Eating disorders have the highest mortality of any mental health condition.
I have treated a number of patients who have been on death’s door from the medical consequences of an eating disorder. I have treated a smaller number of eating disorder patients who have sought my help following suicide attempts.
My experience in dealing with patients who have confronted their own mortality following near death as a result of medical consequences brought on by starvation or purging i.e. organ failures, cardiac arrest, offers a particular window of opportunity in treatment. Most patients affirm that the "wish" is not to die, but rather to make the pain stop. The enormity of the rituals and mind crushing ruminating thoughts and repetitive behaviors often feel like a worse option than death. Some patients are able to acknowledge that the wish to die is to punish themselves and those around them; anger does play a role in motivation. The irrational perception is that death is the only solution to make the thoughts and behaviors stop or as a catastrophic means to actualize anger.
The American Psychological Association published “Myths and Facts About Eating Disorders and Suicide” (2012). The APA’s effort is to help eating disorder clinicians understand the complexities of patients with eating disorders who are suicidal and to dispel the myths surrounding the reasons why patients with eating disorders seek to die.
While Myth #1 versus Fact #1 is widely accepted by most who treat eating disorders, there is an additional thought contradicting Fact #1 worth noting.
Myth #1 states:
“Eating disorders are really a slow suicide.”
Fact #1 in response states:
“Eating disorders are characterized by a desire for thinness and to not feel rather than a desire for death.”
While this is decidedly true for many, if not most eating disorder patients, there are those for whom the desire or fantasy of death is the aim, not just the undesired consequence of wanting to be thin or not feel. In my experience, there are patients for whom the quest for death due to starvation or suicide is the result of an active and conscious wish to end psychological suffering on the one hand, or be an active voice of anger or plan of attack against loved ones or family members who they feel have hurt them. Sometimes, the self-loathing is so great that the plan of attack is to punish themselves through starvation or suicide; i.e. “I am worthless, or don’t deserve to live.”
Sometimes the desire to hurt others as well as themselves is a primary motivation.
Some eating disorder sufferers are determined to take their life through suicide but fail in their truly serious and deliberate attempt. It is often only by shear luck or greater force that someone finds out and has time to get the person to an emergency room.
Whether a patient survives death from a failed suicide attempt or is medically stabilized following starvation, there are resultant psychological issues. Often, patients who are on death’s door and survive feel overwhelming guilt, remorse, shame, and anger over having survived. These feelings are often in response to not only the failure to cease their own pain, but the realization of the pain they caused their loved ones, and/or their regret at being unsuccessful in their effort to deliver a catastrophic message.
Often, we focus on the underbelly, or psychological source of the pain that severely ill eating disorder patients feel and their efforts to end such pain by active suicide or starvation. However, lest we not forget about the aggressive intent of starvation and suicidal attempts. Sometimes it is difficult for clinicians to get comfortable with our patients’ aggressive motivations as our compassion typically trumps or blinds us to their rage and our acceptance of their rage.
However, there are deeper reasons for regret, guilt, shame, and anger.
The enormity of the steps taken, whether passively through the effects brought on by starvation, or actively through the determined, but failed suicide attempt require significant time and attention by the patient and therapist together. Sometimes, this process can take a very long period of time as the patient is not ready to confront the enormity of their wishes or decisions.
In some senses, this protracted process or refusal by some to deal with these events, often for many years, are perhaps indicators that the patient is not yet ready to embrace life.
For those patients that I have had the privilege to support their efforts to work through guilt, shame, remorse, and anger at having survived has enabled the path of sadness; the precursor to the path of knowing a joyful life.
It is not only love that potentially or naturally ends in loss and grief, but grief that enables us to love.
Self-love is dependent upon allowing sadness; compassion and empathy come from experiencing sadness. Love of self and others naturally emanate from compassion and empathy.
Patients who are in the throws of an eating disorder deny and avoid their feelings. Often contemporary relationships are severely hampered due to the lack of emotional safety and trust they feel in them now or their perspective has been influenced from past unsafe relationships. Perhaps, they lack in their own ability to be a safe and trustworthy person. Intimacy, therefore is not sought or seen as attainable or desirable. Their symptoms are all that are needed.
When patients get so close to death their lack of hope, helplessness, and terror are apparent to those around them and generally them as well. It is anger, sadness and their personal grief over many losses, failures, disappointments, and limitations that they have yet to understand and accept, many of which came long before the eating disorder developed or suicide attempt or attempts occurred. Acceptance of the enormity of their near death is also necessary and yet is a lot to expect someone to process. Processing through anger is paramount. Ultimately, it is grief and sadness that initiate recovery and the process toward living a full life, one that enables the capacity to love deeply and wholly.
Helping Health and Mental Health Care Providers Assess Risk
Here are a few things to keep in mind when working with severely ill eating disorder patients who may also be suicidal.
AN is consistently associated with high rates of suicide, especially in the context of significantly elevated SMRs (Standard Mortality Rates) for adolescents and young adults.
Some recent studies have found that suicide risk appears elevated in BN as well.
Self-injurious behaviors are frequent in EDs, with higher rates among EDs that include binge and purge behaviors.
Self-injurious behaviors, which may or may not include suicidal intent, are especially high among adolescents with EDs.*
Mood disorders (i.e. Major Depression) is a risk factor for suicide.
Borderline Personality Disorder is also a risk.
Knowing when Axis I versus Axis II pathology is operating helps a seasoned clinician; however, clinicians cannot make assumptions about whether or not a patient is likely to suicide based solely on whether Axis I or Axis II pathology is at play.
Clinicians must pay close attention to all these factors, plus the duration and severity of illness, substance use and history of substance use, trauma, and self-injurious behaviors (i.e. cutting) as occurrence of these issues may play a role in the increased risk of suicidal behavior.
Finally, for those eating disorder patients who have survived either medically or from a suicide attempt the process of recovery is a deeply personal and psychological journey which time, careful attention, encouragement, and sensitivity are required. This process is one that I have had the privilege to witness.
Judy Scheel, Ph.D., LCSW, CEDS
*(see Kistro Et. Al. The current status of suicide and self-injury one eating disorders: a narrative reivew. Journal of Eating Disorders. July 11, 2014.)