78522106

Terapia psicológica

Sociedad Chilena de Psicología

Clínica

sochpscl@entelchile.net

ISSN (Versión impresa): 0716-6184

CHILE

2004

Paulo P. P. Machado / Bárbara C. Machado / Isabel Brandão / Sonia Gonçalves / António

Roma Torres

SUICIDE ATTEMPTS AND CLINICAL SEVERITY OF EATING DISORDERS:AN

EXPLORATORY STUDY

Terapia psicológica,

, año/vol. 22, número 001

Sociedad Chilena de Psicología Clínica

Santiago, Chile

pp. 57-60

Red de Revistas Científicas de América Latina y el Caribe, España y Portugal

Universidad Autónoma del Estado de México

http://redalyc.uaemex.mx

ISSN 0716-6184

TERAPIA PSICOLÓGICA

2004, Vol.22, Nº 1, 57-60

Suicide attempts and clinical severity of eating disorders:

An exploratory study

Intentos de suicidio y la severidad de los desórdenes alimentarios: Un estudio exploratorio

(Rec: 05-noviembre-2003 Acep: 20-febrero-2004)

El presente estudio examina si existen diferencias en la alimentación desordenada y estudios clínicos en los pacientes con

desórdenes alimentarios que han presentado intentos de suicidio y aquellos que no han intentado suicidio. 144 pacientes con

desórdenes alimentarios (65 con anorexia nerviosa y 78 con bulimia nerviosa) completaron el inventario de desórdenes

alimentarios (EDI; Garner, Omstead & Polivy, 1983), el Checklist de Síntomas – 90 – Revisado (SCL-90; Derrogatis, 1977)

y un cuestionario para evaluar conductas alimentarias y actitudes, información acerca del suicidio y otros síntomas relacio-

nados (PQB y TIB, Cost B6, 1994). Los pacientes con trastornos alimentarios que han tenido intentos de suicidio se diferen-

cian de sus pares con respecto a la historia de su peso, promedio de ingesta compulsiva, utilización del vómito como medida

de control del peso, uso de alcohol y psicotrópicos, patrones menstruales, actitud hacia el sexo, y en algunas de las subescalas

del EDI y el SCL-90. Los resultados del presente estudio muestran que los intentos de suicidio se relacionan con algunos

índices históricos de síntomas y severidad diagnóstica en ambos grupos de desórdenes alimentarios.

Palabras claves: Desórdenes alimentarios, anorexia nerviosa, bulimia nerviosa, intentos de suicidio.

The present study examines whether eating disorders patients with suicide attempts present differences in disordered

eating and clinical traits compared to those without suicide attempts. A total of 144 patients with eating disorders (65

anorexia nervosa and 79 bulimia nervosa) completed the Eating Disorders Inventory (EDI; Garner, Omstead & Polivy,

1983), the Symptom Checklist –90– Revised (SCL-90; Derrogatis, 1977), and a questionnaire to assess eating behaviors

and attitudes, information regarding suicide behaviors and other related traits (PQB and TIB (Machado & Soares, 2000);

Cost B6 (Machado & Soares, 2000). Eating disorder patients with suicide attempts differed from there peers regarding to

the weight history, mean of binge-purge attacks, use of vomiting to weight control, use of alcohol and psycho tropics,

menstrual pattern, sexual attitude, and in some EDI and SCL-90 subscales. The findings of the current study show that

suicide attempts are related to some indices of symptom history and severity for both diagnostic groups of eating disorders.

Keywords: Eating disorders, anorexia nervosa, bulimia nervosa, suicide attempts.

Introduction

Suicidal behavior incorporates a wide variety of acts,

ranging from suicidal gestures to self-harm, attempted sui-

cide or actual suicide. Frequency of suicide behavior tends

to be rare before age 14, increasing during puberty and

adolescence, reaching a peak around age 23 and remains

constant until old age (Shaffer, Garland, Goula, Fisher &

Trautman, 1988). Understandably, suicidal behaviors of

adolescents and young adults generate a great deal of

concern among public health officials, mental health

practitioners, educators and the public at large.

Suicidal behavior was shown to be associated with

psychological disorders like depression, substance abuse,

This study was partially supported by a grant of Fundação para a Ciência

e a Tecnologia / Foundation for Science and Technology, Portugal (FCT/

POCTI/PSI/33252/99) to the first author. Correspondence should be

sent to: Paulo P. P. Machado, PhD, Universidade do Minho, Departa-

mento de Psicologia, Campus de Gualtar, P-4710 BRAGA, PORTU-

GAL. Tel #: +351-53-604240; Fax#: +351-53-678987; E-mail:

pmachado@iep.uminho.pt

eating disorders, posttraumatic stress disorder, personality

disorders, and early onset of the first anxiety or depressive

disorder (Warshaw, Massion, O, Peterson & Pratt 1995).

Bulik, Sullivan, & Joyce (1999) concluded that suicide

attempts are equally common in women with eating

disorders and women with depression. Hentze and Engel

(1991) reported a mortality rate of 23.8% in anorexia

nervosa in 13.5 years follow-up study with 105 patients.

Five of the 25 deaths were due to suicide, and the remaining

patients died of anorexia-related medical complications.

Suicide attempts and suicidal behavior in eating

disorders are commonly associated with emotional

instability, interpersonal problems, self-damaging and

impulsive behaviors, including alcohol and drug abuse,

cognitive rigidity and perfectionism, body dissatisfaction,

low self-esteem and feelings of chronic emptiness. The

purpose of suicide seems to be and an escape and a cessation

of an unbearable psychological pain.

In addition, those patients that attempt suicide tend to

share characteristics that set them apart from those who don’t

attempt it. For example, Yamaguchi, Kobayashi, Tachikawa,

Paulo P. P. Machado

Universidade do Minho, Portugal

A. Roma Torres

Hospital S. João, Portugal

Sonia Gonçalves

Universidade do Minho, Portugal

Isabel Brandão

Hospital S. João, Portugal

Bárbara Machado

Universidade do Minho, Portugal

MACHADO, GONÇALVES, MACHADO, TORRES Y BRANDÃO

TERAPIA PSICOLÓGICA 2004, Vol.22, Nº 1, 57-60

Sato, Hori, Suzuki & Shiraishi (2000) showed that ED

patients with suicide attempts had a more prevalent history

of child abuse, affective instability, unstable self-image,

avoidance of abandonment, maladaptive perfectionism,

personality disorder, and mood disorder; however, the authors

didn’t find differences in symptomatological factors or the

severity of the eating disorder.

Favaro and Santonastaso (1996) found that 13% of 495

out patients with ED reported at least 1 suicide attempt and

29% reported current suicidal ideation, and 26% of

attempters reported multiple attempts. A history of suicide

attempt was more prevalent among binge-eating/purging

anorectics and among purging bulimics than in the other

subgroups. Anorexia nervosa suicide attempters were older,

had longer duration of illness, weighted less, had a more

often used drugs and/or alcohol and tended to be more

obsessive than non-attempters. In cases with bulimia

nervosa, suicide attempters presented with more psychiatric

symptoms and had more frequently been sexually abused.

The purpose of the current study was to: (1) evaluate

the presence of suicide attempts in a clinical population

with ED; (2) evaluate the severity of the clinical symptoms

related to eating disorders; and, (3) evaluate severity of

clinical symptoms associated with mental disorders. In this

study we consider suicide attempts intentional and nonfatal

behaviors resulting in risk for death.

Method

Participants

Participants were patients diagnosed with an eating

disorder that sought help in one of the specialized treatment

units at a Portuguese central hospital. Inclusion criteria was

presence of anorexia nervosa (AN) or bulimia nervosa (BN),

according with DSM-IV criteria (APA, 1994); exclusion

criteria was comorbidity with other axis I disorders and

personality disorders. We collected data from 144 female

patients diagnosed with ED (DSM-IV). Sixty-five (45.1%)

patients were diagnosed with anorexia nervosa, 42 (64.6%)

restrictive subtype and 23 (35.4%) bingeing-purging

subtype. Anorectic patients’ age ranged from 13 – 25 years

old (X=16.8; SD=13.4). Seventy-nine (54.9%) patients had

a diagnosis of bulimia nervosa, 59 (74.7%) purging subtype

and 20 (25.3%) non-purging subtype, their age ranged from

14 – 32 years old (X=21.5; SD=4.3).

Instruments

Therapist-interview at the beginning of treatment

(Cost

B6, c.f., Machado & Soares, 2000): a structured interview

designed to assess eating behaviors and attitudes, essential

clinical data and other relevant information to the

development course of ED;

Patient-Questionnaire at the beginning of treatment

(Cost B6, c.f., Machado & Soares, 2000): a self-report

questionnaire to gather demographic information, eating

pattern, history of the disorder including suicide attempts

and other relevant information to the development course

of eating disorders;

Eating Disorder Inventory (EDI; Garner, Olmsted &

Polivy, 1983):

Self report measure with 64 items in a six

point format with 8 sub-scales: 3 to evaluate attitudes and

behaviors concerning eating, weight and shape: (1) drive

for thinness, (2) bulimia and (3) body dissatisfaction, and

five subscales related to more general organizing constructs

or psychological traits clinically relevant to ED: (1)

ineffectiveness, (2) perfectionism, (3) interpersonal distrust,

(4) interoceptive awareness and (5) maturity fears.

Symptom Checklist –90-R (SCL-90; Derrogatis, 1977):

Self-report inventory in a five-point scale of distress, 9

primary symptom dimensions: (1) Somatization, (2)

obsessive-compulsive, (3) interpersonal sensitivity, (4)

depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8)

paranoid ideation and (9) psychoticism and 3 global indices

of distress: (1) global severity index, (2) positive symptom

distress index and (3) positive symptom total.

Procedure

All patients completed the assessment measures at an

intake interview. Clinical interviews were carried by the

therapist assigned to each case, usually a psychiatrist, or a

research assistant, a clinical psychology graduate student,

trained in the procedure.

Results

Table 1 shows the frequency of suicide attempts in both

groups of eating disorder patients, as well as the method

chosen. A total of 12 (18.5%) anorectic and 25 (31.6%)

bulimic patients reported history of suicide attempts, being

medication overdose the most common behavior.

Table 2 presents the results of each patient group on the

Symptom Checklist (SCL-90-R), and table 3 shows the results

of the same groups on the Eating Disorder Inventory (EDI)

Results showed that anorectic patients with a history of

suicide attempts scored significantly higher in Bulimia EDI

subscale (t

5.28

= -2.42, p<0.10) and in the depression SCL-

90 subscale(t

20.92

= -3.94, p<0.01), than those who did not

attempt suicide. Bulimic patients with a history of suicide

attempts scored higher in Drive for Thinness (t

55.59

= 4.15,

p<0.01) than no-suicide attempters.

Finally, table 4 presents the frequency of impulsive

behaviors sometimes associated with eating disorders.

Results showed that anorectic patients with a history of

suicide attempts more frequently engage in self induced

vomiting than their peers without a history of suicide attempts

SUICIDE ATTEMPTS AND CLINICAL SEVERITY OF EATING DISORDERS: AN EXPLORATORY STUDY

TERAPIA PSICOLÓGICA 2004, Vol.22, Nº1, 57-60

Table 1: Frequency of suicide attempts in ED patients.

AN (N=65)

BN (N=79)

Total (N=144)

Suicide attempts

12 (18.5%)*

25 (31.6%)*

37 (25.7%)*

Medication overdose

4 (6.2%)

15 (19%)

19 (11.7%)

Poison

1 (1.3%)

1 (0.6%)

Cut with knife

3 (4.6%)

3 (1.9%)

* The differences in total results are due to the non-respondents.

Table 2: Means and standard deviations of the SCL-90 scales for both groups of patients with ED (anorexia and bulimia

nervosa) with and without suicide attempts.

Anorexia nervosa

Bulimia nervosa

SCL-90 subscale

With Without

suicide attempts suicide attempts

Somatization

2.28 (0.59)

1.36 (0.68)

1.68 (0.92)

1.85 (0.80)

Obsessive-compulsive 2.16 (0.60)

1.68 (0.75)

2.18 (0.65)

1.88 (0.80)

Interpersonal sensitivity 2.25 (0.69)

2.00 (0.79)

2.41 (0.69)

1.92 (0.93)

Depression

2.47 (0.38)*

1.76 (0.78)

2.25 (0.70)

1.96 (0.73)

Anxiety

2.16 (0.49)

1.45 (0.83)

2.07 (0.58)

1.79 (0.72)

Hostility

2.10 (0.93)

1.66 (0.97)

2.10 (0.88)

1.51 (0.76)

Phobia

1.36 (0.71)

0.74 (0.61)

1.21 (0.73)

0.82 (0.67)

Paranoid Ideation 2.10 (0.57)

1.38 (0.69)

1.87 (0.66)

1.50 (0.83)

Psychoticism

1.59 (0.40)

1.32 (0.65)

1.57 (0.75)

1.39 (0.71)

Add

16.38 (4.47)

12.44 (5.58)

16.17 (5.85)

14.07 (5.42)

GSI

2.17 (0.53)

1.53 (0.64)

1.98 (0.54)

1.72 (0.65)

Total

194.00 (45.96)

14.17 (59.56)

176.41 (48.72)

154.72 (58.64)

*p<0.05

Table 3: Means and standard deviations of the EDI scales for both groups of patients with ED (anorexia and bulimia

nervosa) with and without suicide attempts.

Anorexia nervosa

Bulimia nervosa

EDI subscale

With

Without

With

Without

suicide attempts

Drive for thinness

17.57(6.47)

11.57 (7.57)

20.33 (2.91)*

5.48 (6.00)

Interpersonal distrust

7.00 (5.40)

5.52 (3.76)

6.78 (5.07)

5.56 (4.75)

Perfectionism

7.48 (2.99)

5.48 (3.60)

7.87 (4.15)

5.83 (4.06)

Bulimia

8.17 (6.62)**

1.55 (2.90)

13.44 (4.71)

1.68 (5.83)

Maturity fears

7.14 (5.98)

8.21 (5.17)

8.43 (4.96)

5.18 (4.33)

Interoceptive awareness

12.14 (7.31)

8.61 (6.37)

11.70 (4.50)

9.26 (5.58)

Body dissatisfaction

8.57 (6.55)

10.67 (7.00)

19.67 (6.35)

13.5 (8.08)

Ineffectiveness

10.14 (8.88)

7.86 (6.48)

16.17 (7.67)

9.23 (7.14)

Total

75.20 (23.70)

58.56 (31.96)

104.37 (21.49)

4.34 (29.14)

*p<0.001

**p<0.005

(Fisher’s exact test, p<0.01); and that bulimics without a

history of suicide attempts were more likely to abuse alco-

hol than non suicide attempters (Fisher’s exact test, p<0.05).

Discussion

In the current study we found a relatively high

prevalence of history of suicide attempts in both diagnostic

groups of eating disorders. We found a higher prevalence

of suicide attempts in bulimia nervosa group than in the

MACHADO, GONÇALVES, MACHADO, TORRES Y BRANDÃO

TERAPIA PSICOLÓGICA 2004, Vol.22, Nº 1, 57-60

Table 4: Frequency of reported impulsive behaviors in eating disorder patients with (WSA) and without (WoSA) history of

suicide attempts.

Anorexia Nervosa

Bulimia Nervosa

N= 65

N= 79

WSA

WoSA

WSA

WoSA

Vo m i t

yes

Laxatives

yes

Binges

yes

Alcohol abuse

yes

8**

Drug abuse

yes

*p<0.01; ** p<0.05

anorectic. Both groups of eating disorder patients with

suicide attempts presented a more chaotic eating pattern

(i.e., more binge eating/purge attacks) that may reflect a

larger spectrum of impulsivity.

The anorexia nervosa group with suicide attempts also

had a significantly highest result in the EDI bulimia subscale

that supports the tendency to think about and to engage in

episodes of uncontrollable overeating, differentiating the

bulimic and restricting subtypes.

On the other hand, the bulimic subgroup with suici-

de attempts had a significantly highest result in the drive

for thinness EDI subscale, revealing a most excessive

concern with dieting, preoccupation with weight and fear

of weight gain.

Results show that the presence suicide attempts in eating

disorders patients might be an indicator for the severity of

the patient’s general psychopathology. Bulimia patients with

suicide attempts revealed more concern with weight and diet,

and also more desire to loose weight, and anorectic patients

with these behaviors showed more symptoms of depression

and bulimia than their peers without suicide attempts.

In summary, our study shows that history of suicide

attempts behavior is frequent amongst eating disorder patients

that are treated in specialized clinical centers. Our findings

also suggest this behavior in eating disorders might be related

not only to highest degrees of eating psychopathology but

also general psychopathology, which puts these patients in

an increased risk for suicide attempts. Suicide attempts

seemed to be related to highest degrees of severity in both

anorexia and bulimia nervosa.

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