Managing Suicidality in Eating Disorder Patients

“Eating disorders patients are often emotionally avoidant and risk averse. So, it is particularly important as eating disorder treatment providers that we are NOT. We need to work towards acceptance and manage our own threat sensitivities so that we can assess and manage these patients’ uncomfortable symptoms. We are treating high risk patients whose behaviors or impulses can be dangerous, and suicide is a common complication of eating disorders. Knowing this, we must learn and implement strategies to manage risk at all levels of care.” -Dr. Anne Marie O’Melia

Rates of death by suicide among individuals with eating disorders are elevated compared to other mental health disorders, including depression, bipolar disorder and schizophrenia. In light of the increased rate of suicide among individuals with eating disorders, managing suicidality is imperative at all levels of care. In observance of National Suicide Prevention Awareness Month, Eating Recovery Center’s Dr. Anne Marie O’Melia explores the connection between eating disorders and suicidality as well as best practices for treating suicidal patients.

Why is suicidality so common among eating disorder patients?

Eating disorder behaviors are part of the larger spectrum of self-harm behaviors. Many eating disorder behaviors can be conceptualized as parasuicidal, which means they are characterized by disregard for or poor insight into dangers and consequences. The eating disorder can take over control of one’s decision making and values system—patients can’t work or attend school, they may lose familial and other social support and they may feel burdensome to loved ones, resulting in isolation and then intense despair. Patients may believe they can’t tolerate the distress of recovery (leaving the eating disorder, feeding themselves, gaining weight, etc.) but, at the same time, may also believe they can’t tolerate a life with the unending rules and critical feedback of their eating disorder. To cope with this distress, they use more behaviors and receive less social and familial support.  The pervasive feeling that nothing they do works can result in suicidal thoughts or attempts.

In patients with restricting anorexia nervosa (AN), death by suicide is the second leading cause of death behind cardiac complications. These patients tend to be highly rule-bound and adhere strictly to the eating disorder’s “rules.” Their symptoms are egosyntonic—in other words, their behaviors make them feel proud, joyful and correct. Discomfort associated with breaking eating disorder rules is far greater than anything they can imagine gaining from leaving the disorder. They get to a point where their brain is hijacked, and they have to follow the eating disorder’s rules, even if it means ending their lives or starving themselves to death. Patients with bulimia nervosa (BN) tend to be more impulsive and have more comorbid psychopathology, and are also at high risk for suicide. Bulimic symptoms are generally egodystonic, which means they are characterized by conflict with a person's ideal self-image and drive intense shame and fear of being caught engaging in behaviors. This combination underscores a tendency for BN patients to end their lives in a way that is more deliberate.

Which risk factors are shared for suicide and eating disorders?

Social isolation, low self-esteem and feeling burdensome to loved ones contribute to heightened risk for both suicide and eating disorders. Among eating disorder patients specifically, those at higher risk for suicide include:

• Older patients with a long duration of illness
• Lower weight patients
• Patients with comorbid substance abuse (due to impulsivity and strong family histories of psychopathology)
• Purging subtype patients (at higher risk than patients who restrict due to impulsivity and comorbid psychopathology)
• Patients with a family history of eating disorders (a recent Swedish study of suicidality in eating disorder patients found a significant familial risk factor for suicide if there is a close family member with an eating disorder)
• Patients with a history of trauma and/or abuse

How can providers manage suicidality in eating disorder patients?

As providers, we have to learn to tolerate a fair amount of risk with our patients at all levels of care. Many eating disorder patients are high risk individuals whose behaviors or impulses can be dangerous, and it is not uncommon for them to think about ending their lives, have ideas about suicide or have attempted suicide before. While a common tendency among clinicians is to send a suicidal patient to a psychiatric hospital, this is not always in the best interest of recovery. Ideally, we need to learn to manage suicidality in an appropriate eating disorder setting and not send everyone that says they want to die to the psych hospital.

While full containment at a psych center may seem safer for suicidal patients, the long term risk of harm from sending them away may be greater than that of keeping them on the eating disorder unit. A fundamental problem with sending eating disorder patients to a psych unit is that they will symptom substitute. On the psych unit, patients won’t eat and will continue to lose weight, engage in behaviors, ultimately becoming more isolated and more preoccupied with their eating disorder. Additionally, sending suicidal patients away disrupts the patient/clinician relationship. We know that relationships are fundamental to recovery—relationships replace the eating disorder. If we send patients to the psych hospital every time they scare us, we don’t develop the trusting, tolerant relationships that are integral to recovery. When patients return to the eating disorder unit from the psych hospital, they are often more difficult to treat because their eating disorder is even more engrained and they are resistant toward treatment providers. Practitioners must balance patients’ hopelessness, despair and suicidality while supporting them in their recovery. That means showing up for our patients especially when they are suicidal and reminding them that we can tolerate their despair and carry their hope even when they have lost all hope. Of course there are circumstances in which a patient is too dangerous to themselves or others to stay on an eating disorder unit, and the long term risks of sending them away should be kept in mind when deciding whether to move a patient to a psych unit. Outpatient providers should familiarize themselves with contained, medically-supported inpatient treatment centers and refer suicidal patients as necessary, while practitioners on inpatient units must work continuously to ensure effective systems are in place to manage suicidal patients and keep them safe on the unit.

How is physician involvement helpful in managing suicidality?

Regardless of suicidality, all patients should have a physician that knows their story and collaborates with the treatment team at every level of care due to the medical and psychiatric concerns associated with eating disorders. A clear best practice for managing suicidal eating disorders patients in the inpatient setting is close involvement of full-time physicians.  This heightened medical and psychiatric support affords the ability to carefully monitor medication and perform a safety intervention at any time, ultimately allowing us to tolerate more risk on the eating disorder unit and keep suicidal patients in treatment.

How does Acceptance and Commitment Therapy (ACT) address suicidality?

The ACT therapeutic model works quite well for suicidality—it is effective for all feelings and thoughts, but can be particularly effective with scary thoughts. ACT asks patients to observe thoughts without judgment and separate thoughts and feelings from action. In other words, what we tell ourselves about the thought is more important than the thought itself, and it doesn’t have to drive action. For example, if a patient has a suicidal thought, ACT asks them to stop and think about the thought, examine the intensity of the thought, observe the thought and consider the notion that just because they feel they want to end their life doesn’t mean they will end their life. They can feel badly, recognize great emotional pain, accept this pain and tolerate discomfort without having to do anything about it. Because ACT is increasingly being used to address eating disorder thoughts, there’s a compelling continuity of treatment approach for eating disorder patients with suicidality. Patients acknowledge eating disorder thoughts are there and that there is an urge, but that doesn’t mean they have to engage in behaviors or let the thought drive their action. ACT fosters an understanding that what they do about the thought either moves them toward a life of meaning and values, or it moves them away from what is important to them.

Statistics: Eating Disorders and Suicide

• The suicide mortality rate in people with anorexia nervosa (AN) is the highest of any psychiatric illness. (1) Individuals with AN are 31 times more likely to make a fatal suicide attempt than the general population, and more than half of AN deaths are a result of suicide and not the medical complications of self-starvation. (2)
• Individuals with bulimia nervosa (BN) are nearly eight times more likely to die by suicide than the general population (3) and 1/3 of women with BN will attempt suicide at least once. (4)
• Individuals with binge eating disorder (BED) have been found to have a higher suicide rate than general population (5) and approximately 15 percent of adolescents with BED having attempted suicide. (6)

Sources

1. Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731.
2. Keel, P. K., Dorer, D. J., Eddy, K. T., Franko, D. L., Charatan, D. L., & Herzog, D. B. (2003). Predictors of mortality in eating disorders. Archives of General Psychiatry, 60(2), 179-183.
3. Preti, A., Rocchi, M. B. L., Sisti, D., Camboni, M. V., & Miotto, P. (2011). A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatrica Scandinavica, 124(1), 6-17.
4. Corcos, M., Taïeb, O., Benoit-Lamy, S., Paterniti, S., Jeammet, P., & Flament, M. F. (2002). Suicide attempts in women with bulimia nervosa: frequency and characteristics. Acta Psychiatrica Scandinavica, 106(5), 381-386.
5. Grucza, R. A., Przybeck, T. R., & Cloninger, C. R. (2007). Prevalence and correlates of binge eating disorder in a community sample. Comprehensive Psychiatry, 48(2), 124-131.
6. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.