Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa

Abstract

Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.

Psychological Models of Suicide

“…Direct tests supported the link between self-harm behaviors, acquired capability, and eventually with suicide attempts (Bender, Gordon, Bresin et al, 2011;Joiner, Van Orden, Witte et al, 2009;Selby, Smith, Bulik et al, 2010;Smith, Ribeiro, Mikolajewski et al, 2012;Van Orden, Witte, Cukrowicz et al, 2010;. However, findings regarding increased pain tolerance by non-suicidal self-injury showed inconsistent results (Franklin, Hessel, & Prinstein, 2011;Hooley, Ho, Slater et al, 2010;Nock, Joiner, Gordon et al, 2006).…”

Temporal Associations Between Disordered Eating and Nonsuicidal Self-Injury: Examining Symptom Overlap Over 1 Year

“…Although these behaviors are often painful (Claes, Vandereycken, & Vertommen, 2006;Selby et al, 2010) and carry a risk of negative emotional and social consequences (Leibenluft, Gardner & Cowdry, 1987), they often serve to reduce unwanted emotions and other internal experiences (Haynos & Fruzzetti, 2011;Heatherton & Baumeister, 1991;Klonsky, 2007;Smyth et al, 2007). Current theories posit that the immediate reduction in negative affect provides powerful reinforcement such that these behaviors are repeated despite negative consequences that can accumulate over the long term (Chapman, Gratz, & Brown, 2006;Fairburn, Cooper, & Shafran, 2003;Haynos & Fruzzetti, 2011;Heatherton & Baumeister, 1991).…”

The joint influence of acquired capability for suicide and stoicism on over-exercise among women

“…For instance, Stein et al (2003) found that women with bulimia nervosa (BN) who had been recovered for a year still had elevated pain thresholds compared to healthy controls. Further, Selby et al (2010) found two distinct routes to extreme suicidal behavior among individuals with AN: for the AN-BP subtype, behaviors such as vomiting, laxative use, drug abuse, and non-suicidal self-injury were associated with suicide attempts, whereas for the AN-R subtype, unwavering restriction was related to past attempts.…”

“…Using the IPTS as a framework, Selby et al (2010) and Smith et al (2013Smith et al ( , 2014 speculated that behaviors related to eating disorders, like extreme dietary restriction, binging, and purging, constitute instances of pain and provocation. Specifically, these researchers hypothesized that because individuals with eating disorders must engage in painful behaviors to keep their weight low, they may habituate to pain, which would increase their pain tolerance and ACS and thereby increase their risk for death by suicide.…”