High Suicide Rate in Anorexia Linked to Lethal Methods, Not Fragile Health

Marlene Busko

March 06, 2008

March 6, 2008 — A study of 9 case reports of anorexic patients who died by suicide found that death was a result of using highly lethal methods rather than the result of compromised health.

The study, by investigators in the United States and Germany, will be published in the April 2008 issue of the Journal of Affective Disorders.

"Clinicians really need to do a good job of screening patients with anorexia nervosa . . . because if patients with anorexia report that they do in fact have suicidal intentions, clinicians really need to come up with an immediate plan that would help to keep them safe," lead author Jill Holm-Denoma, PhD, from the University of Vermont, in Burlington, told Medscape Psychiatry.

Their findings support the hypothesis by Thomas E. Joiner, PhD (Why People Die by Suicide. Cambridge, MA: Harvard University Press; 2006), which suggests that anorexic individuals may become accustomed to pain during the course of their illness and die by using methods that are highly lethal, she noted.

Anorexia nervosa is associated with 1 of the highest premature death rates of all mental disorders, and suicide is a leading cause of death among individuals (mainly women) who are anorexic, the group writes.

This high rate of death by suicide might be the result of weak suicide attempts combined with fragile medical health. Alternatively, suicidal anorexic patients might use highly lethal methods with low rescue potential, which would kill even healthy individuals.

To determine which of these 2 explanations is more likely, the group performed a study of 9 case reports of treatment-seeking individuals with anorexia nervosa who were followed for up to 13 years and died by suicide.

Four of the cases were drawn from a sample of 136 women in the Boston area (Herzog DB et al. J Am Acad Child Adolesc Psychiatry. 1993;32:835-842). A fifth case, the only male in the current study, was taken from a study of 81 males that was conducted at the University of Munich, in Germany. Cases 6 to 9 were drawn from patients treated in the Klinik Roseneck Hospital for Behavioral Medicine, in Prien, Germany.

The patients were in their 20s and 30s at the time of death, except for a 40-year-old woman and a 17-year-old boy.

They died by jumping in front of a train (3 cases), hanging (2 cases), taking a drug overdose (2 cases), ingesting poison (1 case), or breathing carbon monoxide (1 case).

Eight of the 9 cases were judged to have used methods that would have led to death for anyone. Seven of the 9 fatal suicide methods occurred in circumstances where there was a low likelihood of being rescued. Many of these individuals had made multiple prior suicide attempts.

Strong Suicidal Intent

The study results show that anorexic individuals who attempt suicide have a strong wish to die and engage in an act of self-injury with a very high likelihood of death, said Dr. Holm-Denoma.

These findings support Dr. Joiner's theory of suicidal behavior that suggests that individuals with anorexia may habituate to the experience of pain as a result of their illness (such as starvation pain and frequent chest pain) and die by using extreme suicide methods, the group concludes.

The study was not designed, however, to be able to extrapolate a clear causal relationship between anorexic features and death by suicide, the investigators note.

J Affect Disord. 2008;107:231-236. Abstract


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