Suicidality and Eating
Disorders:
What you don’t want to know,
but need to ask….
Melissa Freizinger, Ph.D.
Caroline Balz, MA, LMHC
Who we are…
Melissa Freizinger, Ph.D.
Caroline Balz, LMHC
French philosopher Albert Camus (1913-1960) perhaps best explains the
divergent views philosophers and theologians hold concerning suicide when
he said,
“What is called a reason for living is also an excellent reason for dying.”
Objectives for Today
Explore the facts
Experiential exercise: What is your inner dialogue?
Review risk factors and protective factors
Case studies: Tanya and Kelly
– Group Discussion
Theory to practice
– Commonly used interventions
– Tools for Practice:
Assessing safety
Emergency plans for your practice
Risk management for Therapists
Self care for Therapists
Q&A
Exploring the facts:
In 2007 there were 34,598 suicides in the
U.S.
900,875 annual attempts in U.S. in 2009
Every day, approximately 99 Americans
take their own life
Suicide ranks 10th as a cause of death;
Homicide ranks 15th
Rates of SI have increased 60% in the last
50 years
Exploring the Facts
Suicide is the most frequent mental health
emergency
Four out of five people who commit
suicide have attempted to kill themselves
at least once previously
1 out of 5 psychologists will lose a patient
to suicide
Suicide is a frequent cause of malpractice
suits
Exploring the Facts
Clinicians are not expected to
predict or prevent suicide
Clinicians are expected to
identify elevated suicide risks
and take protective steps
where possible
Exploring the facts: Patients
w/ED
Suicide mortality rates among pts. with
AN/BN are 23 times higher than that of the
general population
Suicide is the dominant cause of death in ED
patients who die from non-natural causes
– Is more likely than medical complications
AN has the highest mortality rate of all
psychiatric disorders
Exploring the facts:
Rate of suicide in pt. with ED’s are 57 times
the expected rate of a healthy woman
(Herzog & Luczaj)
Women suffering from anorexia are 12
times more likely to die from suicide than
any other cause of death.
AN patients use extremely lethal means:
burning, hanging, jumping in front of trains.
Suicide occurs not only more often in the
late stages of the disease, but also during
periods of symptom remission.
Exploring the Facts
Lifetime Prevalence Rates:
– 3-20% AN
– 25-35% BN
– 13.5% General population
In a recent study of 342 AN patients, 38% had suicidal
ideation, & 10% had hx of suicide attempt by the age
of 23. The majority (62%) of patients reporting prior
attempts report making more than one (Vervaet et al.,
2008).
6 to 10% of those who attempt suicide will
succeed
Naming our Resistance and
Denial
50% of clinicians do not ask their
clients about suicide and do not
effectively assess suicidal ideation
We all have some stress around
suicidality
Some denial may be functional
Experiential Exercise:
What is your inner dialogue?
Take a moment to write down responses to
the following questions:
– Are you asking clients questions about
their thoughts/intentions about suicide?
– If not, what might be getting in the way?
Proceed to sign which best represents
your internal dialogue
Let’s discuss the context of your
exploration
Risk Factors for Attempts:
Patients with AN and BED
– Mixed AN/BN, AN-PT
– Co-morbidity: Mood disorders, PTSD, OCD
Bingeing/purging symptomatology – using
more than one method to compensate
Impulse control disorder
More extensive treatment history
Earlier onset of symptoms
More dissociative symptoms
AN pts: older, lower weight
Risk Factors for Attempts:
History of Major Depressive Disorder and
higher severity of depressive symptoms
Characteristics correlated with attempts:
sexual abuse history, laxative use and
drug, alcohol or tobacco use
Character traits: impulsivity,
perfectionism, low self-directedness
BN pts: co-morbid symptoms, sexual
abuse history
Hopelessness with regards to recovery
Risk Factors for
Completion:
Alcohol abuse – correlated w/completed
deaths
Cluster B Personality disorders– high
risk for completed suicides
Characteristics which are correlated with
death: duration of illness, spiritual
acceptance, alcohol abuse and social
isolation
The more severe the ED: the higher the
risk for suicide
Case Presentation: Kelly
Background: 32 y/o female, 15 yr hx ED, co-morbid ADHD,
MDD recurrent/severe, 2 previous suicide attempts,
inpatient ED admissions, medical admissions for IV
fluids. Incomplete master’s degree, a strained
relationship with her parents, close relationship with her
sister, no local supports
Symptoms: restricting – below usual hospital admission
weight, orthostatic, fainting, alcohol abuse, driving
drunk, medicine non-compliance, therapy interfering
behaviors, meal plan non-compliance, missing work,
abusing psychotropic meds, endorsing urges to purge
Kelly’s fiancé recently cancelled their wedding leaving
her $10K in debt. He also informed her he is moving out
in one month. Kelly is devastated and feels hopeless.
Case Presentation: Tanya
26 year old college student who lives at home
with her parents. Seven year hx of ED-NOS, comorbid BDD, depression with psychotic features
beginning to emerge
Tanya recently celebrated her 21 birthday with a
good high school friend, the friends’ boyfriend
and a boy whom they were setting her up with
(who “friend-ed” her on Facebook). The night
was a flop b/c Tanya felt the boy didn’t like her
Tanya suspects her mother has disordered
eating and she is refusing psychotropic meds
and family therapy citing she cannot afford it
Case Presentations
Who are you more worried
about?
Why?
Case Presentation:
Discussion
What do I do? How do I know?
Holding hope
Felt sense
Ask the questions
Opening the dialogue
Validate their feelings
Be there in the pain with your patient
Understand the role suicide plays in the
context of their value systems and
experiences
Be curious about the meaning they
attribute to ending one’s life
Protective Factors
Skills in problem solving and a nonviolent way
of handling disputes
Cultural and religious beliefs that discourage
suicide and support instincts for selfpreservation
Family support, friends, and other significant
relationships
Protective Factors
Community involvement
A satisfying social life
Pet ownership
Social integration e.g.. through employment,
constructive use of leisure time
Access to mental health care and services
Commonly Used Interventions:
Safety Contracts:
No empirical evidence supports the
effectiveness in preventing suicide
Reliance on contract alone not a good
practice
Doubtful value when pt. is impulsive,
substance abuser, or prone to disassociation
Therapist must be available 24/7
Does not work if pt. isn’t attached to
therapist
Does not protect therapists from malpractice
Crisis Interventions
Sole focus on treatment – safety
Remove lethal methods
Delay of pt.’s suicidal impulses
Increased sessions/check ins
Focus on solving the immediate
problem
Instruct pt. not to commit suicide
Get a commitment to a plan of action
Assessing Safety:
Assess immediate risk factors – find out
what methods they plan to use – the
higher the risk, the more active the
therapist’s response
Determine whether pt. has written a
note, has any plans for isolating self, or
taken precautions against discovery
How available other people are to her
now and over next several days?
Assess deepening depressive
affect/panic attacks
Theory to Practice
Have up to date crisis planning sheet
Know protective factors
Know risk factors
Monitor pt. in between sessions
Check with a medical professional to
understand the lethality of their
medications
Theory to Practice
Crisis Management
See: Crisis Template in handouts
Handout A
Handout B
Handout C
Sometimes getting really concrete helps us get
unstuck from seemingly insurmountable
concepts
Risk Management for
Therapist:
1. Involve the family and pt.’s
support system
2. Consultation with other
professionals is necessary
3. 24/7 List of
colleagues/supervision
Risk Management for Therapist:
1. Self-assessment of technical and
personal competence
2. Meticulous and timely documentation
is required – maintain records per
legal requirements
3. Involve managed care company and
treatment team members in the
discussions
4. Previous medical and psychotherapy
records must be obtained for each pt.
Self-Care for the Therapist:
Consultation is necessary/essential
Be mindful about your caseload
Raise your own awareness to
countertransference
Know your own limits and beliefs
Healing……
The Om is also often referred to as the sound of the
Earth…creation...the heart of existence.
To become one with the sound of the Om allows one to
become one with the source of all energy.
Q&A
Thank you for your time!
RESOURCE LIST
Cognitive-Behavioral Treatment of Borderline Personality Disorder.
Marsha Linehan. The Guilford Press. (May 14, 1993).
http://behavioraltech.org
Sarah Luczaj, "Just How Strong is the Link between Anorexia and
Suicide?"(March 10, 2008, Counselling Resource.com, website)
Skills Training Manual for Treating Borderline Personality Disorder.
Marsha M. Linehan. The Guilford Press. (May 14, 1993)
Dialectical Behavior Therapy in Clinical Practice: Applications across
Disorders and Settings. Linda A. Dimeff, Kelly Koerner. Marsha M.
Linehan (Foreword). The Guilford Press. (August 14, 2007)
Dialectical Behavior Therapy with Suicidal Adolescents. Alec L. Miller, Jill
H. Rathus, Marsha M. Linehan. The Guilford Press; (November 16,
2006)
Helping Teens Who Cut: Understanding and Ending Self-Injury. Michael
Hollander. The Guilford Press. (June 10, 2008)
Dialectical Behavior Therapy for Binge Eating and Bulimia Debra L. Safer,
Christy F. Telch, and Eunice Y. Chen. The Guilford Press. (May 2009)
No-Harm Contracts: A Review of What We Know. Lisa McConnell Lewis,
Suicide and Life-Threatening Behavior 37(1) February 2007, The
American Association of Suicidology
Suicide and Eating Disorders. The American Association of Suicidology.
www.suicidology.org/c/document_library/