Suicide and suicide attempts are on the rise. According to the Centers for Disease Control and Prevention, suicide rates rose by 33 percent between 1999 and 2019. It is the 10th leading cause of death in the U.S. and affects people of all ages.
The highest rates often occur in American Indian/Alaska Native and non-Hispanic Whites, veterans, and the LGBTQ community. But there’s another segment of the population susceptible to suicide. For those patients with certain disorders—eating disorders (EDs) and borderline personality disorder (BPD)—suicide and suicide attempts are a major risk factor.
Carlos Grillo, Ph.D, co-authored three studies supporting the higher risk of suicidality with these two disorders. Grillo is professor of psychiatry and psychology and director of the Program for Obesity Weight and Eating Research at the Yale School of Medicine.
Adverse childhood experiences (ACEs) may contribute to the problem, especially for patients with eating disorders. One study, published online in the Journal of Eating Disorders, showed that the “prevalence of ACEs among people with EDs was 54.1 to 67.8 percent.
However, there was a caveat. While the presence of ACEs gave a higher probability, it did not mean that everyone with an eating disorder also had ACEs in their personal backgrounds. Yet, Grillo and co-authors Tomoko Udo, Ph.D, and Lauren Forrest, Ph.D, maintained that adverse childhood experiences should be considered a precursor to eating disorders in terms of risk assessment and management.
“The main question was because there is such little understanding about why people with eating disorders attempt suicide, maybe the combination of eating disorders and ACEs might create more risk,” said Forrest, assistant professor with the Department of Psychiatry and Behavioral Health and Department of Public Health Sciences at Penn State University.
“But we didn’t find support for that. Suicidal behavior is really complex, and it seems unlikely that any single risk factor—or any single combination of two risk factors—is going to fully explain suicidal behavior in people with eating disorders,” she said.
Forrest noted she was a little surprised that the interaction between ACEs and EDs didn’t appear to pose a greater risk. However, she also mentioned their research showed a greater tendency for emotional abuse or parents with mental health problems as the childhood trauma.
Feelings of emptiness as well as a fear of abandonment in patients with BPD brought an increased risk in suicidality. In the JAMA Network Open article published online this past May, Grillo and Udo worked with a national cross-sectional study of more than 36,000 adults in the U.S. with a lifetime diagnosis of BPD along with other specific criteria like self-harm and chronic feelings of emptiness.
These elements significantly increased the risk of suicide attempts in those patients. In Grillo’s third co-authored research article last November in the JAMA Psychiatry, a 10-year follow up was done on BPD participants. In that follow up, it was determined that “BPD and the specific criteria of identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment emerged as significant factors associated with prospectively observed suicide attempt status.”
What each of these studies shows is that for some people with a chronic disorder like ED or BPD there’s a suicidal trigger when self-harm, chronic feelings of loneliness or emptiness, or childhood trauma happen to coincide. But the million-dollar question is can you pinpoint when that will happen.
“We know childhood trauma and these disorders are associated with a greater risk for suicide attempts. Do we really know how to avoid suicide? How do we predict that moment?” said Udo, assistant professor at the University of Albany’s Department of Health Policy, Management, and Behavior in the School of Public Health. “It’s a difficult thing to identify. So, the short answer is we don’t know.”
Udo said the results of the research on EDs and BPDs was in line with prior data on associated suicide risk. She pointed out, however, there’s some bias in previous clinical samples which was why they looked at the national scale. Minorities and men are underrepresented. And, both groups have a tendency not to seek treatment.
“So, we looked at the national sample of data so it was more generalizable,” she explained. “Looking at the national numbers, we could account for demographics and remove the bias. We could highlight the people who may have it and not know it. The results confirmed a pattern in suicide attempts. But they also showed these are not just white female issues.”
When it comes to eating disorders, women are often seen as the face of the disorder. But that’s not necessarily true. Binge eating is often associated with obesity in which patients may binge but don’t necessarily purge. Udo said that’s more common in men than most people realize and Forrest agreed.
“Eating disorders are a lot more common in men than people think,” said Forrest. “Men are unfortunately not often included in eating disorder research, but that doesn’t mean they are spared from being affected by eating disorders.”
Udo piggybacked Forrest’s statement further comparing genders. There may be a closer gap between men and women with EDs but BPD is still more common in women than men.
She also said men have more substance abuse and more impulsivity. Women have a tendency to be more emotional, more internalized. Men tend to be more external and can get aggressive.
Women tend to have higher suicide attempts than men, particularly when EDs and ACEs are involved. Women attempt suicide more, but men tend to complete it. Forrest added men tend to use more lethal weapons when they attempt suicide and women tend to use lower lethal means and therefore have a higher likelihood of survival. (For example, men may use guns as their weapon of choice while women will more likely overdose).
Udo said it really comes down to appropriate care. Too often, men and minorities seek out their primary care provider. But in primary care like with an annual physical, they may not disclose pertinent information about their mental health.
Even if they do, primary care physicians often say they feel they are not appropriately trained to have a meaningful conversation about these disorders or can make an appropriate referral to another professional.
Also, the average primary care visit is brief, so primary care physicians don’t feel they have enough time to concentrate on that kind of issue. For Forrest, whose concentration is primarily on eating disorders, it’s about a convergence of issues.
“My goal,” she said, “is to try to understand how a lot of things come together to explain why people die from suicide—how multiple interactions might impact suicide risk.”