., 1999; Corcos et al., 2002; Franko and Keel, 2006; Preti et al., 2011). Various symptoms of BN may be both provocative and painful. "
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    ABSTRACT: We conducted four studies to examine the relationship between over-exercise and suicidality. Study 1 investigated whether over-exercise predicted suicidal behavior after controlling for other eating disorder behaviors in a patient sample of 204 women (144 with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Bulimia Nervosa [BN]). Study 2 tested the prospective association between over-exercise and acquired capability for suicide (ACS) in a sample of 171 college students followed for 3-4 weeks. Study 3 investigated whether pain insensitivity accounted for the relationship between over-exercise and ACS in a new sample of 467 college students. Study 4 tested whether ACS accounted for the relationship between over-exercise and suicidal behavior in a sample of 512 college students. In Study 1, after controlling for key covariates, over-exercise was the only disordered eating variable that maintained a significant relationship with suicidal behavior. In Study 2, Time 1 over-exercise was the only disordered eating behavior that was associated with Time 2 ACS. In Study 3, pain insensitivity accounted for the relationship between over-exercise and ACS. In Study 4, ACS accounted for the relationship between over-exercise and suicidal behavior. Over-exercise appears to be associated with suicidal behavior, an association accounted for by pain insensitivity and the acquired capability for suicide; notably, this association was found across a series of four studies with different populations.
    12/2012; 206(2-3). DOI:10.1016/j.psychres.2012.11.004
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