Anorexia to Suicide — The Desperate Path

By Lindsey Getz

Anorexia has the highest mortality rate of any psychological disorder, thought to be due to the numerous medical complications that accompany it, such as the early onset of osteoporosis, brain shrinkage, and heart attacks. However, suicide is also a real danger; the suicide rate related to anorexia is quite high. Studies cited by the American Association of Suicidology (Holm-Denoma et al, 2008; Kaye, 2008; Keel et al., 2003) indicate that the suicide mortality rate of people with anorexia is one of the highest of all psychiatric illnesses. Individuals with eating disorders often experience intense suffering, and their need for help should be taken seriously. 

“First and foremost, [anorexia] is a severe mental illness that takes over peoples’ lives,” says Michael Rollin, MD, an attending psychiatrist at the Eating Disorder Center of Denver. “It not only takes over their behavior but their physical health and the content of their minds. One of the biggest frustrations of people with eating disorders is that it’s what they spend their day thinking about, planning around, and essentially doing all day long. It hijacks their lives and in that way, they often feel like they have no respite.”

Even more disturbing is the intensity of anorexia’s sufferers’ suicide attempts. Holm-Denoma et al. found that when individuals with anorexia decide to end their life, they typically use highly lethal methods, including jumping in front of moving trains, ingesting household chemicals, and self-immolation, indicating they truly wish to kill themselves and aren’t just sending out a cry for help.

“I can’t speak specifically to that study, but I can say that the self-loathing associated with anorexia is so punishing that it wouldn’t seem extraordinary to me that extreme measures might be taken to end that suffering,” says Connie Quinn, DSW, LCSW-R, site director of The Renfrew Center of New York.

“It’s a very torturous disease,” adds Marty Lerner, PhD, executive director of Milestones in Recovery in Cooper City, FL. “When you look at the desperation of an alcoholic or a drug addict, it’s quite similar. They eventually get to that ‘jumping-off point’ where they can’t live with the disease, but they feel they can’t live without it either. That’s a significant point because it’s where most people either go in the direction of getting help or giving up entirely.”

Red Flags
There isn’t always a clear indication as to whether a particular patient is a suicide risk, But there are still warning signs, such as self-harm tactics. “Cutting can be a pathway for some patients and may ultimately lead to an end,” Quinn says. “Unfortunately, cuts are not always obvious to other people, as a lot of times they are in private areas such as the groin. Some may use these self-injury behaviors as a coping mechanism—to feel better or to feel more alive—and they’ll never take it beyond that self-injury level. But for others, it’s just the start.”

Though it can be difficult to discern a patient’s true intentions, Lerner has found the Is Path Warm? acronym helpful for assessing suicide risk. Created by a task force convened by the American Association of Suicidology (cf Rudd et al, 2006), the acronym stands for:

Ideation (threatening to hurt or kill oneself)
Substance abuse (increased or excessive substance use)

Purposelessness (no reason for living)
Anxiety
Trapped (feeling there’s no way out)
Hopelessness (about the future)

Withdrawal (withdrawing from friends, family, activities)
Anger
Recklessness
Mood changes

“It’s a checklist and if all of those criteria are met, there is a high probability of an attempt,” Lerner says. “When I was first taught about doing mental status exams, one of the questions was ‘Do you have a suicide plan?’ If the patient said no, then the questions stopped. But most people who have a plan won’t admit that they do. I’ve found this checklist to be much more pragmatic.”

When a patient has lost the will to live, his or her lack of participation in activities or relationships, maybe even in getting better, may also be evident. “Many patients reach a point where they feel they simply can’t do it anymore,” Quinn says. “Whether it’s that they’re physically exhausted from the complications of the disease or they’re mentally exhausted, they reach a stage of giving up. For many, these feelings are also coupled with the burden they feel they’ve placed on their families.”

Recovery
While the recovery stage is a positive step, it can’t be assumed that quality of life will improve immediately. Some people with eating disorders struggle with the disease their entire life. Experts agree that recovery is an extremely challenging process not only for the patient but for providers as well. Part of that is because individuals with an eating disorder often feel worse during the recovery than they did while struggling with the eating disorder.

“There are very few things in life where you do the right thing and it feels wrong, but that’s how it is with the recovery process from an eating disorder,” Rollin says. “As you go through the recovery process, it just doesn’t feel right, and that’s likely because the eating disorder was serving some purposes for the patient, particularly emotion regulation.”

This may mean that people with an eating disorder have a higher suicide risk during recovery. “From my own anecdotal experience, I find that most eating disorders have a sense of addiction to them, and their purpose is often self-medicating,” says Lerner. “For example, underneath most eating disorders is a pretty severe depression. Persons who binge and purge usually make that depression worse but persons with anorexia are often able to suppress that depression with their starving. So when one of these persons is in treatment, they’re at a higher risk of suicide because that depression is no longer masked by the eating disorder.”

Lerner says it’s important to pay attention to whether an individual has a condition that predates the eating disorder, such as depression, as eating disorders have a high occurrence of comorbidities. In these cases, the issues regarding the eating disorder may be resolved, but the preexisting condition will continue or possibly worsen, particularly if the eating disorder helped a patient cope with the original condition.

It’s also important for clinicians to realize that recovery can be difficult when it takes place outside an eating disorder treatment center. Because eating disorders require multidisciplinary treatment due to medical complications, dietary needs, and psychological needs, it often takes a team approach for success.

“If a social worker is working with someone one on one and feeling like things are futile, they’re probably in over their head,” Rollin says. “It’s notoriously challenging to work with these patients, even in a specialized setting with a lot of support. If you feel things aren’t working, it’s not your fault as a provider. It’s the fact that this is an incredibly challenging disorder, and you probably need more support.” 

Rollin adds that while there are some dire statistics related to eating disorders and suicide rates, there are also plenty of stories of hope. “I want to emphasize that there are people who recover and who go on to live full lives,” he says. “The stakes are high with eating disorders in that things tend to either go really well or really wrong, and there’s not a lot in between the two extremes. It’s a disorder where you, as the provider, can start to feel hopeless and frustrated right along with the patient. Or, with enough persistence and support, you can also feel a real sense of success as you help people to recover.”

— Lindsey Getz is a freelance writer based in Royersford, PA, and a frequent contributor to Social Work Today.

References
Holm-Denoma, J. M., Witte, T. K., Gordon, K. H., et al. (2008). Death by suicide among individuals with anorexia as arbiters between competing explanations of the anorexia-suicide link. Journal of Affective Disorders, 107(1-3), 231-236.

Kaye, W. (2008). Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior, 94(1), 121-135.

Keel, P. K., Dorer, D. J., Eddy, K. T., Franko, D., Charatan, D., & Herzog, D. B. (2003). Predictors of mortality in eating disorders. Archives of General Psychiatry, 60(2), 179-183.

Rudd, M. D., Berman, A. L., Joiner, T. E. Jr., et al. (2006). Warning signs for suicide: Theory, research, and clinical application. Suicide and Life-Threatening Behavior, 36(3), 255-262.