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Attempted Suicide and Self-Injury in Patients Diagnosed With Eating Disorders

Daniel Stein, Lisa R.R. Lilenfeld, Prudence C. Wildman, and Marsha D. Marcus
Eating disorders (ED) patients are at high risk for developing suicidal behavior. The aim of the present study was to investigate factors associated with suicidal behavior in ED patients. One hundred fty patients at an outpatient ED clinic were included in the study. Data were gathered by retrospective chart analysis. We found that 48 patients (32%) had a history of parasuicide (i.e., suicide attempts, self-injury, or both). A signicantly greater percentage of parasuicidal patients than nonparasuicidal patients had EDs with bingeing/pursing symptomatology, used more than one type of purging method, and had a lifetime history of a drug use disorder, impulse control problems, and bipolar disorder, as well as a more extensive outpatient and inpatient treatment history. The ndings of this study support an increased tendency toward impulsivity among parasuicidal ED outpatients. 2004 Elsevier Inc. All rights reserved.

UICIDAL BEHAVIOR has emerged as an issue of considerable concern in the treatment of eating disorders (EDs) in recent years.1 Elevated rates of suicide and attempted suicide have been consistently reported in anorexia nervosa (AN),2,3 and to a lesser extent in bulimia nervosa (BN).4 The frequency of attempted suicide and the severity of the medical threat of the attempts in AN1,5,6 and BN5,6 are comparable to those found in major depression and conduct disorder, and greater than those found in schizophrenia and anxiety disorders. Suicidal risk across all ED diagnoses is increased in the context of impulsivity.7 The rate of attempted suicide is higher in BN compared with AN, and in AN of the bingeing/purging type compared with restrictive AN.8 Across all ED diagnoses, outpatients who attempt suicide have a greater risk of additional impulsive self-injurious behaviors, and the risk for self-destructive behavior appears to be elevated in the context of comorbid substance use disorders or borderline personality disorder.710 Regarding the inuence of ED severity, AN patients who commit3 or attempt suicide8 tend to weigh less and report a signicantly longer duration of illness compared to nonsuicidal patients. In the case of bingeing/purging pathology, higher rates of suicide attempts and/or self-injurious behaviors are found among those individuals who abuse laxatives and diuretics,7 and particularly among those who engage in multiple compensatory purging behaviors (e.g., both self-induced vomiting and laxative abuse).3,8 The aim of the present study was to assess factors contributing to a history of parasuicide, that is suicide attempts and/or other intentional self-

injurious behaviors11,12 in EDs. We hypothesized that a history of parasuicide among ED outpatients would be associated with binge eating/purging symptomatology, use of multiple purging methods, younger age of ED onset, and more extensive treatment history, as well as higher rates of comorbid mood, substance use, and impulse control disorders.

The study included 150 patients (145 females, 5 males) treated in the outpatient eating disorders clinic at Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, between 1997 and 1999. Thirty-one of these patients (21%) had a history of one or more suicide attempts, another 17 patients (11%) had a history of self-injury without suicide attempts, and 102 patients (68%) had no documented history of any parasuicidal behavior. Twenty of the 31 suicidal patients had additional self-injurious behavior, and the remaining 11 had no evidence of self-injury. No age differences were found between the parasuicidal and nonparasuicidal patients at the time of the study [28 8.9 years and 26 9.4 years, respectively; t(148)1.24, P .22]. Parasuicidal patients with AN had an older mean age at the time of intake [38 6.7 v 24 9.9; t(35) 2.72, P .01) compared to nonparasuicidal AN patients. Suicidal patients with AN, BN,

From the The Chaim Sheba Medical Center, afliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Psychology, Georgia State University, Atlanta, GA; and the Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA. Supported by The American Foundation for Suicide Prevention (L.R.R.L.). Address reprint requests to Daniel Stein, M.D., Pediatric Psychosomatic Department, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel. E-mail: 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4506-0012$30.00/0 doi:10.1016/j.comppsych.2004.07.011

Comprehensive Psychiatry, Vol. 45, No. 6 (November/December), 2004: pp 447-451



binge-eating disorder (BED), or EDnot otherwise specied (ED-NOS) did not differ from nonsuicidal patients with the same diagnoses in current, minimum, or maximum weights, or mean percent of ideal body weight. The mean number of suicide attempts in the parasuicidal group was two (range, one to six). Forty-eight percent of those who attempted suicide made two or more attempts. The suicide/ self-injury methods used by our patients included scratching/ cutting (29 patients [60%]), medication overdose (23 [48%]), head banging/punching wall (7 [15%]), hitting/pinching oneself (6 [13%]), burning/scalding (4 [8%]), loaded gun (1 [2%]), and asphyxiation (1 [2%]). Twenty parasuicidal patients (43%) used more than one self-harm strategy, either in the same or in different self-harm episodes.

(i.e., those with suicide attempts only, self-injury only, and those with a history of both), and second, including only those patients with a history of suicide attempts (with or without additional self-injurious behavior). Finally, because multiple parasuicidal acts are particularly characteristic of individuals who have a history of multi-impulsive behaviors in addition to impulsive consummatory patterns,11,17 analyses were also conducted excluding those patients who had only one parasuicidal episode. Between-group differences were analyzed using a 2 analysis, or a t test as appropriate. Logistic regression analysis was used to evaluate the signicance of the presence of multiple purging behaviors, more than 5 cumulative years in outpatient ED treatment, and history of substance use disorder and of impulse control problems in predicting group membership.

The present study was a retrospective chart review, approved by the Biomedical Institutional Review Board of the University of Pittsburgh. Each chart was independently reviewed by two masters or doctoral level psychologists with extensive diagnostic assessment experience, who were blind to the aim of the study (explained as an investigation of factors associated with outcome of EDs). For each patient, this outpatient ED clinic conducts a systematic assessment of past and current ED symptomatology, other related comorbid disturbances, suicide attempts, and selfinjurious behaviors. Patients were regularly weighed throughout their treatment. All patients included in this study were actively ill with an ED when admitted to the clinic. A structured clinical interview, based on the principles of the Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition (SCID-I/P, version 2.0),13 was used for the assessment of EDs and comorbid DSM-IV14 axis I disorders at the time of the intake. In the case of more than one lifetime ED for a patient, we used the primary, which was usually the current ED, for analyses. ED-NOS diagnoses were given for patients who met all but one of the diagnostic criteria for either AN, BN, or BED. Age of onset of the ED, age at intake to our facility, treatment history, current, minimum and maximum weight, and the presence of impulse control problems were also systematically recorded. Lifetime suicide attempts and self-injurious behaviors were routinely assessed and recorded in the patients charts according to denitions and methods as those listed in the Parasuicide History Interview-2 (PHI-2),15 a semistructured interview that obtains detailed information on each parasuicide episode. A suicide attempt was dened as a non-fatal self-destructive act that was sufciently serious to require medical evaluation and was peformed with the intent to end ones life; self-injurious behavior was dened as any self-destructive act that was not life-threatening, and was performed without the intent to end ones life. The use of medications in order to lose weight was not considered a parasuicidal behavior. All intake data were reviewed and nal consensus diagnoses were achieved in weekly team meetings.


Statistical Analysis
Because of the controversy regarding whether self-injurious acts represent an alternative form of suicidal behavior,16 every analysis was run rst with all parasuicidal patients included

The following results are from analyses in which all parasuicidal patients were included. Unless otherwise noted, the results were similar when patients with self-injury only, or with only one selfdestructive episode, were excluded from the analyses. Four parasuicidal patients (3%) and 33 (32%) nonparasuicidal patients were diagnosed with AN [2(1) 10.13, P .001]. The parasuicidal AN group included one restricting type (2% of all parasuicidal patients) and three binge eating/purging type patients (6% of all parasuicidal patients), whereas the respective rates among nonparasuicidal AN patients were 19 (19% of all nonparasuicidal patients) and 14 (14% of all nonparasuicidal patients). There were no between-group differences in rates of BN, BED, or ED-NOS. However, a signicantly higher proportion of parasuicidal (43 of 48; 90%) than nonparasuicidal (75 of 102; 73%) patients had an ED with some binge eating and/or purging symptomatology (2(1) 5.01, P .025). Parasuicidal AN patients had a signicantly later onset of their ED (19.5 6.8) compared to nonparasuicidal (14.5 2.5) AN patients [t(1) 2.94, P .006]. Although not statistically signicant, a tendency toward earlier ED onset was noted for parasuicidal BN [15.6 3.6 v 17.4 4.1, t(1) 1.65], BED [13.4 4.4 v 17.8 7.8, t(1) 1.46], and ED-NOS patients [14.2 6.0 v 15.7 5.9, t(1) 0.76]. Compared with the nonparasuicidal group (16 [16%]), a greater percentage of parasuicidal patients (14 [29%]) had more than one purging behavior (e.g., both self-induced vomiting and laxative abuse) [2(1) 3.67, P .05]. Parasuicidal

SELF HARM AND EATING DISORDERS Table 1. Simultaneous Evaluation of Multiple Predictors of Parasuicidal StatusAll Patients Included (N 150)
Independent Variable Regression Coefcient (b) Standard Error of b



P Value

More than 5 years of treatment Multiple purging strategies Impulse control problem Substance use disorder

0.71 0.51 1.50 0.88

0.45 0.45 0.74 0.05

2.44 1.28 4.11 2.85

NS NS .04 NS

NOTE. Table summarizes results using logistic regression analysis. Entire sample (N 150) included in analysis. The overall model was signicant (2(4) 17.11, P .002). Abbreviation: NS, not signicant, df 1.

ED patients also showed an elevated rate of any impulse control problem (8 [17%]), compared with nonsuicidal patients [3 (3%); 2(1) 9.05, P .003]. Specically, eight parasuicidal patients evidenced some lifetime impulse dyscontrol behavior (often more than one type), including shoplifting (n 1), compulsive shopping (n 2), sexual promiscuity (n 1), being verbally abusive (n 1), and hitting/punching others (n 4) or objects (n 5). Three of the nonparasuicidal group evidenced similar impulse dyscontrol behavior, including sexual promiscuity (n 2), and being verbally abusive (n 1). Parasuicidal (36 [75%]) and nonparasuicidal (74 [74%]) patients had similar lifetime rates of major depression [2(1) 0.05, P .85] and dysthymia [2 (4%) v 2 (2%); 2(1) 0.63, P .4]. However, patients with parasuicidal histories (8 ([7%]) had elevated rates of bipolar disorder than did the nonparasuicidal group [2 (2%); 2(1) 11.52, P .001]. Parasuicidal patients had elevated rates of drug use disorder (11 [23%] v 11 [11%]) and any substance use disorder (16 [33%] v 18 [18%]) compared with the nonparasuicidal group [2(1) 3.84, P .05, and 2(1) 4.58, P .03, respectively]. Rates of alcohol use disorder and combined alcohol/drug use disorder did not differ between the two groups in the initial analysis. However, when those patients with only self-injury histories were excluded from the analysis, the parasuicidal group had a signicantly higher rate of alcohol use disorder (11of 31 patients [35%]), compared with the nonparasuicidal group (15 of 102 patients [15%]; 2(1) 6.53, P .011).

Analysis of treatment history revealed that a greater percentage of parasuicidal patients had more than 5 cumulative years of treatment (16 [33%] v 15 [15%]) and more psychiatric hospitalizations related to the ED or other psychopathology (31 [65%] v 29 [28%]), compared with the nonparasuicidal group [2(1) 6.91, P .009, and 2(1) 17.78, P .001, respectively]. Table 1 summarizes the results of the logistic regression analysis. All predictor variables, when considered together, signicantly predicted group allocation (2(4) 17.11, P .002), and impulse control problems had a signicant individual predictive capacity. When those with only self-injury behavior were removed from the analysis, we found that both impulse control problems and substance use disorder had signicant individual predictive capacities, and our overall model was again signicant (2(4) 21.97, P .001; Table 2).

The present study found a lower rate of AN and higher rates of EDs of the binge eating/purging spectrum among patients who manifested parasuicidal behavior compared to those who did not have a history of such behavior. These results mirror ndings of previous studies.3,7,8,10,11,18 Forty-three (37%) of our 117 outpatients with binge eating/ purging symptomatology had a history of parasuicide, which is in the range of 15% to 40% reported elsewhere.58 Among those with parasuicidal histories, more than 90% had an ED with binge eating/purging symptomatology.

Table 2. Simultaneous Evaluation of Multiple Predictors of Parasuicidal StatusPatients With Only Self-Injury Excluded
Independent Variable Regression Coefcient (b) Standard Error of b


P Value

More than 5 years of treatment Multiple purging strategies Impulse control problem Substance use disorder

0.57 0.66 1.85 1.41

0.54 0.53 0.79 0.56

1.09 1.53 5.47 6.31

NS NS .02 .01

NOTE. Table summarizes results using logistic regression analysis. N 133 included in analysis (n 17 self-injury only patients excluded). The overall model was signicant (2(4) 21.97, P .001). Abbreviation: NS, not signicant, df 1.



Compared with the nonparasuicidal group, the parasuicidal patients had an elevated lifetime history of impulse control problems, as well as substance use disorder (specically drug abuse and dependence). These patients were also more likely to have used more than one purging method (e.g., both self-induced vomiting and laxative abuse), lending support to the association noted between the severity of compensatory behaviors and risk of attempted suicide and self-destructive behaviors.18 Almost half (48%) of those who attempted suicide (31% of all parasuicidal patients) had multiple suicide attempts, and a signicant percentage (42%) of those with a history of parasuicide had both self-injurious behavior and at least one suicide attempt. Previous studies have shown a particularly high rate of parasuicide among individuals with BN who have a history of multiple impulsive behaviors beyond impulsive consummatory patterns, including impulsive substance use, recurrent shoplifting, and sexual promiscuity.11,17 These patients, often described as multi-impulsive,7,11,17 are also more likely to have a history of sexual abuse, less favorable occupational and social functioning, and borderline or any DSM-IV cluster B personality disorder.11,19 By contrast, BN patients with no evidence of non-ED impulsivity, often described as uni-impulsive, are more likely to have restrained personality traits19 and little family history of substance abuse or impulse control problems.20,21 Thirty-two of our parasuicidal patients (67%), all with binge eating/ purging symptomatology, can be classied as multi-impulsive, in that they had a history of at least two nonED-related impulsive behaviors, including substance use disorders, suicide attempts, self-injury, physical and verbal assault of others, and hitting objects.11 The elevated overall dyscrontrol found in these patients may reect a reduction of the inhibitory neurotransmitter serotonin, found in both impulsive, aggressive
1. Apter A, Gothelf D, Orbach I, Weizman R, Ratzoni G, Har-Even D, et al. Correlation of suicidal and violent behavior in different categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry 1995;34:912-918. 2. Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry 1995;152:1073-1074. 3. Herzog DB, Greenwood DN, Dorer DJ, Flores AT, Ekeblad ER, Richards A, et al. Mortality in eating disorders: a descriptive study. Int J Eat Disord 2000;28:20-26. 4. Mitchell JE, Pyle RL, Hatsukami D, Goff G, Glotter D,

suicidal behavior22 and in patients with active binge eating/purging pathology.23 Regarding other comorbidity, as shown previously,7,8 our parasuicidal patients had elevated rates of bipolar disorder compared to the nonparasuicidal group, although there were no group differences in lifetime rates of major depressive disorder (MDD). This may be due to a ceiling effect, as extremely high rates of MDD were found across this entire clinical sample, similar to ndings of others.9 Although there is controversy regarding whether self-injurious acts represent an alternate form of suicidal behavior,16 denitions of parasuicide comparable to ours have been previously used,24 including in studies of ED patients.18 The current ndings of similar associations of both types of self-destructive behavior with eating-related as well as noneating-related impulse dysregulation, lend support to the view that these behaviors may lie on the same continuum.25 The main limitation of our study is that it was based on a retrospective chart review. Additionally, the number of suicidal patients with AN was small, precluding any meaningful conclusions about suicidal behavior in subtypes of AN. In conclusion, our ndings support the existence of signicant differences in the suicidal behavior of ED patients with restricting versus bingeing/ purging symptomatology.1,12 Whereas suicide in the former group may be associated primarily with depression, suicidal behavior in the latter group is characterized by various manifestations of impulsivity. Future prospective, longitudinal outcome studies with parasuicidal ED patients are needed to enhance characterization of the ED, comorbid disorders, and suicidal behavior, as well as assess whether specic treatment strategies can reduce the risk of suicidal behavior among these patients.
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met P, Flament MF. Suicide attempts in women with bulimia nervosa: frequency and characteristics. Acta Psychiatr Scand 2002;106:381-386. 8. Favaro A, Santonastaso P. Suicidality in eating disorders: clinical and psychological correlates. Acta Psychiatr Scand 1997;95:508-514. 9. Visselman JO, Roig M. Depression and suicidality in eating disorders. J Clin Psychiatry 1985;46:118-124. 10. Wiederman MW, Pryor T. Substance use and impulsive behaviors among adolescents with eating disorders. Addict Behav 1996;21:269-272. 11. Lacey JH. Self-damaging and addictive behavior in bulimia nervosa: a catchment area study. Br J Psychiatry 1993; 163:190-194. 12. Linehan MM. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press, 1993. 13. First MB, Spitzer RL, Gibbon M, Williams JB. Structured Clinical Interview for Axis-I, DSM-IV Disorders. New York, NY: New York State Psychiatric Institute: Biometrics Research Department, 1995. 14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Ed. 4. Washington, DC: American Psychiatric Association, 1994. 15. Linehan M, Heard H, Brown M, Wagner A. The Parasuicide History Interview-2. Submitted. 16. Walsh WB, Rosen PM. Self Mutilation. New York, NY: Guilford Press, 1998. 17. Fichter MM, Quadieg N, Rief W. Course of multiimpulsive bulimia. Psychol Med 1994;24:591-604.

18. Favaro A, Santonastaso P. Purging behaviors, suicide attempts and psychiatric symptoms in 398 eating disordered subjects. Int J Eat Disord 1996;20:99-103. 19. Vitousek K, Manke F. Personality variables and disorders in anorexia nervosa and bulimia nervosa. J Abnorm Psychol 1994;103:137-147. 20. Bulik CM, Sullivan PF, Fear J, Pickering A. Predictors of the development of bulimia nervosa in women with anorexia nervosa. J Nerv Ment Dis 1997;185:704-707. 21. Lilenfeld LR, Kaye WH, Greeno CG, Merigankas KR, Plotnicov KH, Pollice C, et al. Psychiatric disorders in women with bulimia nervosa and their rst-degree relatives: effects of comorbid substance dependence. Int J Eat Disord 1997;22:253264. 22. Mann JJ. Role of the serotonergic system in the pathophysiology of major depression and suicidal behavior. Neuropsychopharmacology 1999;21(Suppl 2):99-105. 23. Jimerson DC, Wolfe BE, Metzger ED, Finkelstein DM, Cooper TB, Levine JM. Decreased serotonin function in bulimia nervosa. Arch Gen Psychiatry 1997;54:529-534. 24. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. Psychiatric comorbidity in treatment-seeking anorexics and bulimics. J Am Acad Child Adolesc Psychiatry 1992;31:810-818. 25. Kehrer CA, Linehan MM. Interpersonal and emotional problem solving skills and parasuicide among women with borderline personality disorder. J Pers Disord 1996;10:345354. 26. Hintikka J, Viinama ki H, Tanskanen A, Kontula O, Koskela K. Suicidal ideation and attempted suicide in the Finnish general population. Acta Psychiatr Scand 1998;98:23-27.