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).