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Eating Disorders

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Research articles:

Bulik, C., Thornton, L., Pinheiro, A., Plotnicov, K., Klump, K., Brandt, H., & ... Kaye, W. (2008). Suicide attempts in anorexia nervosa. Psychosomatic Medicine, 70(3), 378-383. Retrieved from EBSCOhost.

OBJECTIVE: To explore prevalence and patterns of suicidal attempts in persons with anorexia nervosa (AN). METHODS: Participants were the first 432 persons (22 male, 410 female) enrolled in the NIH funded Genetics of Anorexia Nervosa Collaborative Study. All participants had current or lifetime AN. The participants ranged in age from 16 to 76 (mean = 30.4, SD = 11.3). Suicidal behavior and intent was assessed via the Diagnostic Interview for Genetic Studies. We compared frequency and severity of attempts across diagnostic subtypes and comorbidity, and personality features associated with the presence of suicide attempts in persons with AN. RESULTS: About 16.9% of those with AN attempted suicide. Significantly fewer persons with the restricting subtype (7.4%) reported at least one attempt than those with purging AN (26.1%), AN with binge eating (29.3%), and a mixed picture of AN and bulimia nervosa (21.2%). After controlling for major depression, suicide attempts were associated with substance abuse, impulsive behaviors and traits, Cluster B personality disorders, panic disorder, and post-traumatic stress disorder as well as low self-directedness and eating disorder severity. CONCLUSIONS: Suicide attempts in AN are not uncommon, are frequently associated with the intention to die, occur less frequently in persons with the restricting subtype of the illness, and after controlling for depression are associated with a constellation of behaviors and traits associated with behavioral and affective dyscontrol.

Forcano, L., Álvarez, E., Santamaría, J. J., Jimenez-Murcia, S., Granero, R., Penelo, E., & ... Fernández-Aranda, F. (2010). Suicide attempts in anorexia nervosa subtypes. Comprehensive Psychiatry, 52(4), 352-358. doi:10.1016/j.comppsych.2010.09.003

OBJECTIVE: The risk for suicide attempts is elevated in anorexia nervosa (AN), yet we know little about the relation between suicide and personality in this group. We explored the prevalence of lifetime suicide attempts in women with AN and compared those who had and had not attempted suicide on eating disorder symptoms, general psychopathology, and personality both relative to a healthy control group and then across AN subtypes. METHOD: One hundred four outpatients with restricting AN, 68 outpatients with purging AN, and 146 comparison individuals participated in the study. RESULTS: The prevalence of suicide attempts differed significantly across the 3 groups (P = .003), with 0% in the controls, 8.65% in the restricting AN group, and 25.0% in the purging AN group. Depression measures were elevated in those with suicide attempts. Within the restricting AN group, those who attempted suicide scored significantly higher on Phobic Anxiety, measured by means of the Symptom Checklist–Revised, than those who did not (P = .001). CONCLUSION: The presence of purging and depressive symptoms in individuals with AN should increase vigilance for suicidality; and among restrictors, greater anxiety may index greater suicide risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Forcano, L., Fernández-Aranda, F., Álvarez-Moya, E., Bulik, C., Granero, R., Gratacòs, M., & ... Estivill, X. (2009). Suicide attempts in bulimia nervosa: Personality and psychopathological correlates. European Psychiatry, 24(2), 91-97. doi:10.1016/j.eurpsy.2008.10.002

Abstract: Background: Little evidence exists about suicidal acts in eating disorders and its relation with personality. We explored the prevalence of lifetime suicide attempts (SA) in women with bulimia nervosa (BN), and compared eating disorder symptoms, general psychopathology, impulsivity and personality between individuals who had and had not attempted suicide. We also determined the variables that better correlate with of SA. Method: Five hundred sixty-six BN outpatients (417 BN purging, 47 BN non-purging and 102 subthreshold BN) participated in the study. Results: Lifetime prevalence of suicide attempts was 26.9%. BN subtype was not associated with lifetime SA (p =0.36). Suicide attempters exhibited higher rates on eating symptomatology, general psychopathology, impulsive behaviors, more frequent history of childhood obesity and parental alcohol abuse (p <0.004). Suicide attempters exhibited higher scores on harm avoidance and lower on self-directedness, reward dependence and cooperativeness (p <0.002). The most strongly correlated variables with SA were: lower education, minimum BMI, previous eating disorder treatment, low self-directedness, and familial history of alcohol abuse (p <0.006). Conclusion: Our results support the notion that internalizing personality traits combined with impulsivity may increase the probability of suicidal behaviors in these patients. Future research may increase our understanding of the role of suicidality to work towards rational prevention of suicidal attempts. [Copyright &y& Elsevier]

Foulon, C. C., Guelfi, J. D., Kipman, A. A., Adès, J. J., Romo, L. L., Houdeyer, K. K., & ... Gorwood, P. P. (2007). Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts. European Psychiatry, 22(8), 513-519. doi:10.1016/j.eurpsy.2007.03.004

Abstract: Objective: Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap. Method: Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable. Results: Major depressive disorder (p <0.001) and subtype switch from the restrictive to the bingeing/purging type (p <0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type. Conclusions: Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors. [Copyright &y& Elsevier]

Franko, D. L., & Keel, P. K. (2006). Suicidality in eating disorders: Occurrence, correlates, and clinical implications. Clinical Psychology Review, 26(6), 769-782. doi:10.1016/j.cpr.2006.04.001

Abstract: This review summarizes the published studies on suicide and suicide attempts in individuals with eating disorders, highlighting rates of occurrence, clinical correlates, and implications for practitioners. Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3–20% of patients with anorexia nervosa and in 25–35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms. [Copyright &y& Elsevier]

Franko, D. L., Keel, P. K., Dorer, D. J., Blais, M. A., Delinsky, S. S., Eddy, K. T., & ... Herzog, D. B. (2004). What predicts suicide attempts in women with eating disorders?. Psychological Medicine, 34(5), 843-853. doi:10.1017/S0033291703001545

Background. Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. Method. In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n= 136) or bulimia nervosa (n= 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. Results. Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9 %) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. Conclusions. Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial comorbidity. [ABSTRACT FROM AUTHOR]

Guillaume, S. S., Jaussent, I. I., Olié, E. E., Genty, C. C., Bringer, J. J., Courtet, P. P., & Schmidt, U. U. (2011). P02-127 - Characteristics of suicide attempts in anorexia and bulimia nervosa : A case-control study. European Psychiatry, 26, 723. doi:10.1016/S0924-9338(11)72428-2

Objective: People with eating disorders (ED) are at high risk for suicidal behavior. Among different ED, anorexia nervosa (AN) has the highest rates of completed suicide whereas suicide attempt rates are similar or lower than in bulimia nervosa (BN). Attempted suicide is a key predictor of completed suicide, thus this mismatch is intriguing. We sought to explore whether the clinical characteristics of suicidal acts differ between suicide attempters with AN, BN or without an ED. Method: Case-control study in cohort of suicide attempters (n=1563). Forty-four patients with AN and 71 with BN were compared with 235 non-ED attempters matched for sex, age and education, using interview measures of suicidal intent and severity. Results: AN patients were more likely to have made a serious attempt (OR=3.4, 95% CI 1.4–7.9), with a higher expectation of dying (OR=3.7, 95% CI 1.1–13.5), and an increased risk of lethality (OR=3.4, 95% CI 1.2–9.6). BN patients did not differ from the control group. Conclusion: There are distinct features of suicide attempts in AN. This may explain the higher suicide rates in AN. Deaths from suicide in AN may not be the result simply of their greater physical frailty. [ABSTRACT FROM AUTHOR]

Preti, A. A., Rocchi, M. L., Sisti, D. D., Camboni, M. V., & Miotto, P. P. (2011). A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatrica Scandinavica, 124, 6-17. doi:10.1111/j.1600-0447.2010.01641.x

A comprehensive meta-analysis of the risk of suicide in eating disorders. Past meta-analyses on suicide in eating disorders included few available studies. PubMed/Medline search for papers including sample n ≥ 40 and follow-up ≥5 years: 40 studies on anorexia nervosa (AN), 16 studies on bulimia nervosa (BN), and three studies on binge eating disorder (BED) were included. Of 16 342 patients with AN, 245 suicides occurred over a mean follow-up of 11.1 years (suicide rate = 0.124 per 100 person-years). Standardized mortality ratio (SMR) was 31.0 (Poisson 95% CI = 21.0-44.0); a clear decrease in suicide risk over time was observed in recent decades. Of 1768 patients with BN, four suicides occurred over a mean follow-up of 7.5 years (suicide rate = 0.030 per 100 person-years): SMR was 7.5 (1.6-11.6). No suicide occurred among 246 patients with BED (mean follow-up = 5.3 years). AN and BN share many risk factors for suicide: the factors causing lower suicide rates per person-year in BN compared to AN should be investigated. [ABSTRACT FROM AUTHOR]

Selby, E. A., Smith, A. R., Bulik, C. M., Olmsted, M. P., Thornton, L., McFarlane, T. L., & ... Woodside, D. (2010). Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa. Behaviour Research & Therapy, 48(7), 634-645. doi:10.1016/j.brat.2010.03.016

Abstract: Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR. [Copyright &y& Elsevier]

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