Suicide and Eating Disorders: A Co-Occurring Condition
By: Kate Daley
It’s not uncommon for an individual to experience more than one mental health condition at once.
Those with eating disorders are no exception. Depression and anxiety are two of the most common co-occurring disorders in individuals diagnosed with an eating disorder (ED). When an individual is depressed, it can be common to turn to self-injurious behaviors and suicide when suffering becomes overwhelming.
The Statistics:
Anorexia nervosa (AN) is the most lethal mental health diagnosis after opioid use disorder. Medical complications from this disorder are the first leading cause of death while suicide is the second. In relation to the general population, those with binge eating disorder (BED) and bulimia nervosa (BN) have elevated rates of suicidal behavior. Matched to comparison groups relative to age and gender, the chance is 18 times more likely for those with AN to die by suicide and seven times more likely for those with BN.
The Link:
Research suggests that eating disorders may not be the cause of suicide but rather the comorbid disorders that exist alongside them like depression and other mood disorders. Genetics and temperament also play a role in risk for EDs and suicide. While an individual may be born with certain genetic predispositions, nutritional and environmental factors can further influence outcomes. Environmental factors such as cultural and social norms and expectations, media messaging, family dynamics, access to healthcare, and level of food security compound risk. While not exclusive, traits such as perfectionism, rigidity, impulsivity, hypersensitivity, and emotional instability can increase the chance for an eating disorder to develop during difficult periods of life. Because perfectionism is a risk factor for suicide, Dr. Karen Lynn Cassiday, FAED states we need to challenge this perfectionism by, “...offer[ing] treatments that have patients practicing risk-taking, making mistakes, recovering from mistakes, laughing at mistakes, appreciating daily small experiences, and seeing the beauty in the challenge of stressors,” (Cassiday, 2018). Other research suggests that those with EDs, specifically AN, have a higher capability to die by suicide due to significant and frequent participation in painful ED behaviors. This makes sense because to complete suicide, one must have both a desire and capability to do so. Capability is determined by factors such as level of fearlessness and pain tolerance. Pain tolerance and fearlessness build over time, ultimately leading to lethal attempts. Finally, some research indicates that ED symptoms lead to increased feelings of loneliness, burdensomeness, and lack of belonging which can lead to suicidal thoughts. No matter the cause, there is a strong association between EDs and suicidality.
Risk Factors:
Illness severity, substance abuse, alexithymia, excessive exercise, and co-occurring psychiatric illnesses such as borderline personality disorder all increase the risk of an individual with an ED to experience suicidality. While self-injurious behaviors usually do not have suicidal intent, these behaviors can increase the risk of suicidality. There is a higher prevalence of non-suicidal self-injury in BN and AN binge-purge subtype patients. In terms of age, adolescents with EDs tend to have an increased risk for suicidal behavior and suicide completion. This is why it can be imperative to know the warning signs to get individuals timely and appropriate treatment.
Recognize The Warning Signs:
While this list is not at all inclusive of every sign, the following are often the most common.
Communicating with language related to suicide (i.e., “I wish I would not wake up,” “I'm going to kill myself”)
Intense feelings of shame and guilt
Expressing feeling like a burden
Feelings of intense hopelessness
Communication of suicide plans (i.e., texting, social media)
Preparing for death (i.e., giving away possessions)
Previous attempts to kill oneself
Self-harm/non-suicidal self-injury (i.e., cutting, burning, hitting)
Impulsive/risky behaviors (i.e., speeding)
Obsession or fixation with death
Changes to appearance (i.e., hygiene, weight)
Changes in usual behaviors and/or feelings
Changes in sleeping patterns (more or less sleep)
Sudden change in mood from depressed to calm or improved
What This Means:
As a result of the close tie between EDs and suicide, clinicians and caretakers must recognize warning signs, address concerning behaviors, and assess risk frequently. Clinicians are encouraged to regularly assess for suicide risk in patients with ED diagnoses due to the increased likelihood of suicidal behaviors in these individuals. Clinicians and caretakers can work with folks to help them access an appropriate level of care and treatment approach given their unique circumstances and needs.
Resources
April R Smith, Kelly L Zuromski, Dorian R Dodd, Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research, Current Opinion in Psychology,
Volume 22, 2018, Pages 63-67, ISSN 2352-250X, https://doi.org/10.1016/j.copsyc.2017.08.023.
Cassiday, K. L. (2018, August 3). Learning to live well with depression and eating disorders. National Eating Disorders Association. https://www.nationaleatingdisorders.org/blog/learning-live-well-depression-eating-disorders
Hackert, April N. et al. Journal of the Academy of Nutrition and Dietetics, Volume 120, Issue 11, 1902 - 1919.e54, https://www.jandonline.org/article/S2212-2672(20)30904-7/fulltext#secsectitle0010
Konstantinovsky, M. (2022, September 15). Suicide rates are higher in eating disorder populations - here’s what you need to know. Equip Health. https://equip.health/articles/understanding-eds/suicide-and-eating-disorders
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