Which Comes First? An Examination of Associations and Shared Risk Factors for Eating Disorders and Suicidality
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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.
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.
KeywordsEating disorders; anorexia nervosa Bulimia nervosa Binge eating disorders Suicidality Suicidal ideation; suicide attempt; suicide
Compliance with Ethical Standards
Conflict of Interest
April R. Smith, Shelby N. Ortiz, Lauren N. Forrest, and Dorian R. Dodd declare no conflict of interest.
Elizabeth A. Velkoff reports support from the National Science Foundation Graduate Research Fellowship Program under Grant No. DGE 1645475 during the conduct of the study. Any opinion, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC; 2012.Google Scholar
- 7.• Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EV, Xieyining M, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143:187–232. After reviewing 365 studies from the past 50 years, the authors concluded that the ability to predict suicide has not improved over time; studies have continued to remain homogenous due to a lack in variety of risk factors that are tested. CrossRefPubMedGoogle Scholar
- 9.Favaro A, Santonastaso P. Suicidality in eating disorders: clinical and psychological correlates. Acta Psychiatr Scand. 1997;95:508–14. https://doi.org/10.1111/j.1600-0447.1997.tb10139.x.CrossRefPubMedGoogle Scholar
- 10.Milos G, Spindler A, Hepp U, et al. Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects. Gen Hosp Psychiatry. 2004;26:129–35. https://doi.org/10.1016/j.genhosppsych.2003.10.005.CrossRefPubMedGoogle Scholar
- 11.Carano A, De Berardis D, Campanella D, et al. Alexithymia and suicide ideation in a sample of patients with binge eating disorder. J Psychiatric Pract. 2012;18:5–11. https://doi.org/10.1097/01.pra.0000410982.08229.99.CrossRefGoogle Scholar
- 12.Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68:714–23. https://doi.org/10.1001/archgenpsychiatry.2011.22.CrossRefPubMedPubMedCentralGoogle Scholar
- 16.• Smith AR, Velkoff EA, Ribeiro JD, Franklin J. Are eating disorders and related symptoms risk factors for suicidal thoughts and behaviors? A meta-analysis. Suicide Life Threat Behav. 2018 https://doi.org/10.1111/sltb.12427. Smith and colleagues conducted a meta-analysis and only included studies where there was at least one longitudinal analysis predicting suicide ideation, attempt, or death from an ED diagnosis and/or symptom. Only 14 longitudinal studies were identified, and within those studies, EDs were significant (but weak) predictors of suicide attempts, but not death.
- 17.Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health. 2000;90(2):251–7. https://doi.org/10.2105/AJPH.90.2.251.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Eichen DM, Kass AE, Fitzsimmons-Craft EE, Gibbs E, Trockel M, Taylor CB, et al. Non-suicidal self-injury and suicidal ideation in relation to eating and general psychopathology among college-age women. Psychiatry Res. 2016;235:77–82. https://doi.org/10.1016/j.psychres.2015.11.046.CrossRefPubMedGoogle Scholar
- 20.Glenn CR, Klonsky DE. Factors to consider in the assessment of suicidal thoughts and behaviors in adolescents. Symposium conducted at the meeting of Association for Behavioral and Cognitive Therapy, National Harbor, Maryland; 2012.Google Scholar
- 26.• Zerwas S, Larsen JT, Petersen L, Thornton LM, Mortensen PB, Bulik CM. The incidence of eating disorders in a Danish nationwide register study: associations with suicide risk and mortality. J Psychiatr Res. 2015;65:16–22. https://doi.org/10.1016/j.jpsychires.2015.03.003. The authors found that eating disorders significantly increase the likelihood of a suicide attempt or suicide death. Authors also identified age of onset for the different eating disorder diagnoses and found that for anorexia, the peak age of risk was earlier for males than females. CrossRefPubMedPubMedCentralGoogle Scholar
- 28.Bulik CM, Sullivan PF, Joyce PR. Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression. Acta Psychiatr Scand. 1999;100:27–32. https://doi.org/10.1111/j.1600-0447.1999.tb10910.x.CrossRefPubMedGoogle Scholar
- 31.• Forrest LN, Zuromski KL, Dodd DR, Smith AR. Suicidality in adults and adolescents with binge eating disorder: results from the National Comorbidity Survey Replication and Adolescent Supplement. Int J Eat Disord. 2017;50:40–9. https://doi.org/10.1002/eat.22582. Using a large, nationally representative adolescent and adult sample, the authors investigated relationships between binge eating disorder and suicidality. Binge eating disorder was associated with elevated odds of suicide ideation, planning, and attempt; however, this relationship weakened when controlling for comorbid conditions. Additionally, suicidality tended to occur prior to binge eating disorder onset among adults, but after binge eating disorder onset among adolescents. CrossRefPubMedGoogle Scholar
- 33.• Keshaviah A, Edkins K, Hastings ER, Krishna M, Franko DL, Herzog DB, et al. Re-examining premature mortality in anorexia nervosa: a meta-analysis redux. Comp Psychiatry. 2014;55:1773–84. https://doi.org/10.1016/j.comppsych.2014.07.017. The authors conducted a meta-analysis of 40 studies published between 1966 and 2010 in order to calculate all-cause and suicide-specific standardized mortality ratios (SMRs). The authors’ SMR estimates were lower than previous studies; participants with anorexia nervosa were found to be 5.2 times more likely to die prematurely from any cause and 18.1 times more likely to die by suicide than gender and aged matched samples. CrossRefGoogle Scholar
- 36.• Yao S, Kuja-Halkola R, Thornton LM, Runfola CD, D’Onofrio BM, Almqvist C, et al. Familial liability for eating disorders and suicide attempts: evidence from a population registry in Sweden. JAMA psychiatry. 2016;73(3):284–91. https://doi.org/10.1001/jamapsychiatry.2015.2737. This study used a large Swedish registry to investigate whether there was a shared familial risk for both eating disorders and suicide. Results revealed that significant associations between eating disorders and suicide were not fully explained by comorbid conditions. The association between eating disorders and suicide is partly influenced by familial risk factors that appear to be genetic in origin. CrossRefPubMedGoogle Scholar
- 37.Joiner TE. Why people die by suicide. Cambridge: Harvard University Press; 2005.Google Scholar
- 41.Strigo IA, Matthews SC, Simmons AN, Oberndorfer T, Klabunde M, Reinhardt LE, et al. Altered insula activation during pain anticipation in individuals recovered from anorexia nervosa: evidence of interoceptive dysregulation. Int J Eat Disord. 2013;46:23–33. https://doi.org/10.1002/eat.22045.CrossRefPubMedGoogle Scholar
- 43.• Witte TK, Zuromski KL, Gauthier JM, Smith AR, Bartlett M, Siegfried N, et al. Restrictive eating: associated with suicide attempts, but not acquired capability in residential patients with eating disorders. Psychiatry Res. 2016;235:90–6. https://doi.org/10.1016/j.psychres.2015.11.043. The authors tested whether the capability for suicide (pain tolerance and fearlessness about death) would account for the relationship between anorexia nervosa and suicide attempts within a sample of 100 eating disorder patients. Although dietary restriction was associated with past suicide attempts, anorexia diagnosis was not associated with either past suicide attempts or capability for suicide CrossRefPubMedGoogle Scholar
- 44.• Smith AR, Dodd DR, Forrest LN, Witte TW, Bodell L, Ribeiro JD, et al. Does the Interpersonal–Psychological Theory of Suicide (IPTS) provide a useful framework for understanding suicide risk among eating disorder patients? A test of the validity of the IPTS. Int J Eat Disord. 2016;49:1082–6. https://doi.org/10.1002/eat.22588. The key components of the interpersonal theory of suicide were tested in a sample of 100 eating disorder patients. The authors found that perceived burdensomeness was associated with suicidal ideation, and perceived burdensomeness and fearlessness about death were associated with past suicide attempts. However, the eating disorder groups did not have greater fearlessness about death relative to a control group or a psychiatric comparison group. CrossRefPubMedGoogle Scholar
- 47.Kwan MY, Gordon KH, Carter DL, Minnich AM, Grossman SD. An examination of the connections between eating disorder symptoms, perceived burdensomeness, thwarted belongingness, and suicide risk among undergraduate students. Suicide Life Threat Behav. 2017;47:493–508. https://doi.org/10.1111/sltb.12304.CrossRefPubMedGoogle Scholar
- 48.• Forrest LN, Bodell LP, Witte TK, Siegfried N, Bartlett ML, Goodwin N, et al. Associations between eating disorder symptoms and suicidal ideation through thwarted belongingness and perceived burdensomeness among eating disorder patients. J Affective Disord. 2016;195:127–35. Using 100 eating disorder patients, this study found that eating disorder symptoms are related to thwarted belongingness and burdensomeness. The authors concluded that eating disorder symptoms may affect suicidal behavior by elevating suicide ideation. CrossRefGoogle Scholar
- 49.• Dodd D, Smith A, Bodell L. Restraint feeds stress: the relationship between eating disorder symptoms, stress generation, and the interpersonal theory of suicide. Eat Behav. 2014;15:567–73. https://doi.org/10.1016/j.eatbeh.2014.08.004. This study looked at eating disorder symptoms, negative life events, burdensomeness, and belongingness at two time points. The authors found that dietary restraint predicted negative events at follow-up. Dietary restraint also indirectly increased burdensomeness and low belongingness. CrossRefPubMedPubMedCentralGoogle Scholar
- 50.Trujillo A, Forrest L, Claypool H, Smith A. Assessing the relationship among thwarted belongingness, perceived burdensomeness, and eating disorder symptoms. Suicide and life threatening behavior. Under review.Google Scholar
- 53.• Wade TD, Fairweather-Schmidt AK, Zhu G, Martin NG. Does shared genetic risk contribute to the co-occurrence of eating disorders and suicidality? Int J Eat Disord. 2015;48(6):684–91. https://doi.org/10.1002/eat.22421. Using a large Australian twin registry, the authors evaluated whether suicidality and eating disorders have a common genetic pathway. Results suggested that shared genetic risk factors account for the co-occurrence of eating disorders and suicidality, even when controlling for a depression diagnosis. CrossRefPubMedGoogle Scholar
- 60.• Kask J, Ekselius L, Brandt L, Kollia N, Ekbom A, Papadopoulos FC. Mortality in women with anorexia nervosa: the role of comorbid psychiatric disorders. Psychosom Med. 2016;78(8):910–9. https://doi.org/10.1097/PSY.0000000000000342. Using Swedish registers, mortality patterns were assessed within inpatient individuals with anorexia. Mortality in patients with anorexia was greater in the presence of a psychiatric comorbidity. Substance abuse, particularly alcohol use disorder, also increased mortality. CrossRefPubMedGoogle Scholar
- 70.• Forrest LN, Smith AR, White R, Joiner TE. Disconnected: an examination of interoception in individuals with suicidality. J Abnorm Psychol. 2015;124:754–63. https://doi.org/10.1037/abn0000074. The authors of this study investigated if interoceptive abilities differed among those with varying degrees of suicidality. Findings suggest that impaired interoception may be important for engaging in serious self-injury. CrossRefPubMedGoogle Scholar
- 71.• Smith A, Forrest L, Velkoff E. Out of touch: Interoceptive deficits are elevated in suicide attempters with eating disorders. Eat Disord. 2018;5(3):457–69. https://doi.org/10.1080/10640266.2018.1418243. Using two eating disorder samples, the authors found that suicide attempters and those engaging in non-suicidal self-injury had the greatest interoceptive deficits. Findings suggest that lack of access to emotion regulation strategies might link interoceptive deficits and self-injury. CrossRefGoogle Scholar
- 76.• Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clin Psychol Sci Prac. 2017;5(3):457–69. https://doi.org/10.1177/2167702617691560. The authors of this paper discuss how they used data from electronic health records to develop machine learning algorithms that accurately predicted future suicide attempts. CrossRefGoogle Scholar
- 77.• Smith AR, Zuromski K, Dodd DR. Eating disorders and suicidality: What we know, what we don’t know, and suggestions for future research. Curr Opin Psychol. 2018;22:63–7. https://doi.org/10.1016/j.copsyc.2017.08.023. This paper reviews the current suicidality literature within each eating disorder diagnosis and discussed the theoretical explanations for the elevated risk for suicidality among those with eating disorders. CrossRefPubMedGoogle Scholar
- 78.• Bryan CJ, Rudd DM. The importance of temporal dynamics in the transition from suicidal thought to behavior. Clin Psychol Sci Prac. 2016;23:21–5. https://doi.org/10.1111/cpsp.12135. This work discussed how the fluid vulnerability of theory of suicide provides a working model for conceptualizing suicide risk. CrossRefGoogle Scholar
- 79.• Nock MK, Kesser RC, Franklin JC. Risk factors for suicide ideation differ from those for the transition to suicide attempt: The importance of creativity, rigor, and urgency in suicide research. Clin Psychol Sci Prac. 2016;23:31–4. https://doi.org/10.1111/cpsp.12133. The authors of this work commented on the article by May and Klonsky (2016). The authors focus their commentary on how the meta-analysis omitted important studies and discussed how the meta-analysis was designed in a way that precludes the examination of actual risk factors for the transition from suicidal ideation to attempt. CrossRefGoogle Scholar
- 80.• May MM, Klonsky DE. What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clin Psychol Sci Prac. 2016;23:5–20. https://doi.org/10.1111/cpsp.12136. The authors of the study investigated what differentiates attempters from ideators by analyzing 27 studies. Depression, alcohol use disorders, hopelessness, gender, race, marital status, and education all were similar between the two groups. The authors found that anxiety disorders, trauma, drug use disorders, and sexual abuse history were moderately elevated in attempters compared to ideators. CrossRefGoogle Scholar
- 81.• Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, et al. Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army study to assess risk and resilience in service members (Army STARRS). JAMA Psychiatry. 2015;72(1):49–57. https://doi.org/10.1001/jamapsychiatry.2014.1754. This study used administrative data available before hospital discharge to predict suicides using machine learning methods. The strongest predictors were male sex, late age of military enlistment, criminal offenses, prior suicidality, and possessing weapons. CrossRefPubMedPubMedCentralGoogle Scholar