Anorexia has the highest mortality rate of any psychiatric disorder, with death rates estimated as high as 17% (Keel et al., 2003). It was previously thought that the majority of anorexia-related deaths were a result of physical complications secondary to the disorder. However, recent research reveals that most anorexia-related deaths are due to suicide (Fedorowicz, Falissard, Foulon, Dardennes, Guelfi, et al., 2007).
Joiner (2005) has proposed an Interpersonal-Psychological Theory of Suicide (IPTS), which suggests that individuals who are at risk for suicide are those who (1) have strong feelings of perceived burdensomeness, (2) lack feelings of belongingness, and (3) have acquired a capacity to enact lethal self-injury. Individuals with anorexia may be particularly vulnerable to these factors that place them at high risk for suicide.
Joiner suggests that individuals die by suicide when they feel that their death would relieve a burden to others. In other words, people kill themselves when they believe that their death is worth more than their life. As compared to other psychiatric disorders, anorexia may be particularly associated with feelings of perceived burdensomeness, based on the requirements of caregivers in supporting their family member’s mental and physical health (de la Rie, van Furth, De Koning, Noordenbos & Donker, 2005).
Individuals who die by suicide are likely to experience a lack of connection to others. This tendency may also be a hallmark of anorexia (Limbert, 2010). Anecdotally, individuals with anorexia often report that they lose friendships and social interactions as a result of their disorder. Often, their relationship to the eating disorder replaces their relationship to others. Also, anorexia has a high comorbidity with disorders related to social difficulties, including social phobia, major depressive disorder, and avoidant personality disorder (Binder, Cumella, & Sanathara, 2006). This may exacerbate feelings of disconnection and social isolation.
The IPTS suggests that individuals develop the ability to die by suicide through repeated exposure to painful and/or injurious events. Individuals with anorexia may meet this criteria through several paths. First, individuals with anorexia engage in eating disorder behaviors, which are dangerous and self-injurious (e.g., self-induced vomiting, laxative use, diuretic use). Many may utilize extreme versions of these behaviors (e.g., Ipecac syrup, water purging), which can be even more dangerous. Repeated use of these behaviors results in a habituation to dangerous/injurious behaviors, which sets the stage for a lethal suicide attempt. Secondly, individuals with anorexia are also likely to engage in self-harm behaviors. Research indicates that approximately 25% to 45% (Claes, Vandereycken, & Vertommen, 2003; Herpertz, 1995; Paul et al., 2002) of individuals with eating disorders also engage in self-injury. Individuals who engage in self-injurious behavior may develop somewhat of a tolerance to self-harm so that more injurious behaviors are required to achieve the same effect. Finally, the effects of starvation may result in a numbing effect, so that individuals with anorexia may experience an increased pain tolerance, which may exacerbate acquired lethality. The combination of dangerous and injurious eating disordered behaviors, self-harm behaviors, and starvation may create the perfect storm of risk factors for the acquired capacity to enact lethal self-injury.
Joiner’s theory of suicide provides a compelling framework for conceptualizing the high suicide rate for anorexia. This framework may also be helpful in developing interventions for treatment and prevention of suicide in anorexia. Treatments aimed at these factors may assist clinicians in circumventing suicidal behavior in anorexia and may ultimately result in saving lives.
Dr. Nicole Siegfried, Clinical Director
Dr. Mary Bartlett, Suicide Prevention and Risk Consultant