Staff Perspective: Eating Disorders and Suicide Risk

Staff Perspective: Eating Disorders and Suicide Risk

Dr. Lisa French

September is National Suicide Prevention Awareness Month. This month is dedicated to focusing awareness on training and resources specific to suicide prevention with the hope of decreasing stigma and increasing help-seeking behavior. When deciding what to write about, I wanted to focus on two areas that have really been pivotal in my clinical career path: eating disorders (EDs) and suicide prevention. Early in my graduate studies, my clinical focus was on the assessment and treatment of EDs. However, once I became a military psychologist, and especially after joining CDP, my work has been more focused on suicide prevention. Given my background, I thought this would be a good opportunity to address the ED-suicide link, especially since both EDs and suicide are often considered taboo, stimagtized topics in our society.

The three EDs that I will focus on are Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). Per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychological Association, 2013), AN is characterized by a distorted body image and restricted dietary intake that leads to severe weight loss with an intense fear of gaining weight or becoming fat. BN is defined by episodes of binge eating (i.e., eating an unusually large amount of food in a short period of time with feelings of lack of control during the episode) followed by various forms of inappropriate compensatory behavior, such as self-induced vomiting or excessive exercise to avoid weight gain. BED is classified as recurring episodes of binge eating without inappropriate compensatory behaviors.

Before even considering suicide risk, it is important to note that EDs are one of the most fatal mental health disorders in the United States due to serious medical complications that can arise from disordered eating and compensatory behaviors with some data showing that AN is surpassed only by substance use disorders for higher mortality risk (Chesney et al., 2014). Additionally, although suicide risk is transdiagnostic, certain mental health conditions, such as EDs, can increase suicide risk. Suicide deaths are more common in those with AN than other EDs (Franko & Keel, 2006), with a meta-analysis of 36 studies showing that one in five deaths of individuals with AN was due to suicide (Arcelus et al., 2011), making it the second leading cause of death for that population. However, we also know that suicidal behavior is elevated in both BN and BED relative to the general population (Crow et al., 2009; Forrest et al., 2017; Udo et al., 2019). When looking at specific ED behaviors (e.g., restricting, binging, purging), research has shown that purging behaviors are an important indicator for suicide risk for both suicide attempts (Bulik et al., 2008, Favaro & Santonastaso, 1997; Franko & Keel, 2006; Milos et al., 2004) and suicidal ideations (Joiner et al., 2022).

There are several explanations for the ED-suicide link. I am going to focus on two here that are nicely outlined by Smith and colleagues (2018). First, we know that individuals with EDs are likely to have co-occurring mental health disorders which are also associated with suicide risk, such as mood disorders, anxiety, and substance/alcohol abuse (Bulik et al., 2008; Franko et al., 2004; Franko & Keel, 2006). Franko and Keel (2006) also found that a history of childhood physical and/or sexual abuse is a correlate of suicidality in individuals with EDs.

A second possible explanation for the heightened risk of suicide in those with ED is Joiner’s Interpersonal Psychological Theory of Suicide (IPTS), which is a suicide-specific theory utilizing an ideation-to-action framework. IPTS posits that for individuals to have suicidal thoughts/urges they must feel like they are a burden to others (perceived burdensomeness) and like they don’t belong (thwarted belongingness). However, for individuals to move from ideations to actual behavior they need to possess the capability for suicide (acquired ability), which involves having a fearlessness about death and an increased pain tolerance, along with the knowledge of how to enact lethal means. Although it has not always held up in research, Joiner (2005) proposed that individuals with EDs have an increased capability for suicide as their frequent engagement in painful behaviors allows for habituation. Research has more consistently shown support for perceived burdensomeness to heighten suicide risk in those with EDs, specifically that ED patients may feel like a burden to others, and that this perceived burdensomeness then increases suicidal thinking (Smith et al., 2016, Zeppegno et al., 2021).

Although most of the ED research data we have is focused on the general population, we are starting to see more research looking at the prevalence of EDs in military-connected individuals. Williams and colleagues (2018) reported there was a 44.7% increase in crude annual incidence rates of total EDs identified in active component Service members between 2013 and 2016, with higher incidence rates for Service members who were female and younger in age (29 years or younger). Another study found that military family members are more likely than their civilian counterparts to experience disordered eating with 21% of military children (dependent female adolescents) and 26% of the parent population reporting abnormal eating attitudes and behaviors (Waasdorp et al., 2007).

One likely contributing factor for Service members developing EDs is the focus on staying fit to meet the military’s weight and physical fitness standards. Service members can feel a lot of pressure to look a certain way, especially when in uniform, which can then lead to body image issues and weight stigma. Additionally, not meeting fitness standards can directly impact their military career (i.e., administrative discharge). Service members can also experience military-related stressors (e.g., trauma, deployment) that can trigger maladaptive eating behaviors as well as increase the chances of them experiencing co-morbid conditions such as mood disorders, anxiety disorders, and PTSD. One recent study showed that military sexual trauma was associated with EDs while combat exposure was not, with women who reported a military sexual trauma having twice the odds of meeting criteria for an ED compared to women who did not report a military sexual trauma (Breland et al., 2018). Military family members also experience military-related stressors (e.g., frequent moves, family separations) that can impact psychological functioning, which can then increase risk for eating disorders.

So, what do we need to know as providers? First, we need to be aware of risk factors and warning signs of EDs. EDs can arise from a combination of longstanding psychological, interpersonal, and social conditions as well as biological factors.

  • Psychological: As mentioned above, individuals with EDs often have comorbid disorders such as anxiety, substance/alcohol abuse, and mood disorders. Many of these conditions carry with them their own suicide risk. Additional psychological risk factors are exposure to stressful events, body image issues, feelings of inadequacy and loneliness, emotional instability, personality traits such as perfectionism and impulsivity, and a lack of appropriate coping skills.
  • Interpersonal: Families who place a strong emphasis on intellectual, cultural and recreational achievement may play a role in the development of EDs. EDs are often used as a coping strategy for individuals (especially young women) who have suffered social and behavioral disturbances. EDs allow them to be in control of at least one thing in their life, in this case food.
  • Social: This can include cultural factors, peer pressure, and messages from traditional/social media that affect both men and women. Women especially are socialized into being concerned with their appearance and to make efforts to enhance their beauty. Social pressures to be thin often promote poor body image, which in turn may prompt dieting efforts or EDs. This includes pressure for racial and ethnic minority groups to assimilate to Western ideals of beauty and ways of life.
  • Biological: Individuals who have a family history of EDs are at increased risk, especially if it is present in an immediate family member such as a parent or sibling. Additional biological factors include engaging in dieting behaviors and physical changes to the body such as puberty and menopause.

EDs are serious mental health disorders associated with high levels of comorbidity and suicide risk. Therefore, early detection is vital. As providers, being aware of ED symptoms/warning signs is important. The below list is not exhaustive, but includes some common symptoms and warning signs of EDs (from the National Center of Excellence for Eating Disorders, the National Eating Disorder Association, and the National Institute of Mental Health):

  • Spending a lot of time thinking and talking about eating and food
  • Preoccupation with weight and shape to include body checking and excessive self-weighing
  • Eating when stressed or when feeling uncertain of how to cope
  • Hiding, hoarding or discarding food
  • Eating alone because of feeling embarrassed about how one eats
  • Food rituals such as cutting food into small pieces or excessive chewing of food
  • Eating unusually large amounts of food in a distinct period/eating rapidly
  • Frequent trips to the bathroom after eating
  • Self-induced vomiting or abuse of laxatives, diet pills or diuretics
  • Compulsively exercising/rigid exercise regime despite weather, fatigue and/or injury
  • Dramatic increase or decrease in weight not related to a medical condition

Finally, providers must be approachable and non-judgmental. As previously mentioned, there can be a lot of stigma around EDs. Since many ED behaviors are secretive and often seen as taboo and shameful, it can make it more challenging for individuals to be self-disclosing and honest about their symptoms. It is important to screen individuals who are at risk for EDs and to provide psychoeducation about the harmful effects of disordered eating. As a clinician, you want to avoid any blaming or shaming language and instead have an open and honest conversation about your concerns and available treatment options. Additionally, it is recommended to incorporate a comprehensive mental health evaluation into the clinical assessment of ED patients for the assessment of suicide risk and to ensure patients are receiving the appropriate level of treatment. Patients with EDs, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of their ED. For more guidance, the following resources are recommended:

As a reminder, 988 is the new three-digit dialing code for the National Suicide Prevention Lifeline. If you or a loved one needs help, please reach out.

Lisa French, Psy.D., is a Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

American Psychiatric Association. (2013). Feeding and eating disorders. In Diagnostic and
     statistical manual of mental disorders
(5th ed.).

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.

Breland, J. Y., Donalson, R., Li, Y., Hebenstreit, C. L., Goldstein, L. A., & Maguen, S. (2018).
     Military sexual trauma is associated with eating disorders, while combat exposure is not.
     Psychological Trauma, 10(3), 276-281.

Bulik, C. M., Thornton, L., Pinheiro, A. P., Plotnicov, K., Klump, K. L., Brandt, H., Crawford,
     S., Manfred, M. F., Halmi, K. A., Johnson, C., Kaplan, A. S., Mitchell, J., Nutzinger, D.,
     Strober, M., Treasure, J., Woodside, D. B., Berrettini, W. H., & Kaye, W. H. (2008).
     Suicide attempts in anorexia nervosa. Psychosomatic Medicine, 70, 378-383.

Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in
     mental disorders: A meta-review. World Psychiatry, 13(2), 153-160.

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., &
     Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders.
     American Journal of Psychiatry, 166(12), 1342-1346.

Favaro, A., & Santonastaso, P. (1997). Suicidality in eating disorders: Clinical and psychological
     correlates. Acta Psychiatrica Scandinavia, 95(6), 508-514.

Forrest, L. N., Zuromski, K. L., Dodd, D. R., & Smith, A. R. (2017). Suicidality in adolescents
     and adults with binge-eating disorder: Results from the national comorbidity survey
     replication and adolescent supplement. International Journal of Eating Disorders, 50(1),

Franko, D. L., & Keel, P. K. (2006). Suicidality in eating disorders: Occurrence, correlates, and
     clinical implications. Clinical Psychology Review, 26(6), 769-782.

Franko, D. L., Keel, P. K., Dorer, D. J., Blais, M. A., Delinsky, S. S., Eddy, K. T., Charat, V.,
     Renn, R., & Herzog, D. B. (2004). What predicts suicide attempts in women with eating
     disorders? Psychological Medicine, 34, 843-853.

Joiner, T. (2005). Why people die by suicide. Harvard University Press.

Joiner, T. E., Robinson, M., McClanahan, S., Riddle, M., Manwaring, J., Rienecke, R. D., Le
     Grange, D., Duffy, A. Mehler, P. S., & Blalock, D. V. (2022). Eating disorder behaviors
     as predictors of suicidal ideation among people with an eating disorder. International
     Journal of Eating Disorders
, 1-9.

Milos, G., Spindler, A., Hepp, U., & Schnyder, U. (2004). Suicide attempts and suicidal ideation:
     Links with psychiatric comorbidity in eating disorder subjects. General Hospital
, 26, 129–135.

Smith, A. R., Dodd, D. R., Forrest, L. N., Witte, T. K., Bodell, L., Ribeiro, J. D., Goodwin, N.,
     Siegfried, N., & Bartlett, M. (2016). Does the interpersonal-psychological theory of suicide provide a useful framework for understanding
     suicide risk among eating disorder patients? A test of the validity of the IPTS. International Journal of Eating Disorders,
     49(12), 1082-1086.

Smith, A. R., Zuromski, K. L. & Dodd, D. R. (2018). Eating disorders and suicidality: What we
     know, what we don’t know, and suggestions for future research. Current Opinion in
, 22, 63-67.

Udo, T., Bitley, S. & Grilo, C. M. (2019). Suicide attempts in US adults with lifetime DSM-5
     eating disorders. BMC Medicine, 17(1), 1-13.

Waasdorp, C. E., Caboot, J. B., Robinson, C. A., Abraham, A. A., & Adelman, W. P. (2007).
     Screening military dependent adolescent females for disordered eating. Military
, 172(9), 962-967.

Williams, V. F., Stahlman, S., & Taubman, S. B. (2018). Diagnoses of eating disorders, active
     component service members, U.S. Armed Forces, 2013-2017. Medical Surveillance
     Monthly Report
, 25(6), 18-25.

Zeppegno, P., Calati, R., Madeddu, F., & Gramaglia, C. (2021). The interpersonal-psychological
     theory of suicide to explain suicidal risk in eating disorders: A mini-review. Front
, 12, 1-10.