Avoidant restrictive food intake disorder and suicidal ideation
Most DSM-5 eating disorder diagnoses are associated with elevated suicide risk; however, little is known about the relationship between Avoidant/Restrictive Food Intake Disorder (ARFID) and suicidal ideation. The aim of the current study was to examine suicidal ideation within an adult ARFID sample. Patients with eating disorders (N = 936), some of whom met criteria for a current DSM-5 diagnosis of ARFID (n = 79), completed the Beck Depression Inventory II Item 9, regarding suicidal ideation. The study was conducted within an eating disorder treatment facility that offers inpatient, residential, partial hospitalization program, and intensive outpatient levels of care. Findings suggest no significant pairwise differences in suicidal ideation prevalence between participants with ARFID and those with any other ED diagnosis. Thorough screening for suicidal thoughts and risk among those with ARFID is warranted at all levels of care. We suggest that future research expand upon this work in a larger adult ARFID sample.
Introduction
Eating disorders (EDs) are serious mental illnesses with high mortality rates, including deaths by suicide (Smith et al., 2018). One-quarter to one-third of individuals with ED diagnoses experience suicidal ideation. Additionally, an ED diagnosis significantly increases the likelihood of suicide attempts (odds ratio of 2.19) relative to the general population (Smith et al., 2018). Furthermore, prior meta-analyses suggest that suicide risk in EDs is much higher, for example, suicide mortality ratios of 18-35 times greater than that of the general population among those with AN (Keshaviah et al., 2014; Preti et al., 2011).
Ideation may be considered less serious than suicidal behavior because it refers specifically to thoughts surrounding death rather than suicide attempts or deaths, although Jobes and Joiner argued that ideation is also of importance clinically (Jobes and Joiner, 2019). Specifically, suicidal ideation is the most common manifestation of suicidality and can impart future risk towards suicide attempts and/or death by suicide as lethal attempts oftentimes frequently include suicidal desire, consideration, and planning (Joiner, 2005). Recent research suggests that suicidal ideation prevalence and intensity may be quite consistent across various EDs (e.g., Anorexia Nervosa [AN], Bulimia Nervosa [BN], Binge-Eating Disorder [BED], and Other Specified Feeding or Eating Disorder [OSFED]; Duffy et al., 2021). This is not the first study to address suicidal ideation among individuals with Avoidant/Restrictive Food Intake Disorder (ARFID), but rather it is to our knowledge the first to compare ARFID to other ED groups within an adult population.
ARFID is a relatively new DSM diagnosis, first appearing in DSM-5, characterized by an extremely restricted dietary intake regimen resulting in some combination of significant weight loss, significant nutritional deficiency, need for enteral feeding or oral nutritional supplements, and/or a marked interference in psychosocial functioning, all in the absence of shape and weight concerns (American Psychiatric Association, 2013). Notably, ARFID can have independent symptoms from other EDs (e.g., fears around choking and vomiting) but still has levels of distress and impairment comparable to those seen in both AN and BN (Zickgraf et al., 2016). Moreover, in one study, 12% of ARFID participants developed body image concerns and their diagnoses were changed to AN (Norris et al., 2014) suggesting that ARFID may, in some cases, be a precipitant of AN. Although ARFID is less present in the literature than other EDs, a large study of 5,737 Australians found a prevalence rate of 0.3%, in comparison to 0.4-0.5% for AN (Hay et al., 2017). However, other studies have reported higher rates of ARFID symptoms in adults ranging from 0.8 to 4.8% (Chua et al., 2022, 2021; Fitzsimmons-Craft et al., 2019; Hilbert et al., 2021). ARFID presents with a wide array of serious medical and psychological consequences (e.g., Nakai et al., 2016; Norris et al., 2014).
Importantly, adolescent research has indicated that patients presenting with acute symptoms of ARFID were more likely to endorse suicidal ideation and self-harm in comparison to their chronic onset peers (Dumcombe Lowe et al., 2019). Another study examining a sample of children and adolescents with ARFID found 8% reported current suicidal ideation and 14% reported lifetime ideation (Kambanis et al., 2020). Research, comparing adolescent patients with ARFID to AN or atypical AN, did not find a difference in suicidal ideation between the groups (Keery et al., 2019).
In this study, we sought to further examine suicidal ideation, a crucial indicator of clinical intensity, within an adult ARFID sample, and in comparison to other ED groups. If ARFID is found to be associated with elevated rates of suicidal ideation, as seen in other EDs, this would suggest a need for specific attention to suicide risk assessment and intervention in the treatment of ARFID patients.
