Discussion
The current study aimed to examine the relationship between problematic
eating behaviors and suicidal behaviors and overall risk level, using
the IPTS framework. The present findings indicate that individuals who
struggle with maladaptive eating behaviors exhibit higher levels of
thwarted belongingness and perceived burdensomeness and suicidal
thought/behaviors. This has been found in previous literature among
college students with maladaptive eating behaviors (Kwan et al., 2017),
and among those with clinically diagnosed EDs (Forrest et al., 2016;
Pisetsky et al., 2017). While most of these studies used the EDE-Q
global index to determine the severity of maladaptive eating behaviors
and their relationship to thwarted belongingness and perceived
burdensomeness, our study examined each subscale of the EDE-Q. The
results indicated moderate to strong correlations between thwarted
belonginess, perceived burdensomeness, and all subscales and global
scores of the EDE-Q. These results suggest that maladaptive eating
behaviors and body dissatisfaction (as measured by EDE-Q Shape and
Weight Concerns) are associated with aspects of the interpersonal theory
of suicide that may result in suicidal ideation. Our correlations
between fearlessness about death and EDE-Q subscales varied slightly
from Zuromski and Witte’s (2015) findings; whereas they found
significant small negative correlations between FAD and EDE-Q Shape
concerns, we found mostly negligible correlations.
As explained in Van Orden and colleagues (2010) components of perceived
burdensomeness include self-hatred, self-blame, and shame. Individuals
who struggle with symptoms of eating pathology may hold negative beliefs
about themselves and their self-worth (APA, 2013). These negative
feelings toward self may facilitate further self-hatred and guilt, thus
influencing their feelings of burdensomeness. Additionally, individuals
who struggle with maladaptive eating behaviors often compare themselves
to others (Fairburn, 2008) and their perceived discrepancies, between
them and others, may influence feelings of belongingness. According the
IPTS, experiencing thwarted belongingness and perceived burdensomeness
simultaneously can result in passive suicidal ideation (Van Orden et
al., 2010). Our results are consistent with the IPTS theory, indicating
that maladaptive eating behaviors and attitudes have moderate
correlations with constructs of the IPTS that influence passive suicidal
ideation. In addition, our findings may help explain why there has been
some inconsistency in the literature, especially findings based on
studying EDs as opposed to examining specific eating pathology. For
example, we found that binging and laxative use had the lowest number of
associations with various suicide behaviors, whereas, purging and
feelings of loss of control when eating were correlated with most
suicide related behaviors. Laxative use and purging could both satisfy
the criterion related to compensatory strategies; as such, if an ED
sample (e.g., anorexia) did not distinguish between the various
compensatory strategies, it is possible that findings could be skewed
and unstable across samples due to the dimensional differences within
the compensatory strategies criterion.
When we examined suicide risk categories as defined by the IPTS and
specific problematic eating behaviors, results demonstrated moderate
correlations with loss of control, number of days binge eating episodes
occur, and purging. Excessive exercise and binging episodes were
approaching moderate correlations. However, we found stronger
correlations when we assessed specific problematic eating behaviors and
specific suicide risk behaviors. For instance, purging behaviors appear
to be of particular concern. Although purging did not have the strongest
associations with all suicide risk behaviors, purging did have
correlations with intent to kill oneself, and confidence that one could
attempt suicide. Excessive exercise was also approaching a moderate
effect size with intent to kill oneself. Based on these findings, it may
be suggested that clinicians treating clients who present with purging
behaviors and who engage in excessive exercise may want to gather more
information about suicide risk, particularly related to suicide intent,
and regarding their confidence in attempting suicide. Additionally,
because it is common for maladaptive eating behaviors to shift (APA,
2013) it is recommended that clinicians closely monitor clients for
changes in symptom presentation, since some symptoms are more strongly
associated with suicide risk.
Because our data are correlational, we cannot assume the direction of
causality between maladaptive eating behaviors and suicide risk. It may
be that individuals engage in maladaptive eating behaviors to cope with
suicidal thoughts. Cognitive behavioral interventions are often the
first-line treatment for maladaptive eating behaviors and target issues
related to shape, weight, and food (Fairburn, 2008). Although these
interventions may aid in alleviating some maladaptive eating behaviors,
they may not target all the underlying issues that lead an individual to
engage in these behaviors. While some research indicates that emotion
regulation plays an essential role in the development and maintenance of
EDs (Leppanen et al. 2022), not all treatments acknowledge the
difficulties that these individuals face with tolerating and effectively
regulating emotional arousal. Therefore, if an individual in treatment
for maladaptive eating experiences suicidal ideation, they may not have
developed other adaptive emotion regulation strategies and may resort to
their maladaptive eating behaviors. These results highlight the
importance of evaluating eating behaviors as a mechanism of managing
suicidal thoughts in order to identify alternative adaptive strategies
to manage suicidal ideation that may decrease utilization of maladaptive
eating behaviors and aid in recovery efforts.
The primary limitation to the current study is our sample size.
Considering the large effect sizes found between some behaviors that
were not predicted (e.g., feelings of loss of control and non-suicidal
self-injury), as well as many small effect sizes (e.g., purging and
various forms of suicide related behaviors), replication will be
important to increase confidence in these findings. Some may argue that
our sample consisting of college students may also be a limitation;
however, we believe that is less of a concern due to our focus on
problematic eating behaviors vs. focusing on categorical EDs. In fact,
we believe our results support a suggestion for future researchers to
focus on specific problematic eating behaviors as opposed to simply
categorizing people based on diagnostic considerations due to the
differentiation we found between similar categorical behaviors (e.g.,
use of laxatives vs. purging with suicidal behaviors). We believe it
would be beneficial for future researchers to examine correlations
between eating and suicide behaviors within a broad clinical sample
(e.g., outpatients), as this would likely increase the variability
across all behaviors. In addition, we would recommend that future
researchers, even if they focus on categorical ED diagnoses, consider
specific behaviors – especially considering our findings and general
findings that dimensional based analyses seem to be better supported
(see, for example, Kotov et al., 2017).