Suicidality and Eating Disorders:

1. Suicidality and Eating Disorders: What you don’t want to know, but need to ask…. Melissa Freizinger, Ph.D. Caroline Balz, MA, LMHC

2. 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.”

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. Case Presentation: Tanya 26 year old college student who lives at home with her parents. Seven year hx of ED-NOS, co-morbid 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

17. Case Presentations Who are you more worried about? Why?

18. Case Presentation: Discussion What do I do? How do I know? Holding hope Felt sense Ask the questions

19. 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

20. Protective Factors Skills in problem solving and a nonviolent way of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation Family support, friends, and other significant relationships

21. 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

22. 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

24. 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

25. 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

26. 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

27. Theory to PracticeCrisis Management See: Crisis Template in handouts Handout A Handout B Handout C Sometimes getting really concrete helps us get unstuck from seemingly insurmountable concepts

28. Risk Management for Therapist: • Involve the family and pt.’s support system • Consultation with other professionals is necessary • 24/7 List of colleagues/supervision

29. Risk Management for Therapist: • Self-assessment of technical and personal competence • Meticulous and timely documentation is required – maintain records per legal requirements • Involve managed care company and treatment team members in the discussions • Previous medical and psychotherapy records must be obtained for each pt.

30. 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

31. 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. 

32. Q & A Thank you for your time!

33. 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/