Psychopathological distress predicts suicidal ideation and self-harm in adolescent eating disorder outpatients

Non-suicidal self-injury among individuals with an eating disorder: A systematic review and prevalence meta-analysis

OBJECTIVE

This study aimed to quantify the prevalence of non-suicidal self-injury across eating disorders (EDs) and within diagnostic categories through systematic review and proportional, or so-called prevalence, meta-analysis.

METHOD

Included studies had to contain individuals with a verified diagnosis of an ED. The last literature search was conducted on September 11, 2023, for studies published on or before September 2023 without a restriction on earliest publication year. Results were synthesized and analyzed using the "metaprop" package in R and presented using forest plots. Bias was assessed by a Peters' regression test and funnel plot.

RESULTS

79 studies published between 1985 and 2023 were included encompassing 32,334 individuals with an ED. Importantly, 42 studies were not included in any other meta-analyses on self-injury in EDs to date. Overall prevalence of non-suicidal self-injury was 34.59% (95%CI = 30.49-38.81). Prevalence in anorexia nervosa restrictive type, binge/purge type, bulimia nervosa, binge eating disorder and other specified feeding/eating disorder were 23.19% (95%CI = 16.96-30.03%), 41.98% (95%CI = 32.35-51.91%), 36.97% (95%CI = 30.69-43.46%), 21.21% (95%CI = 14.93-28.12%) and 37.65% (95%CI = 28.59-47.09%), respectively. Prevalence estimations could not be estimated for other ED categories due to lack of a sufficient number of studies.

DISCUSSION

Non-suicidal self-injury is prevalent across both binge/purge and restrictive EDs. Considering the transdiagnostic nature of self-injurious behaviors in ED, the results highlight the importance of assessment and monitoring of self-injury in people with ED, irrespective of specific diagnoses. The method of determining self-injury varied across studies and may limit this study.

PUBLIC SIGNIFICANCE

This study highlights the prevalence of self-injury across eating disorders irrespective of diagnosis and within specific EDs. While diagnoses known to exhibit self-injurious behaviors (e.g., bulimia nervosa, anorexia nervosa binge/purge subtype) demonstrated the highest prevalence of self-injury, all diagnoses were found to have a prevalence greater than 20%. These findings suggest the importance of assessing and monitoring all individuals with an eating disorder for the presence of self-injury.

Predictors of Self-Harm Types in Members of Online Communities: Age As a Moderating Variable

BACKGROUND

Deliberate self-harm includes direct and indirect behaviors that cause harm to the body. Various manifestations of such behavior (e.g., non-suicidal self-injuries) are prevalent in adolescent and youth populations, and they often serve as precursors of subsequent suicidal behavior. The interpersonal dynamics that lead to self-harm behavior remain understudied. Interpersonal sensitivity, defined as an anticipation of criticism and fear of rejection in one's relationships with other people, may become one such factor.

AIM

The present study was conducted to investigate the relationship between interpersonal sensitivity, psychopathological symptoms, and types of self-harm.

METHODS

The sample (n=804, 17-35 years, M=23.3±4.6 years) was recruited in online communities. A survey developed by the authors was used to measure the types of self-harm. Other measures included the Interpersonal Sensitivity Measure and Symptom Checklist-90-R.

RESULTS

It was discovered that superficial self-injuries could be related to more severe types of self-harm, destructive for the body on the whole (e.g., risk-taking, deprivation, fasting, substance abuse). Fear of rejection and psychopathological symptoms emerged as predictors of both superficial self-injuries and self-destructive behavior. Although younger respondents (17-19 years old) were more likely to inflict on themselves superficial self-injuries, those who scored high on fear of rejection were more likely to report more severe self-destructive behavior. Acute psychological distress elevated this risk for both younger and older participants (27-35 years old).

CONCLUSIONS

The results of the study point at the important role the dynamics of interpersonal relationships plays in perpetuating self-harm.

Lifetime prevalence and clinical correlates of nonsuicidal self-injury in youth inpatients with eating disorders: a retrospective chart review

BACKGROUND

Youths with eating disorders (EDs) engaging in nonsuicidal self-injury (NSSI) are at higher suicide risk because EDs and NSSI are associated with suicidality. However, epidemiologic data on NSSI lacks in the vulnerable group of youth ED inpatients.

METHODS

This retrospective chart review included patients up to 18 years of age with an ICD-10 diagnosis of anorexia nervosa, restricting type (AN-R), anorexia nervosa, binge-purge type (AN-BP), and bulimia nervosa (BN), treated at the child and adolescent inpatient department of the University Hospital in Berlin, Germany, between 1990 and 2015. Across and within ED subgroups, lifetime NSSI prevalence, methods of self-harm, and clinical correlates were evaluated. Independent correlations of demographic and clinical factors with NSSI were identified via multivariable regression models.

RESULTS

Of 382 inpatients (median = 15.6 (range = 9-18) years, females = 97.1%), 21.5% reported lifetime NSSI, consisting of cutting = 86.6%, scratching = 12.2%, and hitting = 8.5%. NSSI was more frequent in BN (47.6%) and AN-BP (39.3%) than AN-R (8.3%) (Φ = 0.43). Across ED subgroups, NSSI was associated with a higher prevalence of psychiatric comorbidities (AN-R: Φ = 0.55; AN-BP: Φ = 0.69; BN: Φ = 0.78), suicidal ideation (AN-R: Φ = 0.30; AN-BP: Φ = 0.38; BN: Φ = 0.29), and psychiatric medication use (AN-R: Φ = 0.23; AN-BP: Φ = 0.64; BN: Φ = 0.60). In multivariable regression analyses, NSSI was independently associated with a higher prevalence of psychiatric comorbidities (AN-R: OR = 2.93 [1.42, 6.04]; AN-BP: OR = 2.67 [1.13, 6.31]; BN: OR = 3.75 [1.71, 8.23]). Additionally, independent correlates with NSSI in AN-R included a higher prevalence of suicidal ideation (OR = 0.21 [0.72, 0.64]) and less weekly weight gain (OR = 0.03 [0.02, 0.43]), while in BN, NSSI was correlated with longer inpatient treatment duration (OR = 1.01 [1.00, 1.02]).

CONCLUSIONS

There is a high lifetime prevalence of NSSI among youth with AN and BN requiring inpatient treatment, especially those with binge-purge behaviors. Treatment programs must be tailored to address psychiatric comorbidities and suicidality to improve patient care and suicide prevention.

TRIAL REGISTRATION

This study was not considered a clinical trial but a retrospective chart review based on routinely assessed clinical parameters. The study includes data from human participants, however: (1) no intervention and no prospective assignment to interventions were performed, and (2) no evaluation of an intervention on participants was accomplished.

Relationships between Non-Suicidal Self-Injury and Other Maladaptive Behaviors: Beyond Difficulties in Emotion Regulation

Non-suicidal self-injury (NSSI) co-occurs with both other maladaptive behaviors (e.g., aggression) and emotion dysregulation. However, the extent to which these maladaptive behaviors are linked to NSSI independent of emotion dysregulation is unclear. The present study examined relationships between NSSI and six other maladaptive behaviors among university undergraduates. When controlling for demographic variables, emotion dysregulation, and other maladaptive behaviors, binge eating, purging, illicit drug use, and physical aggression were each related to lifetime NSSI history and/or severity. No maladaptive behaviors were significantly related to the presence of current diagnostic-level NSSI in these multivariate analyses. Results suggest that some maladaptive behaviors may relate uniquely to NSSI risk independent of emotion dysregulation, highlighting the importance of considering such behaviors in self-injury assessment and treatment.

Children and adolescents with eating disorders during COVID-19 confinement: Difficulties and future challenges

OBJECTIVE

To present the adaptations to treatment protocols made in a child and adolescent eating disorders (ED) unit during the eight-week confinement period mandated in response to the COVID-19 pandemic and examine clinical and treatment variables in the outpatient, day hospital, and inpatient care programs.

METHOD

Description of the implementation of a combined teletherapy program for outpatient and day-hospital patients and the adaptations made to the inpatient protocol. Retrospective review of medical records and analysis of general and specific variables related to the pandemic and confinement.

RESULTS

We held 1,329 (73.10%) telehealth consultations and 489 (26.9%) face-to-face outpatient visits with 365 patients undergoing treatment in the outpatient clinic or day hospital. Twenty-eight (7.67%) were initial evaluations. Twenty-two patients were newly admitted and 68 ED-related emergencies were attended. Almost half of the children and adolescents studied experienced reactivation of ED symptoms despite treatment, and severe patients (25%) presented self-harm and suicide risk.

CONCLUSIONS

The implementation of a combined teletherapy program has enabled continuity of care during confinement for children and adolescents with ED. Delivery of treatment to adolescents in the day hospital program posed the biggest challenge due to their greater degrees of severity and higher hospitalization rates. An adapted inpatient program should be maintained throughout confinement, as the need for hospitalization of children and adolescents with ED does not decrease with lockdown.

Suicide attempts in bulimia nervosa: Personality and psychopathological correlates

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.

Brief report: Differences in nonsuicidal self-injury according to binge eating and purging status in an adolescent sample seeking eating disorder treatment

Nonsuicidal self-injury (NSSI) is elevated in adults with eating disorders (EDs), with a particularly increased incidence among individuals who engage in binge eating and/or purging (B/P) behaviors. Despite substantially elevated prevalence of NSSI in adolescence in general, NSSI in child and adolescent ED samples is understudied. There is some evidence for elevated prevalence of NSSI between B/P and restriction-only groups; however, this finding is not consistently reported and research in this area has excluded certain diagnostic groups (e.g., other specified feeding or eating disorder). Our aim was to identify the rates at which a transdiagnostic sample of adolescent patients with EDs (n = 155) report lifetime or past-month NSSI, and whether these rates differ between individuals who engaged in recent B/P behaviors vs. restriction only. Lifetime NSSI was present in 40.6% of the sample, and 23.2% of participants reported engaging in NSSI in the month prior to treatment. Individuals who reported recent B/P behaviors were more likely to report past-month (p = .005, OR = 5.57) and lifetime (p = .004, OR = 4.39) NSSI compared to individuals who did not report B/P behaviors. These results suggest an increase in risk for NSSI in child and adolescent patients in ED treatment who endorse B/P behaviors compared to patients who endorse restriction only. Research is needed to clarify the etiologic factors that may explain this association and the longitudinal changes in NSSI throughout the course of EDs.

Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria

BACKGROUND

Quantification of suicidal risk in specific populations is important for the adoption of targeted prevention and harm reduction measures. Though there remains little systematic evidence, risk of suicide attempts for bulimia nervosa (BN) and binge-purging anorexia nervosa (AN-bp) appears higher than restrictive AN (AN-r); risk in binge eating disorder (BED) is still unclear. The aim of this meta-analysis was to compare proportions of suicide attempts in eating disorder (ED) subgroups.

METHODS

A literature search using combinations of key-words for ED and suicide attempts was performed. Studies reporting proportions of suicide attempters in at least two ED groups, diagnosed according to DSM-IV or -5 and ICD-10 diagnostic criteria were considered. ED subgroups were analyzed in pairs using a binary random effect model for proportions. Publication bias, meta-regression, and sensitivity analyses were performed.

RESULTS

In BN, attempted suicide was more frequent (21%) than in AN (12.5%), but the difference was statistically significant only when BN was compared with AN-r (9-10%). In BED, the proportion of suicide attempts was as high as in AN (10-12%).

CONCLUSIONS

Though limited by heterogeneity across the studies in terms of methodology and aims, inability to control for relevant confounding variables, exclusion of ED not otherwise specified, this study supports suicide attempts as a major issue in EDs, especially in binge-purging subtypes, i.e. BN and AN-bp. Similar suicidal proportions were observed in AN and BED. The reasons for a greater proportion of attempted suicide in binge/purging subtypes need to be explored in future studies.

Socio-demographic and psychological risk factors for suicidal behavior among individuals with anorexia and bulimia nervosa: A systematic review

OBJECTIVE

Suicide is the second leading cause of death among individuals with anorexia nervosa (AN) and is also elevated in bulimia nervosa (BN). We carried out a systematic review in which we analyzed the relationship between AN and/or BN and suicidality (i.e. suicidal ideation or attempted and/or death by suicide) and the major risk factors for suicidal behavior among AN and BN patients by synthesizing the qualitative data from relevant studies.

EVIDENCE ACQUISITION

According to PRISMA guidelines, we conducted a systematic search of the literature on PsycNET, PubMed, Google Scholar, and ScienceDirect. Search terms were "eating disorders" "OR" "anorexia" "OR" "bulimia" combined with the Boolean "AND" operator with "suicide."

EVIDENCE SYNTHESIS

The initial search identified 8,590 records, of which 38 research reports met the predefined inclusion criteria and were analyzed. Eating disorders (EDs) were found to be associated with a marked increase in suicidal behaviors and ideation. ED type, impulsivity, and specific interpersonal features were associated with suicidal behavior.

CONCLUSIONS

Our findings highlight the importance of the combined role of socio-demographic and psychological factors to the co-occurrence of EDs and suicidal behavior. It is imperative that a thorough suicide assessment be conducted routinely for individuals with past and current EDs, and that clinicians be aware that this risk may be ongoing and occur throughout treatment, even after ED symptoms appear to be remitting.

LIMITATIONS

Study limitations include diagnostic definitions of and criteria for EDs, and the different terminology used by researchers to define suicide, including non-suicidal behaviors, which weakens the ability to draw conclusions regarding actual suicidal behaviors versus other self-harm behaviors.

Which Comes First? An Examination of Associations and Shared Risk Factors for Eating Disorders and Suicidality

PURPOSE OF REVIEW

This narrative review evaluates recent literature on the associations between eating disorders and suicidality and discusses potential shared mechanisms that may account for these relationships. Additionally, the review highlights shortcomings with the literature to date and suggests avenues for future research.

RECENT FINDINGS

Individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder experience elevated rates of suicidality compared to the general population. Suicide risk is higher when eating disorders occur with other psychological conditions. Additionally, genetic factors, emotion dysregulation, trauma, stressful life events, and lack of body regard may have roles in the development of both eating disorders and suicidality. Much of the risk for suicidality in eating disorders appears to be driven by comorbid psychopathology and genetic factors. However, the lack of longitudinal research makes it difficult to draw conclusions about the directionality or temporality of these relations; thus, novel methods are needed.

Anorexia nervosa, depression and suicidal thoughts among Chinese adolescents: a national school-based cross-sectional study

Background

Although there is much literature on adolescent suicide, combined effects of depression and anorexia nervosa on suicide were rarely investigated. The aims of this study are to examine the association between anorexia nervosa and suicidal thoughts and explore the interaction between anorexia nervosa and depression.

Methods

This is a cross-sectional study, in the study, a sample of 8,746 Chinese adolescents was selected by multistage stratified method in 2012/2013 from 20 middle schools in 7 provinces across China Mainland. Multilevel logistic model was introduced to explore association between anorexia nervosa and suicidal thoughts. And subgroup analyses were conducted on participants with or without depression.

Results

Multilevel logistic model revealed that demographic variables, including academic achievement, were not the predictive risk factors of suicidal thoughts. Those who suffered from worse severity of perceived anorexia nervosa were at increased risk of thinking about suicide. The interaction between depression and anorexia nervosa was significant, however, subgroup analyses showed that the associations were significant only among the adolescents without depression.

Conclusions

Our results indicate that all levels of anorexia nervosa serve as predictable indicators of suicidal thoughts in Chinese adolescents, and the effects of anorexia nervosa are modified by depression status.

Concurrent adversities and deliberate self-harm among indigenous Sami and majority Norwegian adolescents: the Norwegian Arctic Adolescent Health Study

Background:

Few studies have investigated proximal relationships between deliberate self-harm (DSH) and concurrent adversities.

Objective:

We aimed to investigate these relationships in a community population of 4881 indigenous Sami and majority Norwegian adolescents, 15 to 16 years old, and related to ethnicity and gender.

Methods:

Youth with and without self-reports of DSH last year were compared on 12 concurrent adversities, on scales measuring family and peer functioning, and on sociodemographic conditions.

Results:

DSH last year was reported by 22.3% of the adolescents, and by more girls (28.8%) than boys (15.9%). All 12 concurrent adversities were related strongly to DSH last year. Deliberate self-harmers reported twice as many concurrent adversities as non-DSHs, and a large effect size (Cohen’s d = 0.80) indicated a strong multiple additive relationship, but among DSHs no ethnic or gender differences were found. Multivariately, among Sami youth sexual abuse [odds ratio (OR), 8.4] was strongly related to DSH, whereas among majority Norwegians sexual abuse (OR, 3.9) and violence (OR, 4.5) were identified as the strongest predictors. Similarly, among boys violence from adults (OR, 8.8) was associated most strongly with DSH, whereas among girls sexual abuse (OR, 4.3) was the most robust predictor. DSHs reported more conflicts with parents, less family support and involvement, and more peer problems than non-DSHs, and DHS girls had more difficulties in these relationships than DHS boys. Only small ethnic differences were found.

Conclusion:

Adolescent DSHs reported twice as many concurrent adversities as non-DSHs, sexual abuse and violence were strongly related to DSH. Ethnic and gender differences in risk factors were found. Clinicians should inquire about traumatic experiences such as sexual and physical abuses, and should have a family, peer, and gender perspective in their work.

Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis

BACKGROUND

Against a backdrop of increasing research, clinical and taxonomic attention in non-suicidal self-injury (NSSI), evidence suggests a link between NSSI and eating disorders (ED). The frequency estimates of NSSI in ED vary widely. Little is known about the sources of this variation, and no meta-analysis has quantified the association between ED and NSSI.

METHOD

Using random-effects meta-analyses, meta-regression analyses, and 1816-6466 unique participants with various ED, we estimated the weighted average percentage of individuals with ED, those with anorexia nervosa (AN) and those with bulimia nervosa (BN) who are reported to have a lifetime history of NSSI across studies. We further examined predictors of NSSI in ED.

RESULTS

The weighted average percentage of patients with a lifetime history of NSSI was 27.3% [95% confidence interval (CI) 23.8-31.0%] for ED, 21.8% (95% CI 18.5-25.6%) for AN, and 32.7% (95% CI 26.9-39.1%) for BN. The difference between BN and AN was statistically significant [odds ratio (OR) 1.77, 95% CI 1.14-2.77, p = 0.013]. The odds of NSSI increased by 24% for every 10% increase in the percentage of participants with histories of suicide attempts (OR 1.24, 95% CI 1.04-1.48, p = 0.020) and decreased by 26% for every 10% increase in the percentage of participants with histories of substance abuse (OR 0.74, 95% CI 0.58-0.95, p = 0.023).

CONCLUSIONS

In the specific context of ED, NSSI is highly prevalent and correlates positively with attempted suicide, urging for NSSI-focused treatments. A novel finding is that NSSI is potentially antagonized by substance abuse.

Self-harm history predicts resistance to inpatient treatment of body shape aversion in women with eating disorders: The role of negative affect

Although self-harm has been observed among patients with eating disorders, the effects of such tendencies on treatment outcomes are unclear. The current study employed structural equation modeling to (a) evaluate the relationship between self-harm and changes in body dissatisfaction and drive for thinness in a large sample of patients (n = 2061) who underwent inpatient treatment, and (b) to examine whether the relationship between self-harm and changes in body dissatisfaction and drive for thinness during inpatient treatment remains significant when controlling for change in negative affect during treatment. Results revealed that patients with a history of self-harm reported significantly less reduction in body dissatisfaction and drive for thinness following treatment. Patients experiencing less change in negative affect also reported significantly less reduction in body dissatisfaction and drive for thinness after discharge from treatment. However, the association between history of self-harm and reduction in body dissatisfaction and drive for thinness after treatment became non-significant when controlling for change in negative affect. This pattern of findings was also replicated among patients with a primary diagnosis of anorexia nervosa (n = 845), bulimia nervosa (n = 565), and eating disorder not otherwise specified (n = 651). The implications of these findings for delineating the specific role of self-harm in the nature and treatment of eating disorders are discussed.

Quarrelsome family environment as an enhanced factor on child suicidal ideation

Suicide is a leading cause of death in adolescents, and develops through a process leading from depression to suicidal ideation and self-injury. In this study, we analyzed and compared suicidal ideation among elementary school children from distinct families and school-related backgrounds. We conducted a cross-sectional study to investigate suicidal ideation in elementary school children in Miaoli County of Western Taiwan. Our study included 979 eligible participants and collected data, including suicidal ideation, depression scores, demographic characteristics, and family and school variables. The results revealed that 175 students (17.9%) exhibited depression, and 146 students (14.9%) had contemplated suicide. A quarrelsome family environment was found to be an important independent factor in child suicidal ideation after controlling for depression status. Children living in quarrelsome families showed a 3.7-fold risk of suicidal ideation compared with children in a harmonious family. Among boys living in quarrelsome family environments, suicidal ideation risk was 7.4-fold higher than for girls living in harmonious families. A 27-fold high increased suicidal ideation risk was also observed among the depressed children who living in the quarrelsome family environment, compared with the non-depressed in the harmonious family environment. This study provides novel evidence indicating the enhanced effects of a quarrelsome family environment combined with depression symptoms and among boys on suicidal ideation. These findings suggest of quarrels in a family environment playing an important role on elementary school children's psychological development, and may help parents in improving their mental health.

The current status of suicide and self-injury in eating disorders: a narrative review

The aim of this paper is to review recent literature on suicide and self-injury in eating disorders (ED) including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Among psychiatric diagnoses, EDs are associated with increased mortality rates, even when specialized treatment is available. Of the mortalities that are reported in individuals with EDs, suicide is among the most commonly reported causes of death. Additionally, suicidal and non-suicidal self-injurious behaviors occur frequently in this clinical population. A literature search was undertaken using the databases of Medline/PubMed and PsycInfo to identify papers describing suicidality in individuals with ED diagnoses. The authors identified studies and review articles published between 2005-2013 (inclusive) that describe the relationship between EDs and suicide, and associated behaviors including self-injurious behaviors, or non-suicidal self-injury (NSSI). The initial search resulted in 1095 papers that met the a priori search criteria. After careful review, 66 papers were included. The majority of papers described clinical cohorts that were studied longitudinally. The diagnosis described most frequently in selected studies was AN. There are limited current data about the prevalence of suicide and NSSI among individuals with EDs. Among the published studies that focus specifically on the relationship between EDs and suicidality, most describe AN in more detail than other EDs. Nonetheless, rates of mortality, and specifically rates of suicide, are undeniably high in ED populations, as are the rates of self-harm. Therefore, it is critical for clinicians and caretakers to carefully evaluate these patients for suicide risk and to refer promptly for appropriate treatment.

Correlates of suicide ideation and attempts in children and adolescents with eating disorders

This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7-18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.

Nonsuicidal self-injury: relationship to behavioral and self-rating measures of impulsivity and self-aggression

Previous research using self-report measures has shown an association between nonsuicidal self-injurious behavior (NSSI) and impulsive tendencies. However, self-injurers have not been shown to be different from comparison groups on laboratory tasks putatively assessing impulsive behavior. One explanation for these contradictory findings is that self-report and laboratory measures of impulsive behavior tap into distinct but related constructs. Moreover, performance on laboratory measures of impulsive behavior can be influenced by myriad contextual and affective factors not present during past self-reported NSSI events. Accordingly, a relationship between behavioral tasks of impulsivity and self-injurious behavior could emerge if both are assessed relatively close in time under controlled laboratory conditions. To test this possibility, both self-ratings and laboratory task measures of self-injurious and impulsive behavior were employed in the current study. This multi-modal assessment approach revealed that self-rated impulsivity was associated with both self-report and behavioral measures of self-injurious behavior. Moreover, behavioral measures of impulsivity were associated with self-injurious behavior, but not NSSI history. These results provide support for the notion that a multi-modal approach to assessing self-injurious behavior is important for better understanding the correlates of nonsuicidal self-injury.

Heart Rate Variability Modulates Eye-Blink Startle in Women With Bulimic Symptoms

The aim of the present study was to examine the modulatory influence of heart rate variability (HRV), an index of autonomic regulation, on eye-blink startle in women with bulimic symptoms. Twenty-four women with bulimic symptoms and 24 control women underwent a psychophysiological test to assess their HRVs during a rest period. They then underwent 20 trials designed to measure their startle motor reflexes while viewing pictures of food and pleasant, neutral, and unpleasant pictures. Women with bulimic symptoms and low HRV had larger startle magnitudes while viewing the pictures than women with both bulimic symptoms and high HRV and control women. A negative relationship between HRV and startle magnitude while viewing food pictures was also found in this group. These findings suggest that poor autonomic regulation, indicated by low HRV, plays a modulatory influence in women with bulimic symptoms.

Self-injury in adolescents with eating disorders: correlates and provider bias

INTRODUCTION

Self-injurious behavior (SIB) is common among adolescents, and has been shown to be associated with eating disorders (ED). This study examines the prevalence of SIB and SIB screening in adolescents with ED, and associations with binge eating, purging, and diagnosis.

METHODS

Charts of 1,432 adolescents diagnosed with ED, aged 10-21 years, at an academic center between January 1997 and April 2008, were reviewed.

RESULTS

Of patients screened, 40.8% were reported to be engaging in SIB. Patients with a record of SIB were more likely to be female, have bulimia nervosa, or have a history of binge eating, purging, co-morbid mood disorder, substance use, or abuse. Patients who engaged in both binge eating and purging were more likely to report SIB than those engaged in restrictive behavior or either behavior alone. Providers documented screening for SIB in fewer than half of the patients. They were more likely to screen patients who fit a profile of a self-injurer: older patients who binge, purge, or had a history of substance use.

CONCLUSIONS

SIB was common in this population, and supports extant literature on associations with bulimia nervosa, mood disorders, binge eating, purging, abuse, and substance use. Providers may selectively screen patients.

Preliminary evidence for a role for impulsivity in cognitive disinhibition in bulimia nervosa

The present study investigated cognitive disinhibition in bulimia nervosa (BN) and examined whether impulsivity could account for this neuropsychological deficiency. Inhibitory processing of 13 women with BN (16-29 years) was compared against that of 13 healthy control participants matched for age, education, and socioeconomic status on a battery of widely used tasks: Stroop task, Haylings sentence completion test, excluded letter fluency, and Matching Familiar Figures Test. The women were also administered the Barratt Impulsiveness Scale (BIS-11). The BN patients displayed significant impairments on all inhibition measures and posited significantly higher impulsivity scores than the controls. Moreover, controlling for impulsivity reduced the group differences in Stroop color naming and excluded letter fluency to nonsignificance, indicating that poor inhibitory control in BN is at least partly attributable to an impulsive disposition.

Suicidal behavior and depression in adolescents with eating disorders

BACKGROUND

Eating disorders are associated with an increased risk of suicide.

AIM OF THE STUDY

To examine suicidal behavior and depression in adolescents with eating disorders, and to identify risk factors associated with suicidal ideation and attempted suicide.

METHODS

Forty-six Israeli adolescent girls with anorexia nervosa or bulimia nervosa completed a self-report battery at the time of assessment or treatment. Suicide attempts and suicidal ideation were investigated in relation to clinical (e.g. body mass index, purging) and psychological (e.g. body dissatisfaction) features of the eating disorders, as well as depression. Twenty-four percent of the subjects had attempted suicide, and 65% reported suicidal thoughts. Fifty-eight percent were moderately to severely depressed.

FINDINGS

The risk of attempted suicide was associated with depression, a history of sexual abuse and longer duration of illness, but it was moderated by hospital treatment. Suicidal ideation was related only to depression.

CONCLUSIONS

The results of this study emphasize the importance of treating aggressively depression in adolescents with eating disorders. Depression seems to amplify illness severity. Currently, strategies for treating eating disorders focus more on the eating disorder behaviors and less on depression. We suggest investing more resources in detecting and treating the co-morbid depression.

Suicide ideation and social desirability among school-aged young people

A mixed male-female sample of 950 school-aged adolescents, corresponding to 10% of the young population aged 15-19 living in a rural district of Northeast Italy, was investigated with self-reported questionnaires about the links between social desirability and suicide ideation. On the whole 30.6% of females and 23.9% of males reported suicidal ideation of some degree, with 5% in both genders reporting suicide ideation of a high degree (i.e. quite a lot/extremely often). Those who scored higher at the Marlowe-Crowne Social Desirability Scale (SDS) reported lower levels of psychiatric symptoms on the Symptom checklist 90R (SCL-90R), with the "denial" subscale of the SDS resulting specifically associated to lower scores on SCL-90R items measuring hopelessness, thoughts about death and suicide ideation. The personality traits measured by the Marlowe-Crowne SDS, such as defensiveness, denial and self-deception, might be conceived as a protection against psychiatric disorders and suicide ideation.

Psychological and weight-related characteristics of patients with anorexia nervosa-restricting type who later develop bulimia nervosa

Background

Patients with anorexia nervosa-restricting type (AN-R) sometimes develop accompanying bulimic symptoms or the full syndrome of bulimia nervosa (BN). If clinicians could predict who might change into the bulimic sub-type or BN, preventative steps could be taken. Therefore, we investigated anthropometric and psychological factors possibly associated with such changes.

Method

All participants were from a study by the Japanese Genetic Research Group for Eating Disorders. Of 80 patients initially diagnosed with AN-R, 22 changed to the AN-Binge Eating/Purging Type (AN-BP) and 14 to BN for some period of time. The remaining 44 patients remained AN-R only from the onset to the investigation period. Variables compared by ANOVA included anthropometric measures, personality traits such as Multiple Perfectionism Scale scores and Temperament and Character Inventory scores, and Beck Depression Inventory-II scores.

Results

In comparison with AN-R only patients, those who developed BN had significantly higher current BMI (p < 0.05) and maximum BMI in the past (p < 0.05). They also scored significantly higher for the psychological characteristic of parental criticism (p < 0.05) and lower in self-directedness (p < 0.05), which confirms previous reports, but these differences disappeared when the depression score was used as a co-variant. No significant differences were obtained for personality traits or depression among the AN-R only patients irrespective of their duration of illness.

Conclusion

The present findings suggest a tendency toward obesity among patients who cross over from AN-R to BN. Low self-directedness and high parental criticism may be associated with the development of BN by patients with AN-R, although the differences may also be associated with depression.

Comorbidity and high-risk behaviors in treatment-seeking adolescents with bulimia nervosa

OBJECTIVE

The purpose of this brief report is to describe the comorbid diagnoses and high-risk behaviors in a sample of adolescents with bulimia nervosa (BN).

METHOD

Eighty adolescents enrolled in a RCT for BN that compared family-based therapy with individual-supportive psychotherapy completed the Eating Disorder Examination and the Schedule for Affective Disorder and Schizophrenia for School Age Children (K-SADS).

RESULTS

A total of 62.5% of the sample had a comorbid diagnosis as determined by the K-SADS. The majority of these presented with a major mood disorder. In addition, 25% of the sample had previously attempted suicide or self-harmed, 65.8% had consumed alcohol, and 30% had used illegal drugs. Suicidal behavior, drug use, and presence of a comorbid diagnosis were not related to diagnosis (full BN vs. subthreshold BN) or age.

CONCLUSION

Comorbidity and high-risk health behaviors in adolescents with BN mirror those of adults with BN although not at similar rates.

Eating disorders and suicide ideation: the mediating role of depression and aggressiveness

OBJECTIVE

Symptoms of depression and aggressiveness are important antecedents and correlates of suicide ideation and completion in adolescents and adults. Among adolescents, eating disorder symptoms were also found to associate with suicidal behavior. This study was aimed at investigating the role of depression and aggressiveness as mediators in the links between eating disorder symptoms and suicide ideation among adolescents, taking into account age and sex as covariates.

METHOD

Data from the Conegliano Eating Disorders Survey were used to investigate the role of depression and aggressiveness in the links between eating disorder symptoms and suicide ideation, resorting to a bootstrapped sampling distribution model.

RESULTS

In a mixed male-female sample of 930 adolescents, eating disorder symptoms were positively related to suicide ideation, taking age and sex into account. Depression and aggressiveness acted as full mediators in the links between eating disorder symptoms and suicidality, and virtually abolished any direct influence of eating disorders on suicide ideation.

CONCLUSION

Because of the cross-sectional nature of this study and the resorting to self-report scales, no firm statement about causal association can be made. However, both suicidal behavior and eating disorder symptoms are a rather widespread occurrence among adolescents, hence the investigation on suicidal tendencies in young people might benefit from the inclusion of measures of eating disorders to prevent the worst outcomes of minor psychological distress.

Eating disorders and attachment: the effects of hidden family processes on eating disorders

AIM

This study examined pattern of attachment in cohort of women with an eating disorder to determine what types of self-protective strategies they used, and further whether there was a specific relationship between strategy and diagnosis.

METHOD

The participants were 62 young women with an eating disorder (19 with anorexia nervosa, 26 with bulimia nervosa and 17 with bulimic anorexia). Attachment was assessed using the Adult attachment interview (AAI), classified using Crittenden's Dynamic-Maturational Method.

RESULTS

The results indicated that all women with an eating disorder were anxiously attached. About half used an extreme coercive Type C strategy while most of the others combined coercion with an extreme dismissing Type A strategy. The content of the AAIs suggested lack of resolution of trauma or loss among the mothers and also of hidden family conflict between the parents. This in turn elicited extreme strategies for generating parent-child contingency from the daughters.

CONCLUSIONS

Central in almost all cases was the women's confusion regarding how parental behaviour was tied causally to their own behaviour. Questions are raised regarding the focus of treatment.