Suicide attempts in women with bulimia nervosa: frequency and characteristics

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Common and differential risk factors behind suicidal behavior in patients with impulsivity-related disorders: The case of bulimic spectrum eating disorders and gambling disorder

BACKGROUND AND AIMS

Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD.

METHODS

A total of 6,077 adults who sought treatment and met criteria either for BSED (n = 2,391) or GD (n = 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated.

RESULTS

The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD.

DISCUSSION

Patients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder.

CONCLUSIONS

Interventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

Eating expectancies and hedonic hunger among individuals with bulimia-spectrum eating disorders who plan binge-eating episodes

OBJECTIVE

Binge planning (BP; i.e., preparatory thoughts and actions to facilitate future binge-eating episodes) is hypothesized to distract individuals from negative affect and increase the salience of food. Thus, individuals who engage in BP may report greater positive eating expectancies (i.e., beliefs about the outcomes of eating) and hedonic hunger (i.e., desire to eat for pleasure), as BP may increase the likelihood of obtaining these expected outcomes; but empirical tests of this possibility are needed.

METHOD

Prior to starting treatment, adults (N = 86) with bulimia-spectrum eating disorders were assessed for engagement in BP and self-reported on eating expectancies and hedonic hunger.

RESULTS

Twenty-nine participants (33.7%) reported planning at least one binge-eating episode in the previous 28 days. Compared to individuals who did not report BP, individuals who reported BP had greater expectancies that eating would alleviate negative affect (t = -2.54, p = .013) and boredom (U = 503.50, p = .006). Groups did not differ on levels of hedonic hunger (t = -1.68, p = .096).

DISCUSSION

These findings suggest that BP status is linked to expectancies that eating will reduce negative affect. However, more data are needed to determine the temporal relationships among eating expectancies, hedonic hunger and BP.

TRIAL REGISTRATION NUMBERS

NCT02716831, NCT03673540.

Clarifying the association of eating disorder features to suicide ideation and attempts

OBJECTIVE

We examine the relationships of eight eating disorder (ED) features to histories of suicide ideation and suicide attempts.

METHOD

Participants were 387 adults (62% female, mean age = 36 years) recruited via an online platform, and oversampled for the presence of ED features, who completed standardized self-report measures of study variables.

RESULTS

Different ED features predicted suicide ideation versus attempts. Specifically, Restrictive Eating (d = 0.44), Purging (d = 0.30), and Body Dissatisfaction (d = 0.27) were higher among ideators compared to nonsuicidal participants. In contrast, Muscle Building (d = 0.31), Excessive Exercise (d = 0.26), Cognitive Restraint (d = 0.23), and Restrictive Eating (d = 0.20) were higher among attempters compared to ideators-however, we note that the p-values for these effects range between 0.02 and 0.04 and it is unclear if they would replicate. Independent replication is important.

CONCLUSION

Findings have implications for the conceptualization of suicide risk in individuals with EDs.

A Comparison between Severe Suicidality and Nonsuicidal Self-Injury Behaviors in Bipolar Adolescents Referred to a Psychiatric Emergency Unit

Background: Severe suicide ideation or attempts and non-suicidal self-injury (NSSI) present both differences and relevant overlaps, including frequent co-occurrence and shared risk factors. Specific categorical diagnoses, namely bipolar disorder (BD), may affect clinical features and natural histories of suicidal or not suicidal self-harm behaviour. Our study aimed to compare suicidality (severe suicidal ideation or suicidal attempts) and NSSI in referred bipolar adolescents. Methods: The sample included 95 bipolar adolescents (32 males, 63 females) aged 11 to 18 years. Thirty adolescents with suicide attempts/suicidal ideation and BD (SASIB) were compared with structured measures to 35 adolescents with NSSI and BD, without suicidal ideation or attempts (NSSIB), and to 30 adolescents with BD, without suicidal ideation or attempts or NSSI (CB). Results: Compared to CB, suicidality and NSSI were both associated with female sex, borderline personality disorder and self-reported internalizing disorders, anxiety/depression and thought disorders. The NSSI were specifically associated with somatic problems. Severe suicidal ideation and suicide attempts were associated with adverse life events, immigration, bullying, eating disorders, social problems, depressive feelings, performance and social anxiety, and feelings of rejection. Conclusions: Both shared and differential features between suicidal and not suicidal adolescents may represent possible targets for diagnostic and preventative interventions.

Suicide attempts in bulimia nervosa: Personality and psychopathological correlates

Background

Little evidence exists about suicidal acts in eating disorders and its relation with personality. We explored the prevalence of lifetime suicide attempts (SA) in women with bulimia nervosa (BN), and compared eating disorder symptoms, general psychopathology, impulsivity and personality between individuals who had and had not attempted suicide. We also determined the variables that better correlate with of SA.

Method

Five hundred sixty-six BN outpatients (417 BN purging, 47 BN non-purging and 102 subthreshold BN) participated in the study.

Results

Lifetime prevalence of suicide attempts was 26.9%. BN subtype was not associated with lifetime SA (p = 0.36). Suicide attempters exhibited higher rates on eating symptomatology, general psychopathology, impulsive behaviors, more frequent history of childhood obesity and parental alcohol abuse (p < 0.004). Suicide attempters exhibited higher scores on harm avoidance and lower on self-directedness, reward dependence and cooperativeness (p < 0.002). The most strongly correlated variables with SA were: lower education, minimum BMI, previous eating disorder treatment, low self-directedness, and familial history of alcohol abuse (p < 0.006).

Conclusion

Our results support the notion that internalizing personality traits combined with impulsivity may increase the probability of suicidal behaviors in these patients. Future research may increase our understanding of the role of suicidality to work towards rational prevention of suicidal attempts.

Personality trait risk factors for attempted suicide among young women with eating disorders

Objective

Clinical observations and a review of the literature led us to hypothesize that certain personality and character traits could provide improved understanding, and thus improved prevention, of suicidal behaviour among young women with eating disorders.

Method

The clinical group consisted of 152 women aged between 18 and 24 years, with DSM-IV anorexia nervosa/restrictive type (AN-R = 66), anorexia nervosa/purging type (AN-P = 37), bulimia nervosa/non-purging type (BN-NP = 9), or bulimia nervosa/purging type (BN-P = 40). The control group consisted of 140 subjects. The assessment measures were the Minnesota Multiphasic Personality Inventory—second version (MMPI-2) scales and subscales, the Beck Depression Inventory (BDI) used to control for current depressive symptoms, plus a specific questionnaire concerning suicide attempts.

Results

Suicide attempts were most frequent in subjects with purging behaviour (30.0% for BN-P and 29.7% for AN-P). Those attempting suicide among subjects with eating disorders were mostly students (67.8%). For women with AN-R the scales for ‘Depression’ and ‘Antisocial practices’ represented significant suicidal risk, for women with AN-P the scales for ‘Hysteria’, ‘Psychopathic deviate’, ‘Shyness/Self-consciousness’, ‘Antisocial Practices’, ‘Obsessiveness’ and ‘Low self-esteem’ were risk indicators and for women with BN-P the ‘Psychasthenia’, ‘Anger’ and ‘Fears’ scales were risk indicators.

Conclusion

This study provides interesting results concerning the personality traits of young women with both eating disorders and suicidal behaviour. Students and those with purging behaviour are most at risk. Young women should be given more attention with regard to the risk of suicide attempts if they: (a) have AN-R with a tendency to self-punishment and antisocial conduct, (b) have AN-P with multiple physical complaints, are not at ease in social situations and have antisocial behaviour, or (c) if they have BN-P and tend to be easily angered with obsessive behaviour and phobic worries. The MMPI-2 is an interesting assessment method for the study of traits indicating a risk of suicidal behaviour in young subjects, after controlling for current depressive pathology.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

A multi factorial model of self-harm behaviors in Anorexia-nervosa and Bulimia-nervosa

BACKGROUND

Co-existence of eating disorders and NSSI, suicide attempts and ideations is well established yet much is not known about the personality traits and behavioral tendencies that maintain this relationship. To this date no empirical work has been produced that offers a multifactorial view on the contributing variables to the occurrence of self-harm behaviors in EDs.

METHOD

Binge eating, depression, impulsivity, ruminations and loss aversion were assessed in a sample of 93 patients diagnosed with Anorexia-Nervosa and Bulimia-Nervosa and other EDs with a history of NSSI and suicide attempts.

RESULTS

Binge eating was found to be a predictor of depression, which in turn was found to be related to NSSI frequency, suicide attempts and suicide ideations. Ruminations were found to mediate a relationship between depression and suicide ideations. Trait impulsivity predicted suicide attempts, while the attentional construct of impulsivity was associated to suicide ideations as well as attempts. Higher loss aversion was positively associated with NSSI frequency and suicide ideations.

CONCLUSION

Our findings suggest that trait and state aspects of impulsivity are related to different self-harm behaviors in EDs. Exploring these differences is potentially of great value in understanding the process of transition from suicidal ideation to suicide attempt and the process of NSSI and may assist clinicians formulate better interventions for patients with EDs at risk. Ways in which individual findings in our model correspond with previous research and future implications are discussed.

Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria

BACKGROUND

Quantification of suicidal risk in specific populations is important for the adoption of targeted prevention and harm reduction measures. Though there remains little systematic evidence, risk of suicide attempts for bulimia nervosa (BN) and binge-purging anorexia nervosa (AN-bp) appears higher than restrictive AN (AN-r); risk in binge eating disorder (BED) is still unclear. The aim of this meta-analysis was to compare proportions of suicide attempts in eating disorder (ED) subgroups.

METHODS

A literature search using combinations of key-words for ED and suicide attempts was performed. Studies reporting proportions of suicide attempters in at least two ED groups, diagnosed according to DSM-IV or -5 and ICD-10 diagnostic criteria were considered. ED subgroups were analyzed in pairs using a binary random effect model for proportions. Publication bias, meta-regression, and sensitivity analyses were performed.

RESULTS

In BN, attempted suicide was more frequent (21%) than in AN (12.5%), but the difference was statistically significant only when BN was compared with AN-r (9-10%). In BED, the proportion of suicide attempts was as high as in AN (10-12%).

CONCLUSIONS

Though limited by heterogeneity across the studies in terms of methodology and aims, inability to control for relevant confounding variables, exclusion of ED not otherwise specified, this study supports suicide attempts as a major issue in EDs, especially in binge-purging subtypes, i.e. BN and AN-bp. Similar suicidal proportions were observed in AN and BED. The reasons for a greater proportion of attempted suicide in binge/purging subtypes need to be explored in future studies.

Socio-demographic and psychological risk factors for suicidal behavior among individuals with anorexia and bulimia nervosa: A systematic review

OBJECTIVE

Suicide is the second leading cause of death among individuals with anorexia nervosa (AN) and is also elevated in bulimia nervosa (BN). We carried out a systematic review in which we analyzed the relationship between AN and/or BN and suicidality (i.e. suicidal ideation or attempted and/or death by suicide) and the major risk factors for suicidal behavior among AN and BN patients by synthesizing the qualitative data from relevant studies.

EVIDENCE ACQUISITION

According to PRISMA guidelines, we conducted a systematic search of the literature on PsycNET, PubMed, Google Scholar, and ScienceDirect. Search terms were "eating disorders" "OR" "anorexia" "OR" "bulimia" combined with the Boolean "AND" operator with "suicide."

EVIDENCE SYNTHESIS

The initial search identified 8,590 records, of which 38 research reports met the predefined inclusion criteria and were analyzed. Eating disorders (EDs) were found to be associated with a marked increase in suicidal behaviors and ideation. ED type, impulsivity, and specific interpersonal features were associated with suicidal behavior.

CONCLUSIONS

Our findings highlight the importance of the combined role of socio-demographic and psychological factors to the co-occurrence of EDs and suicidal behavior. It is imperative that a thorough suicide assessment be conducted routinely for individuals with past and current EDs, and that clinicians be aware that this risk may be ongoing and occur throughout treatment, even after ED symptoms appear to be remitting.

LIMITATIONS

Study limitations include diagnostic definitions of and criteria for EDs, and the different terminology used by researchers to define suicide, including non-suicidal behaviors, which weakens the ability to draw conclusions regarding actual suicidal behaviors versus other self-harm behaviors.

Which Comes First? An Examination of Associations and Shared Risk Factors for Eating Disorders and Suicidality

PURPOSE OF REVIEW

This narrative review evaluates recent literature on the associations between eating disorders and suicidality and discusses potential shared mechanisms that may account for these relationships. Additionally, the review highlights shortcomings with the literature to date and suggests avenues for future research.

RECENT FINDINGS

Individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder experience elevated rates of suicidality compared to the general population. Suicide risk is higher when eating disorders occur with other psychological conditions. Additionally, genetic factors, emotion dysregulation, trauma, stressful life events, and lack of body regard may have roles in the development of both eating disorders and suicidality. Much of the risk for suicidality in eating disorders appears to be driven by comorbid psychopathology and genetic factors. However, the lack of longitudinal research makes it difficult to draw conclusions about the directionality or temporality of these relations; thus, novel methods are needed.

Cohort survey of college students' eating attitudes: interventions for depressive symptoms and stress coping were key factors for preventing bulimia in a subthreshold group

Background

The aim of this study was to examine the necessity of early intervention for students with potential bulimia by investigating how the eating attitudes of college students change and examining the relation between bulimic symptoms and depressive symptoms or the ability to cope with stress.

Methods

The study participants were students who entered Hiroshima University in 2014. This study was conducted at two time points: Time-1 in 2014 and Time-2 in 2017. The Eating Attitudes Test-26 (EAT-26), Bulimic Inventory Test, Edinburgh (BITE), Beck Depression Inventory-II (BDI-II), and Coping Inventory for Stressful Situations (CISS) were administered at Times 1 and 2, and the responses were compared between the time points. Next, we compared the BDI-II scores of the BITE improved and worsened groups. In addition, we divided the participants into a clinical group, subthreshold group, and healthy group based on the BITE score at Time-1to compared their depressive symptoms and the ability to cope with stress.

Results

Significantly higher BITE and BDI-II scores were recorded for both males and females at Time-2 than at Time-1. The BDI-II score at Time-1 was significantly higher in the BITE worsened group than in the BITE improved group. The BDI-II scores at Time-1 were significantly higher for both males and females in the subthreshold group than in the healthy group. Furthermore, significantly higher CISS-T and CISS-E scores were recorded at Time-1 for females in the subthreshold group than for females in the healthy group.

Conclusions

Based on these results, intervention for students the subthreshold group is important, and the key to intervention may be to address not only eating behaviors but also depressive symptoms and stress coping.

Trial registration

UMIN000029474 Registered 9 October, 2017 (retrospectively).

Impact of Depressive Symptoms and Alcohol Use on Disordered Eating and Suicidality: A Moderated Mediation Study

While previous studies have tested the mediating or moderating effects of select factors on disordered eating pathologies, no empirical studies have examined a moderated mediation model. Thus, filling a gap in the literature base, the current study examined a moderated mediation model to test the associations among disordered eating, depressive symptoms, alcohol use, and suicidality. The current study sample included 1,598 students (mean age 21.3 years; 80.9% female) across major universities in the United States. Results showed that disordered eating was significantly associated with suicidality, and the association was mediated by depressive symptoms. Further, the indirect effect of disordered eating via depressive symptoms varied in magnitude as a function of alcohol use. Findings suggest that clinical mental health counselors and other providers working with emerging adults should be vigilant in recognizing behaviors and thoughts associated with disordered eating and related signs and symptoms, including depressive symptoms and alcohol use.

Risk Factors for Overdose in Treatment-Seeking Youth With Substance Use Disorders

OBJECTIVE

Overdoses (ODs) are among the leading causes of death in youth with substance use disorders (SUDs). Our aim was to identify the prevalence of OD and characteristics associated with a history of OD in youth presenting for SUD outpatient care.

METHODS

A systematic retrospective medical record review was conducted of consecutive psychiatric and SUD evaluations for patients aged 16 to 26 years with DSM-IV-TR criteria SUD at entry into an outpatient SUD treatment program for youth between January 2012 and June 2013. Unintentional OD was defined as substance use without intention of self-harm that was associated with a significant impairment in level of consciousness. Intentional OD was defined as ingestion of a substance that was reported as a suicide attempt. T tests, Pearson χ² tests, and Fisher exact tests were performed to evaluate characteristics associated with a history of OD.

RESULTS

We examined the medical records of 200 patients (157 males and 43 females) with a mean ± SD age of 20.2 ± 2.8 years. At intake, 58 patients (29%) had a history of OD, and 62% of those patients had a history of unintentional OD only (n = 36). Youth with ≥ 2 SUDs were 3 times more likely to have a history of OD compared to youth with 1 SUD (all P < .05). Compared to those without a history of OD, those with an OD were more likely to be female and have lifetime histories of alcohol, cocaine, amphetamine, anxiety, depressive, and/or eating disorders (all P < .05).

CONCLUSIONS

High rates of OD exist in treatment-seeking youth with SUD. OD was associated with more SUDs and psychiatric comorbidity.

Anorexia Nervosa, Major Depression, and Suicide Attempts: Shared Genetic Factors

The extent to which genetic and environmental factors influenced anorexia nervosa (AN), major depressive disorder (MDD), and suicide attempts (SA) were evaluated. Participants were 6,899 women from the Swedish Twin Study of Adults: Genes and Environment. A Cholesky decomposition assessed independent and overlapping genetic and environmental contributions to AN, MDD, and SA. Genetic factors accounted for a substantial amount of liability to all three traits; unique environmental factors accounted for most of the remaining liability. Shared genetic factors may underlie the coexpression of these traits. Results underscore the importance of assessing for signs of suicide among individuals with AN.

Is childhood trauma associated with lifetime suicide attempts in women with bulimia nervosa?

PURPOSE

The purpose of this study was to explore the association between specific forms of childhood abuse and neglect with lifetime suicide attempts in women with bulimia nervosa (BN).

METHODS

Two hundred and four women aged 18-65 (mean 25.6 years, SD 9.13) with full or subclinical BN were recruited in five US Midwestern communities and specialized eating disorder clinics. Participants completed questionnaires including the Childhood Trauma Questionnaire (CTQ) and self-reported whether they had ever had a lifetime suicide attempt. Logistic regression analyses were used to predict lifetime suicide attempts from each subscale of the CTQ.

RESULTS

Childhood emotional, physical, and sexual abuse were significantly associated with the presence of a lifetime suicide attempt in women with BN. Childhood emotional and physical neglect were not associated with suicide attempts.

CONCLUSIONS

Individuals with BN who have experienced childhood emotional and sexual abuse are at increased risk of a lifetime suicide attempt. Future research is needed to understand the mechanism to address in treatment and prevention efforts. It is important for clinicians to be aware of the potential increased risk of suicide in individuals with BN with a history of childhood abuse.

Depression and Personality Traits Associated With Emotion Dysregulation: Correlates of Suicide Attempts in Women with Bulimia Nervosa

OBJECTIVE

The objective of this study was to identify personality traits and psychiatric comorbidities associated with a lifetime history of a suicide attempt in women with bulimia nervosa (BN).

METHOD

Data from two samples of women with BN (n = 204 and n = 133) were examined. Participants in both samples completed the Dimensional Assessment of Personality Pathology-Basic Questionnaire and reported whether they had ever had a lifetime suicide attempt. Comorbid psychopathology was based on self-reported questionnaire and interview data. Univariate and multivariate logistic regression analyses were run, predicting a lifetime suicide attempt.

RESULTS

Based on the Dimensional Assessment of Personality Pathology-Basic Questionnaire, identity problems were associated with a lifetime suicide attempt in both samples; cognitive dysregulation, anxiousness and insecure attachment were associated with a lifetime suicide attempt in one but not both samples. Lifetime anxiety disorder was associated with a lifetime suicide attempt in one sample, and depression was associated with a lifetime suicide attempt in both samples. Multivariate analyses revealed that only depression was uniquely associated with a lifetime suicide attempt in both samples.

DISCUSSION

Although personality traits associated with aspects of emotion dysregulation were associated with a lifetime suicide attempt, depression was found to have the strongest association with a lifetime suicide attempt in two samples of women with BN. These findings suggest that depression severity may be the most important target of treatment and suicide prevention efforts in women with BN.

The joint influence of acquired capability for suicide and stoicism on over-exercise among women

We investigated longitudinal relationships among eating disorder behaviors, stoicism, and the acquired capability for suicide (ACS), which is a construct comprised of pain tolerance and fearlessness about death. University students (n=150) completed assessments measuring stoicism, ACS, and eating disorder behaviors at two time points approximately 30days apart. Among women, there was a quadratic relationship between ACS and over-exercise behaviors, such that as ACS increased the positive association between ACS and over-exercise became more pronounced. Further, among women, ACS moderated the relationship between stoicism and over-exercise, such that high levels of ACS in combination with stoicism predicted increases in over-exercise. Results suggest that ACS in combination with stoicism may lead women to engage in more eating disordered behaviors, like over-exercise.

Disordered eating attitudes, alexithymia and suicide probability among Turkish high school girls

We aimed to examine association between disordered eating attitudes (DEAs), alexithymia and suicide probability among adolescent females and to explore potential link between alexithymia and suicide probability in subjects with DEAs. 381 female students completed Eating Attitude Test (EAT-26), Toronto Alexithymia Scale (TAS-20) and Suicide Probability Scale (SPS). It was found that 13.2% (n=52) of the subjects have DEAs. Results indicated that total TAS-20 score and scores of Difficulty in Identifying Feelings (DIF) and Difficulty in Describing Feelings (DDF) subscales were significantly higher in DEAs group than in those non DEAs group (p<0.05). Additionally, total SPS score (p<0.001), Hopelessness (p=0.001), Suicide Ideation (p<0.001) and Hostility (p=0.003) subscales scores of SPS were significantly higher in the alexithymic DEAs than the non-alexithymic DEAs group. In order to control potential effect of depression, SPS subscales were used as covariate factors in ANCOVA. Negative Self-Evaluation subscale yielded a statistically significant difference between groups, other subscales did not. Results point out these; DEAs are relatively frequent phenomenon among female students in Turkey and presence of alexithymia was associated with an increased suicide probability in adolescents with DEAs. The results should be evaluated taking into account that depressive symptomatology was not assessed using a depression scale.

Attempted Suicide in Patients With Eating Disorders

Background: Suicide is a major cause of mortality for patients with eating disorders (ED), especially for patients with anorexia nervosa. Attempted suicide is also relatively common in patients with anorexia or bulimia nervosa. Aims: This study aimed at examining associations between attempted suicide and trait- and state-dependent characteristics in a large clinical population of ED patients. Method: The sample consisted of 1,436 in- and outpatients of the Centre for Eating Disorders of the Ghent University Hospital. Measures of ED symptoms, psychopathology, and personality traits were compared between ED patients with and ED patients without a history of attempted suicide. Results: A history of attempted suicide was found in 11.8% of the ED patients and lifetime suicidal ideation was reported by 43.3%. Multivariate analyses showed that a history of attempted suicide was associated with higher scores on depression, purging symptomatology, early-developed cognitive schemes (impaired autonomy and increased inhibition), and social insecurity. Conclusion: These findings support the increased risk of suicidal behavior in ED. The presence of particular personality traits, of cognitive schemes, and of purging and depressive symptoms should increase vigilance for suicidal behavior.

Suicide attempts in women with eating disorders

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.

Self-image and suicide in a Swedish national eating disorders clinical register

OBJECTIVE

Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors.

METHOD

Women (N=2269) aged 12 to 45 (M=22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register.

RESULTS

Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt.

CONCLUSION

Assessing self-image might assist with identifying women with BN at elevated risk for suicide.

Correlates of suicide ideation and attempts in children and adolescents with eating disorders

This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7-18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.

Attitudes toward life and death and suicidality among inpatient female adolescents with eating disorders

This study investigated whether attitudes about life and death are associated with suicidal behavior in eating disorders (EDs). We examined 43 nonsuicidal inpatients with EDs, 32 inpatients with EDs who attempted suicide, and 21 control participants with scales assessing attitudes to life and death, body-related attitudes, core ED symptoms, depression, and anxiety. Both ED groups showed less attraction to life and more repulsion from life than did the control participants. The suicide attempters showed greater attraction to death, less repulsion from death, and more negative attitudes toward their body than did the nonsuicidal ED and control participants. Fear of life was associated with elevated depression, body-related problems, and childhood sexual abuse. Pathological attitudes toward death were associated with greater depression and body-related problems. Suicide attempts were found in the inpatients with EDs showing binge/purge ED pathology and maladaptive attitudes toward death. This study suggests that whereas fear of life is a core feature of an ED, maladaptive attitudes toward death appear only in ED patients who have attempted suicide.

Comorbidity-independent risk for suicidality increases with bulimia nervosa but not with anorexia nervosa

BACKGROUND

Eating disorders are serious psychiatric illnesses with high levels of suicidality and high comorbidity. However, no study has established the extent to which suicidality is uniquely associated with eating disorders rather than attributable to comorbid mood, anxiety, or substance use disorders. The current study examined whether unique associations between eating disorders and suicidality exist and whether potential associations differ by eating disorder diagnosis.

METHODS

Participants were women (n = 364) from the second stage of a large epidemiological study examining eating and health related attitudes and behaviors. The Structured Clinical Interview for Axis I diagnoses (SCID-I) was used to determine lifetime psychiatric diagnoses and lifetime suicidality.

RESULTS

A multiple regression model including eating and comorbid disorders indicated that bulimia nervosa (BN) was significantly associated with suicidality above and beyond risk predicted by comorbid disorders. No unique association was found for anorexia nervosa (AN) or eating disorder not otherwise specified while controlling for comorbidity.

CONCLUSIONS

BN is independently associated with suicidality, and findings emphasize the need to incorporate suicide risk assessment in standardized assessments of eating disorders.

Exercise caution: over-exercise is associated with suicidality among individuals with disordered eating

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.

Suicide attempts in 107 adolescents and adults with kleptomania

Suicide attempts in kleptomania have received little investigation. This study examined rates, correlates, and predictors of suicide attempts in kleptomania. A total of 107 adolescent and adult subjects (n = 32 [29.9%] males) with DSM-IV kleptomania were assessed with standard measures of symptom severity, psychiatric comorbidity, and functional impairment. Subjects had high rates of suicide attempts (24.3%). The suicide attempt in 92.3% of those who attempted suicide was attributed specifically to kleptomania. Suicide attempts were associated with current and life-time bipolar disorder (p = .047) and lifetime personality disorder (p = .049). Individuals with kleptomania have high rates of suicide attempts. Bipolar disorder is associated with suicide attempts in individuals with kleptomania and underscores the importance of carefully assessing and monitoring suicidality in patients with kleptomania.

Characteristics of suicide attempts in anorexia and bulimia nervosa: a case-control study

Objective

Compared to other eating disorders, anorexia nervosa (AN) has the highest rates of completed suicide whereas suicide attempt rates are similar or lower than in bulimia nervosa (BN). Attempted suicide is a key predictor of suicide, thus this mismatch is intriguing. We sought to explore whether the clinical characteristics of suicidal acts differ between suicide attempters with AN, BN or without an eating disorders (ED).

Method

Case-control study in a cohort of suicide attempters (n = 1563). Forty-four patients with AN and 71 with BN were compared with 235 non-ED attempters matched for sex, age and education, using interview measures of suicidal intent and severity.

Results

AN patients were more likely to have made a serious attempt (OR = 3.4, 95% CI 1.4–7.9), with a higher expectation of dying (OR = 3.7,95% CI 1.1–13.5), and an increased risk of severity (OR = 3.4,95% CI 1.2–9.6). BN patients did not differ from the control group. Clinical markers of the severity of ED were associated with the seriousness of the attempt.

Conclusion

There are distinct features of suicide attempts in AN. This may explain the higher suicide rates in AN. Higher completed suicide rates in AN may be partially explained by AN patients' higher desire to die and their more severe and lethal attempts.

Suicide attempts in anorexia nervosa subtypes

OBJECTIVE

The risk for suicide attempts is elevated in anorexia nervosa (AN), yet we know little about the relation between suicide and personality in this group. We explored the prevalence of lifetime suicide attempts in women with AN and compared those who had and had not attempted suicide on eating disorder symptoms, general psychopathology, and personality both relative to a healthy control group and then across AN subtypes.

METHOD

One hundred four outpatients with restricting AN, 68 outpatients with purging AN, and 146 comparison individuals participated in the study.

RESULTS

The prevalence of suicide attempts differed significantly across the 3 groups (P = .003), with 0% in the controls, 8.65% in the restricting AN group, and 25.0% in the purging AN group. Depression measures were elevated in those with suicide attempts. Within the restricting AN group, those who attempted suicide scored significantly higher on Phobic Anxiety, measured by means of the Symptom Checklist-Revised, than those who did not (P = .001).

CONCLUSION

The presence of purging and depressive symptoms in individuals with AN should increase vigilance for suicidality; and among restrictors, greater anxiety may index greater suicide risk.

Suicidal behavior and depression in adolescents with eating disorders

BACKGROUND

Eating disorders are associated with an increased risk of suicide.

AIM OF THE STUDY

To examine suicidal behavior and depression in adolescents with eating disorders, and to identify risk factors associated with suicidal ideation and attempted suicide.

METHODS

Forty-six Israeli adolescent girls with anorexia nervosa or bulimia nervosa completed a self-report battery at the time of assessment or treatment. Suicide attempts and suicidal ideation were investigated in relation to clinical (e.g. body mass index, purging) and psychological (e.g. body dissatisfaction) features of the eating disorders, as well as depression. Twenty-four percent of the subjects had attempted suicide, and 65% reported suicidal thoughts. Fifty-eight percent were moderately to severely depressed.

FINDINGS

The risk of attempted suicide was associated with depression, a history of sexual abuse and longer duration of illness, but it was moderated by hospital treatment. Suicidal ideation was related only to depression.

CONCLUSIONS

The results of this study emphasize the importance of treating aggressively depression in adolescents with eating disorders. Depression seems to amplify illness severity. Currently, strategies for treating eating disorders focus more on the eating disorder behaviors and less on depression. We suggest investing more resources in detecting and treating the co-morbid depression.

Differences in non-suicidal self-injury and suicide attempts in adolescents

As suicide attempts and self-injury remain predominant health risks among adolescents, it is increasingly important to be able to distinguish features of self-harming adolescents from those who are at risk for suicidal behaviors. The current study examined differences between groups of adolescents with varying levels of self-harmful behavior in a sample of 373 high school students with a mean age of 15.04 (SD = 1.05). The sample was 48% female and the distribution of ethnicity was as follows: 35% Caucasian, 37.2% African-American, 16% Multi-ethnic, 9.2% Hispanic, and 2.3% Asian. The sample was divided into three groups: no history of self-harm, non-suicidal self-injury (NSSI) only, and NSSI in addition to a suicide attempt. Differences in depressive symptoms, suicidal ideation, social support, self-esteem, body satisfaction, and disordered eating were explored. Results indicated significant differences between the three groups on all variables, with the no self-harm group reporting the lowest levels of risk factors and highest levels of protective factors. Further analyses were conducted to examine specific differences between the two self-harm groups. Adolescents in the NSSI group were found to have fewer depressive symptoms, lower suicidal ideation, and greater self-esteem and parental support than the group that also had attempted suicide. The clinical implications of assessing these specific psychosocial correlates for at-risk adolescents are discussed.

The validity and utility of subtyping bulimia nervosa

OBJECTIVE

To review the evidence for the validity and utility of subtyping bulimia nervosa (BN) into a purging (BN-P) and a nonpurging subtype (BN-NP), and of distinguishing BN-NP from binge eating disorder (BED), by comparing course, complications, and treatment.

METHOD

A literature search of psychiatry databases for studies published in peer-reviewed journals that used the DSM-definitions of BN and BED, and included both individuals with BN-NP and individuals with BN-P and/or BED.

RESULTS

Twenty-three studies compared individuals with BN-NP (N = 671) to individuals with BN-P (N = 1795) and/or individuals with BED (N = 1921), two of which reported on course, 12 on comorbidity and none on treatment response-the indicators for validity and clinical utility. The differences found were mainly quantitative rather than qualitative, suggesting a gradual difference in severity from BN-P (most severe) through BN-NP to BED (least severe).

DISCUSSION

None of the comparisons provided convincing evidence for the validity or utility of the BN-NP diagnosis. Three options for the position of BN-NP in DSM-V were suggested: (1) maintaining the BN-NP subtype, (2) dropping nonpurging compensatory behavior as a criterion for BN, so that individuals currently designated as having BN-NP would be designated as having BED, and (3) including BN-NP in a broad BN category.

The role of body image and disordered eating as risk factors for depression and suicidal ideation in adolescents

There is much empirical literature on factors for adolescent suicide risk, but body image and disordered eating are rarely included in these models. In the current study, disordered eating and body image were examined as risk factors for suicide ideation since these factors are prevalent in adolescence, particularly for females. It was hypothesized that disordered eating and body image, in addition to depressive symptoms, would contribute to suicide ideation. It was also hypothesized that these relationships would be stronger for females than for males. Structural equation modeling was used to test a model of risk for suicide ideation incorporating the above factors in a sample of 392 high school students. Results indicated that disordered eating contributed to both suicide ideation and depressive symptoms, while body image only contributed to depressive symptoms. Depressive symptoms contributed to suicide ideation. The model was found to be cross-validated with males and females, and no gender differences emerged. Implications of these findings and their importance in constructing future models of adolescent suicide risk are discussed.

Suicide attempts in anorexia nervosa

OBJECTIVE

To explore prevalence and patterns of suicidal attempts in persons with anorexia nervosa (AN).

METHODS

Participants were the first 432 persons (22 male, 410 female) enrolled in the NIH funded Genetics of Anorexia Nervosa Collaborative Study. All participants had current or lifetime AN. The participants ranged in age from 16 to 76 (mean = 30.4, SD = 11.3). Suicidal behavior and intent was assessed via the Diagnostic Interview for Genetic Studies. We compared frequency and severity of attempts across diagnostic subtypes and comorbidity, and personality features associated with the presence of suicide attempts in persons with AN.

RESULTS

About 16.9% of those with AN attempted suicide. Significantly fewer persons with the restricting subtype (7.4%) reported at least one attempt than those with purging AN (26.1%), AN with binge eating (29.3%), and a mixed picture of AN and bulimia nervosa (21.2%). After controlling for major depression, suicide attempts were associated with substance abuse, impulsive behaviors and traits, Cluster B personality disorders, panic disorder, and post-traumatic stress disorder as well as low self-directedness and eating disorder severity.

CONCLUSIONS

Suicide attempts in AN are not uncommon, are frequently associated with the intention to die, occur less frequently in persons with the restricting subtype of the illness, and after controlling for depression are associated with a constellation of behaviors and traits associated with behavioral and affective dyscontrol.

Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders

OBJECTIVE

The objective of the present study was to identify factors associated with suicidal behaviors among patients with eating disorders.

METHOD

A large database including sociodemographic and clinical characteristics of 1,009 consecutive patients hospitalized for an eating disorder in Paris, France, was examined. Data gathered upon admission to hospital were analyzed to identify factors associated with a history of suicide attempt or current suicidal ideation, among the whole sample as well as among each subtype of eating disorder.

RESULTS

Among the whole sample, the factor most strongly associated with suicide attempt or suicidal ideation was the diagnostic category, with the highest odds ratio for bulimia nervosa followed by anorexia nervosa of the binging/purging subtype. Among diagnostic subgroups, the strongest factors were drug use, alcohol use, and tobacco use.

CONCLUSION

Suicide risk should be monitored carefully among patients with eating disorders, paying particular attention to combinations of risk factors.

Clustering of eating disorder symptoms in a general population female twin sample: a latent class analysis

BACKGROUND

Previous studies have reported that the current DSM-IV eating disorder (ED) criteria do not adequately describe ED symptomatology. The objective of the current study was to examine the clustering of ED symptoms in a general population sample using latent class analysis (LCA).

METHOD

ED symptoms from 3723 female young adult twins (mean age 22) were analyzed using LCA, and resulting classes were compared on external validators reflecting ED and other co-morbid psychiatric diagnoses, substance use disorders (SUDs), and suicidality.

RESULTS

The optimal solution consisted of five latent classes characterized as: (1) Unaffected; (2) Low Weight Gain; (3) Weight Concerned; (4) Dieters; and (5) ED. Members of the ED class had significantly higher prevalence of co-morbid psychiatric disorders, SUDs, and suicidality than the Unaffected and Low Weight Gain classes, and elevated rates of suicidality and major depression compared to the Weight Concerned and Dieter classes, which differed from each other primarily in terms of current body mass index (BMI). Dieter class members were more likely to be overweight and obese and less likely to be underweight than Weight Concerned class members. The majority of women with an ED diagnosis were assigned to the ED class, and few differences were found between ED class members with and without an ED diagnosis.

CONCLUSIONS

The results add to the evidence that many women with significant ED psychopathology are not being identified by the DSM-IV ED categories.

Suicide and attempted suicide in eating disorders, obesity and weight-image concern

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Meta-analyses have shown that individuals suffering from anorexia nervosa and bulimia nervosa commit suicide more often than their counterparts in the general population; also a few studies have suggested that suicide is the major cause of death among patients with anorexia nervosa, refuting the assumption that inanition generally threatens the life of these patients. Data concerning suicide in bulimia nervosa, on the other hand, are still scarce but suicide attempts are easily found among cohorts of patients with bulimia nervosa, which constitutes a risk factor for completed suicide. Suicidality in obesity and individuals with disturbed weight status has been reported. Both in the case of bulimia nervosa and obesity more long-term follow-up studies need to be completed before the risk of suicide for such disorders may be compared with that for anorexia nervosa.

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

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.

Suicide attempts versus suicidal ideation in bulimic female adolescents

BACKGROUND

Suicide attempts by adolescents continue to be a major public health problem. The purpose of this study was to examine the difference in the family functioning and sociopsychopathological risk factor relationship between female bulimic adolescents with suicidal ideation only, and those who attempted suicide.

METHODS

A group of 211 patients were observed for 12 months. Data from 63 subjects (SUG [suicide group], age 17.2 +/- 1.3 years) who had attempted suicide were then compared with 148 (control group, age 18.1 +/- 1.5 years) who had expressed suicidal ideation but did not follow through.

RESULTS

Those in the suicide attempt group had been exposed more frequently to physical/sexual violence in childhood. As adults they either lived alone or were dissatisfied with their partnership. The frequency of borderline personality disorders and depressive disorders in this group was significant. Psychosomatic symptoms, disturbed coenesthesia, substance abuse, social impairment and interference with their perception of their own life circumstances, as well as their job performance, often preceded the suicide attempt. Nine genuine risk factors that occurred significantly more often in the SUG were calculated out of all the stress factors using stepwise logistic regression: 'as a child I was even hit with a stick or whip', 'I had no set orientation in life', 'I had a feeling of loneliness despite family and friends', 'I could not relax', 'incapable of dealing with the public', 'I do not like to be touched', 'parents have psychiatric disorders', 'misuse of stimulants', and 'as a child I felt lonely' (odds ratio, 10.56-1.90).

CONCLUSION

Adverse family experiences and multiple sociopsychopathological factors may increase the risk of suicide in female bulimic adolescents.

Familial and sociopsychopathological risk factors for suicide attempt in bulimic and in depressed women: prospective study

OBJECTIVE

This study was carried out to examine sociopsychopathological predictors of prospective observed suicide attempts in bulimic women purging type without comorbid major depression (BNG) at the time of study entry and in woman with major depression without comorbid eating disorder at the time of study entry (MDG).

METHODS

Data from 28 BNG (age 23.5 +/- 3.6) and 126 MDG women (age 33.4 +/- 5.1) who had attempted suicide during 12 months' monitoring were compared.

RESULTS

A univariate comparison of the two groups revealed various differences. Analysis of risk factors for suicide attempts using stepwise logistic regression was conducted separately for each group. The derived logistic models showed that patients from the BNG group had a history of higher incidence of sexual abuse in childhood, as well as abuse of laxatives and illicit drugs; they also lacked orientation in life, felt lonely despite family and friends, tended to direct their anger outward, and were unable to relax.

CONCLUSIONS

Sociopsychopathological risk factors for suicide attempts in the BNG and MDG appear to vary.

Psychopathological distress predicts suicidal ideation and self-harm in adolescent eating disorder outpatients

OBJECTIVE

This study evaluated the differences in suicidal behaviour between adolescent anorexia nervosa (AN) and bulimia nervosa (BN), and the association of age, menarche timing, duration of eating disorder (ED), depression and general psychopathological symptoms (GSI) with suicidal behaviour in adolescent ED.

METHODS

The study group comprised 57 adolescent outpatients (girls) attending for assessment because of eating disorders. Suicidal ideation, deliberate self-harm and suicidal attempts were assessed in self-report questionnaires.

RESULTS

In both ED groups, one adolescent had attempted suicide before assessment. Suicidal ideation and/or deliberate self-harm were reported in over half of the cases. Bulimics had significantly more suicidal ideation and deliberate self-harm than anorectics. In multivariate analysis, BN and depression predicted suicidal ideation, but only GSI persisted as predicting deliberate self-harm.

CONCLUSIONS

Suicidal behaviour is common in adolescent ED. Type of ED (BN), depression and higher GSI are strongly associated with suicidal ideation and deliberate self-harm. Our results point to the need to evaluate psychopathological symptoms in adolescent ED, especially in BN, in the initial assessment to prevent severe suicidal behaviour.