An empirical test of the interpersonal theory of suicide in a heterogeneous eating disorder sample

Clarifying the relationship between physical injuries and risk for suicide attempt in a Swedish national sample

INTRODUCTION

The Interpersonal-Psychological Theory of Suicide proposes that capability for suicide is acquired through exposure to painful and provocative events (PPEs). Although there is robust evidence for a positive association between aggregate measures of PPEs and risk for suicidal behavior, little is known about the contributions of physical injuries. The present study investigated the relationship between injuries and risk of subsequent suicide attempt (SA).

METHODS

Data were from Swedish population-based registers. All individuals born in Sweden between 1970 and 1990 were included (N = 1,011,725 females and 1,067,709 males). We used Cox regression models to test associations between 10 types of injuries (eye injury; fracture; dislocation/sprain/strain; injury to nerves and spinal cord; injury to blood vessels; intracranial injury; crushing injury; internal injury; traumatic amputation; and other or unspecified injuries) and risk for later SA. Analyses were stratified by sex and adjusted for year of birth and parental education. Additional models tested for differences in the pattern of associations based on age group and genetic liability for SA. In co-relative models, we tested the association between each injury type and risk for SA in relative pairs of varying genetic relatedness to control for unmeasured familial confounders.

RESULTS

All 10 injury types were associated with elevated risk for SA (hazard ratios [HRs] = 1.2-7.0). Associations were stronger in the first year following an injury (HRs = 1.8-7.0), but HRs remained above 1 more than 1 year after injury exposure (HRs = 1.2-2.6). The strength of associations varied across injury type, sex, age, and genetic liability for SA. For example, the magnitude of the association between crushing injury and risk for SA was larger in females than males, whereas other injuries showed a similar pattern of associations across sex. Moreover, there was evidence to support positive additive interaction effects between several injury types and aggregate genetic liability for SA (relative excess risk due to interaction [RERI] = 0.1-0.3), but the majority of these interactions became non-significant or changed direction after accounting for comorbid psychiatric and substance use disorders. In co-relative models, the pattern of associations differed by injury type, such that there was evidence to support a potential causal effect of eye injury, fracture, dislocation/sprain/strain, intracranial injury, and other and unspecified injuries on risk for SA. For the remaining injury types, HRs were not significantly different from 1 in monozygotic twins, which is consistent with confounding by familial factors.

CONCLUSIONS

Injuries are associated with increased risk for subsequent SA, particularly in the first year following an injury. While genetic and familial environmental factors may partly explain these associations, there is also evidence to support a potential causal effect of several injury types on future risk for SA.

Unsound sleep, wound-up mind: a longitudinal examination of acute suicidal affective disturbance features among an eating disorder sample

BACKGROUND

Suicide is one of the most commonly reported causes of death in individuals with eating disorders. However, the mechanisms underlying the suicide and disordered eating link are largely unknown, and current assessments are still unable to accurately predict future suicidal thoughts and behaviors. The purpose of this study is to test the utility of two promising proximal risk factors, sleep quality and agitation, in predicting suicidal ideation in a sample of individuals with elevated suicidal thoughts and behaviors, namely those with eating disorders.

METHODS

Women (N = 97) receiving treatment at an eating disorder treatment center completed weekly questionnaires assessing suicidal ideation, agitation, and sleep. General linear mixed models examined whether agitation and/or sleep quality were concurrently or prospectively associated with suicidal ideation across 12 weeks of treatment.

RESULTS

There was a significant interaction between within-person agitation and sleep quality on suicidal ideation [B(s.e.) = -0.02(0.01), p < 0.05], such that on weeks when an individual experienced both higher than their average agitation and lower than their average sleep quality, they also experienced their highest levels of suicidal ideation. However, neither agitation nor sleep quality prospectively predicted suicidal ideation.

CONCLUSIONS

This study was the first to examine dynamic associations between interpersonal constructs and suicidal ideation in individuals with eating disorders. Results suggest that ongoing assessment for overarousal symptoms, such as agitation and poor sleep quality, in individuals with eating disorders may be warranted in order to manage suicidal ideation among this vulnerable population.

Suicide capability within the ideation-to-action framework: A systematic scoping review

Suicide capability is theorised to facilitate the movement from suicidal ideation to suicide attempt. Three types of contributors are posited to comprise suicide capability: acquired, dispositional, and practical. Despite suicide capability being critical in the movement from ideation-to-attempt, there has been no systematic synthesis of empirical evidence relating to suicide capability that would enable further development and refinement of the concept. This study sought to address this synthesis gap. A scoping review was conducted on suicide capability studies published January 2005 to January 2022. Eleven electronic databases and grey literature sources were searched returning 5,212 potential studies. After exclusion criteria application, 90 studies were included for final analysis. Results synthesis followed a textual narrative approach allocating studies based on contributors of suicide capability. Most studies focused on investigating only one factor within contributors. Painful and provocative events appear to contribute to acquired capability more so than fearlessness about death. Whilst emerging evidence for dispositional and practical contributors is promising, the small number of studies prevents further conclusions from being drawn. An unexpected additional cognitive contributor was identified. The focus of a single factor from most studies and the limited number of studies on contributors other than acquired capability limits the theoretical development and practical application of suicide capability knowledge. Given that suicide is a complex and multifaceted behaviour, future research that incorporates a combination of contributors is more likely to advance our understandings of suicide capability.

Examining the association of eating psychopathology with suicidality: Comparing cross-sectional and longitudinal tests of interpersonal-psychological mediators

Eating disorders (EDs) are associated with high mortality rates from suicide. Empirical tests of the Interpersonal-Psychological Theory of Suicide (IPTS) have provided preliminary cross-sectional support for its application to individuals with EDs. Because IPTS seeks to predict development and changes in suicidal ideation (SI), longitudinal investigations are ideal. The purpose of this study was to conduct cross-sectional and longitudinal mediational tests of the effect of ED psychopathology on SI as explained by perceived burdensomeness, thwarted belongingness, and hopelessness. Participants were undergraduate students (N = 738) who completed self-report measures of ED symptoms and IPTS variables at up to three time points across 10 weeks. Multiple mediation analyses were conducted on cross-sectional and longitudinal data. Cross-sectional analyses indicate mostly consistent findings with existing literature; however, results from the longitudinal analyses failed to identify any mediational effects of ED psychopathology on SI. These differences emphasize the importance of empirical tests in both cross-sectional and longitudinal data. Given the inconsistent results, the utility of IPTS features in explaining the association between ED psychopathology and SI is unclear. Future studies should seek to replicate these findings using other methods of measurement across time (e.g., ecological momentary assessment) and within clinical ED samples.

Proposal for a Model of Suicidal Ideation in Medical Students in Colombia: A Simulation Study

Suicidal behaviour is a global public health problem, and one population group with high prevalence rates is medical students, especially in the ideation component. Various models have tried to explain it, but there are few inferential studies in the Colombian population. The structural equation models used in controlled social sciences to explain this problem and their analytical power allow generalisations to be made with a certain degree of precision. These analyses require a large amount of data for robust estimation, which limits their usability when there are restrictions to access the data, as is the case today due to Covid-19, and a question that stands out in these models is the evaluation of the fit. Through a set of 1,200 simulated data, an appropriate model fit was found (x₅₂₄² = 1.732,300, p < 0,001, CFI = 0.97, GFI = 0.97, TLI = 0.97, RMSEA = 0.04[0.042-o.046], SRMR = 0.06) for the predictors of depression and perceived burdensomeness, which were analysed using the JASP program. The role of thwarted belongingness is discussed, as well as the appropriateness of the assessment instrument used to evaluate it an considerations regarding suicidal ideation monitoring, evaluation and intervention in medical students.

Emotion dysregulation and suicidality in eating disorders

OBJECTIVE

Suicidality in eating disorders (EDs) is high, and identification of therapeutically targetable traits associated with past, current, and future suicidality is of considerable clinical importance. We examined overall and ED subtype-specific associations among suicidal ideation, suicide attempts, and general and specific aspects of emotion dysregulation in a large sample of individuals with ED, at presentation for treatment and 1-year follow-up.

METHOD

Using registry data from 2,406 patients, scores on the Difficulties in Emotion Dysregulation Scale (DERS) at initial registration were examined as predictors of recent suicidal ideation and self-report lifetime suicide attempts. Associations were examined in the full sample and in each ED subtype. In 406 patients, initial DERS scores were examined as predictors of suicidality at 1-year follow-up.

RESULTS

Overall DERS was associated with suicidal ideation and suicide attempts, even when adjusting for ED psychopathology and current depression. Perceived lack of emotion regulation strategies showed unique associations with suicidal ideation and suicide attempts, both in the full sample and in most ED subtypes. Initial DERS was also associated with follow-up suicidal ideation and suicide attempts, although this association did not remain when adjusting for past suicidality.

DISCUSSION

Results suggest that emotion dysregulation may be a potential mechanism contributing to suicidality in EDs, beyond the effects of ED psychopathology and current depression. Although the prevalence of suicidality differs across ED subtypes, emotion dysregulation may represent a risk trait for future suicidality that applies transdiagnostically. Results support addressing emotion dysregulation in treatment in order to reduce suicidality.

The Interpersonal-Psychological Theory of Suicide to Explain Suicidal Risk in Eating Disorders: A Mini-Review

Suicide is a major cause of death in Eating Disorders (EDs) and particularly in anorexia nervosa (AN). The aim of the present mini-review was to summarize the literature focusing on the interpersonal-psychological theory of suicide (IPTS) by Thomas E. Joiner, as applied to explain suicidal risk in EDs. PubMed database was used to search articles focused on IPTS in EDs; 10 studies were eventually included. The majority of the included studies reported data from the same sample, even though the hypotheses and analyses for each study were unique. The investigated suicidal outcomes were suicidal ideation (SI) (40%), non-suicidal self-injury (10%), suicide attempt (40%) and suicide (10%). In ED patients Perceived Burdensomeness (PB) may play an important role, especially regarding SI risk. ED patients may feel like a burden to their close ones, and actually some of the ED symptoms may be an expression of anger and hate against the self. Overall, currently available research has supported some IPTS derived predictions (i.e., ED symptoms may increase PB and thereby SI), but not others (i.e., the elevated suicide rate in AN may be due to higher acquired capability for suicide). Further research on IPTS tenets as well as on other theoretical perspectives and constructs (e.g., interoceptive awareness), hopefully with a longitudinal design and adequate follow-up duration, might allow a more thorough understanding of the complex topic of suicidal behavior in ED patients.

Proposal for a Model of Suicidal Ideation in Medical Students in Colombia: A Simulation Study

Suicidal behaviour is a global public health problem, and one population group with high prevalence rates is medical students, especially in the ideation component. Various models have tried to explain it, but there are few inferential studies in the Colombian population. The structural equation models used in controlled social sciences to explain this problem and their analytical power allow generalisations to be made with a certain degree of precision. These analyses require a large amount of data for robust estimation, which limits their usability when there are restrictions to access the data, as is the case today due to Covid-19, and a question that stands out in these models is the evaluation of the fit. Through a set of 1,200 simulated data, an appropriate model fit was found (x5242=1.732,300;p<0,001, CFI = 0.97, GFI = 0.97, TLI = 0.97, RMSEA = 0.04[0.042-0.046], SRMR = 0.06) for the predictors of depression and perceived burdensomeness, which were analysed using the JASP program. The role of thwarted belongingness is discussed, as well as the appropriateness of the assessment instrument used to evaluate it an considerations regarding suicidal ideation monitoring, evaluation and intervention in medical students.

A longitudinal examination of the relationship between eating disorder symptoms and suicidal ideation

OBJECTIVE

Cross-sectional research demonstrates significant correlations between eating disorders (EDs) and suicidal thoughts and behaviors. Although suicide ideation (SI) is a risk factor for suicidal behavior, longitudinal research investigating SI among EDs is limited. Thus, the aim of this study was to offer insight into the dynamic relationship between EDs and SI by investigating if these variables predicted one another at weekly time points.

METHOD

Autoregressive cross-lagged modeling was used to test bidirectional relationships between ED symptoms and suicidal ideation among an ED patient sample (n = 92). Participants completed a measure of suicidal ideation and the Eating Disorder Examination-Questionnaire (EDE-Q) weekly for 5 weeks.

RESULTS

SI and ED symptoms were correlated with each other at each time point. Unexpectedly, the majority of cross-lagged pathways were nonsignificant. However, SI at Week 4 predicted ED symptoms at Week 5, while controlling for Week 4 ED symptoms. This pattern of results was found when the shape concerns, weight concerns, and eating concerns subscales of the EDE-Q were entered into the model. Moreover, Week 2 shape concerns predicted Week 3 SI and Week 3 eating concerns predicted Week 4 SI. No significant cross-lagged pathways were found with the dietary restraint subscale.

DISCUSSION

Nonsignificant cross-lagged pathways may indicate that third variables better explain the relations between certain ED symptoms and SI over time. However, there were instances where ED symptoms and SI predicted one another. Given this, targeting suicidal thoughts in therapy may help to reduce eating pathology and vice versa.

Assessing Longitudinal Relationships among Thwarted Belongingness, Perceived Burdensomeness, and Eating Disorder Symptoms

OBJECTIVE

Past work has documented a cross-sectional relationship between eating disorders (ED) and suicidality, but few studies have examined the directionality of this relationship. Informed by the interpersonal-psychological theory of suicide (IPTS), this study examines the bidirectional, longitudinal relationship between ED symptoms and two determinants of suicide ideation-thwarted belongingness (TB) and perceived burdensomeness (PB).

METHOD

Ninety-two treatment-seeking individuals with ED (94.5% White, 95.6% female) completed baseline (T1) measures of ED symptoms along with TB and PB. Of those, 75 (81.5%) completed a follow-up assessment eight weeks later (T2).

RESULTS

Separate linear regression models revealed that T1 ED symptoms did not predict T2 TB (b = .03, p = .42) or T2 PB (b = -.01, p = .68). Similarly, T1 TB did not predict T2 ED symptoms (b = .25, p = .37). T1 PB did significantly predict T2 ED symptoms (b = 0.52, p = .04). Further, among participants with AN/sub-AN, T1 TB and PB predicted T2 ED symptoms (p's ≤ .03).

CONCLUSION

Our results reveal the need for a nuanced understanding of the relationship between ED and suicidality. This study found that PB predicts greater ED symptoms and, among the AN/sub-AN sample, TB does as well.

Body dissatisfaction and symptoms of bulimia nervosa prospectively predict suicide ideation in adolescents

OBJECTIVE

Symptoms of eating disorders have been established as significant concurrent correlates with suicide ideation and behaviors in adolescent samples, but very few studies have examined eating disorder symptoms as prospective risk factors for suicide. The current study examined eating disorder symptoms as prospective risk factors for suicide ideation in an unselected community sample of adolescents.

METHOD

Data were collected from 436 adolescents in middle and high school at baseline and 6- and 12-month follow-ups. Adolescents completed self-report measures assessing eating disorder symptoms and suicide ideation and behaviors at each time point during school hours.

RESULTS

Regression analyses found that body dissatisfaction was a significant prospective predictor of suicide ideation severity at the 6- and 12-month follow-ups, symptoms of bulimia nervosa (binge-eating disorder and purging) predicted suicide ideation severity at the 12-month follow-up only, and symptoms of anorexia nervosa (drive for thinness and restricting) were not significant predictors of suicide ideation at either follow-up. Exploratory analyses found the same pattern of results for the sample of girls only, while no significant predictors were found for boys only.

DISCUSSION

This is the first longitudinal study of disordered eating and suicide ideation in American adolescents. Symptoms of bulimia nervosa and body dissatisfaction seem to be true risk factors for suicidal ideation. The current study demonstrates the importance of disordered eating behaviors in the development of suicidal ideation in adolescents, particularly for adolescent girls.

Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA.

METHODS AND RESULTS

We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers.

DISCUSSION

We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.

Psychometric Properties of the Interpersonal Outcome Expectancies for Thinness (IOET) Scale: Evidence for Validity, Reliability, and Utility in the Study of Eating Disturbances in Females

Introduction: Interpersonal context is believed to represent a powerful factor that often fosters and sustains eating disturbances in females. The present study focused on the development of a measure tapping into positive interpersonal expectancies predicated on being thin believed to be positively involved in eating disorders in females, namely, the Interpersonal Outcome Expectancies for Thinness (IOET).

Method: In Study 1, a total of 361 U.S. female college students completed the IOET for factor analysis. In Study 2, to assess for construct validity, an independent sample of 184 U.S. female college students completed a test battery including the IOET and measures of eating attitudes and disturbances, positive and negative affectivity, and general optimism.

Results: In Study 1, results from an exploratory factor analysis indicated a one-factor solution for the IOET accounting for 76.70% of the total variance. In Study 2, the IOET was found to possess good test-retest reliability (6-week) in a subset sample of U.S. female participants. Moreover, in support for construct validity, we found IOET scores were positively associated with scores on measures of eating disturbances (e.g., bulimic symptoms) and negative affectivity. Additionally, IOET scores were negatively associated with scores on a measure of general optimism. Finally, in support of utility, the IOET was found to add incremental validity to the prediction of eating disturbances, even after accounting for general optimism and affectivity.

Discussion: The present findings provide promising evidence for the validity, reliability, and utility of the IOET as a measure of a maladaptive cognitive schema associated with eating disorders in females. Implications for the theory and clinical assessments were discussed.

Nonsuicidal self-injury and disordered eating: Differences in acquired capability and suicide attempt severity

Nonsuicidal self-injury (NSSI) and eating disorders are both strongly related to suicide behaviors, and both can be conceptualized as painful and provocative events that associate with acquired capability for suicide. Individuals who self-injure report greater acquired capability than those who do not engage in these behaviors, but results are mixed in eating disorder samples. Given that NSSI and disordered eating (DE) commonly co-occur, it is important to examine how acquired capability for suicide and suicide attempt severity may differ between individuals who engage in either, both, or neither of these behaviors. It was expected that individuals with both NSSI and DE would report the greatest acquired capability, assessed by fearlessness about death and fear about suicide, and suicide attempt severity, compared to NSSI only, DE only, and controls. In a sample of 1179 undergraduates, results indicated no differences on fearlessness about death, but the NSSI + DE group reported the lowest scores on fear of suicide and greatest suicide attempt severity compared to the other groups. Differences between fearlessness about death and fear about suicide are discussed, as well as the possible additive effect of engaging in both direct (NSSI) and indirect (DE) self-harm on fear about suicide and suicide risk.

Social Difficulties As Risk and Maintaining Factors in Anorexia Nervosa: A Mixed-Method Investigation

Anorexia nervosa (AN) is a serious psychiatric disorder characterized by severe restriction of energy intake and dangerously low body weight. Other domains of functioning are affected, including social functioning. Although difficulties within this domain have started to be acknowledged by the literature, some important gaps remain to be filled. Do social difficulties predate the onset of the illness? What difficulties in particular are relevant for the development and maintenance of the illness? The aim of this study is to combine the use of quantitative and qualitative methods to answer these questions. Ninety participants with lifetime AN (88 women and 2 men) completed an online survey assessing memories of involuntary submissiveness within the family, fear of negative evaluation from others, perceived lack of social competence, feelings of social belonging, eating disorder symptoms, and work and social adjustment. Participants also answered three open questions regarding their experience of social relationships before and after the illness onset. The findings provided support for the hypothesized relationships between the study variables. Involuntary submissiveness and fear of negative evaluation predicted eating disorder symptoms and these associations were partially mediated by perceived lack of social competence. Two-thirds of the sample recalled early social difficulties before illness onset and recognized that these had played a role in the development of the illness. A larger proportion of participants stated that the eating disorder had affected their social relationships in a negative way. This study sheds some light on patients' perspective on the predisposing and maintaining role that social difficulties play in AN and identifies key psychological variables that could be targeted in treatment.

From ideation to action: recent advances in understanding suicide capability

Suicide capability is one of few risk factors associated with suicide attempts among ideators. In the decade since the Interpersonal Psychological Theory of Suicide introduced the concept of acquired capability (i.e. the ability to face the fear and pain associated with death), understanding of the capability to attempt suicide has grown. Acquired (e.g. NSSI), dispositional (e.g. genetic), and practical contributors (e.g. access to firearms) appear to influence suicide capability via mechanisms such as the fear of death, persistence through pain, and familiarity with suicide methods. Self-report methods have shown mixed results, highlighting the importance of developing behavioral measures of suicide capability.