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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders a
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Susan Dickerson Mayes , Julio Fernandez-Mendoza , Raman Baweja , a
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Susan Calhoun , Fauzia Mahr , Richa Aggarwal & Mariah Arnold
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Department of Psychiatry, Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA Published online: 19 May 2014.
To cite this article: Susan Dickerson Mayes, Julio Fernandez-Mendoza, Raman Baweja, Susan Calhoun, Fauzia Mahr, Richa Aggarwal & Mariah Arnold (2014) Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders, Eating Disorders: The Journal of Treatment & Prevention, 22:4, 352-366, DOI: 10.1080/10640266.2014.915694 To link to this article: http://dx.doi.org/10.1080/10640266.2014.915694
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Eating Disorders, 22:352–366, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.915694
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Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders SUSAN DICKERSON MAYES, JULIO FERNANDEZ-MENDOZA, RAMAN BAWEJA, SUSAN CALHOUN, FAUZIA MAHR, RICHA AGGARWAL, and MARIAH ARNOLD Department of Psychiatry, Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7–18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.
Almost all individuals who die by suicide have a psychiatric disorder (Gvion & Apter, 2011), and most psychiatric disorders are associated with increased risk of suicide attempts (Goldston et al., 2009). Suicide behavior in children and adults is linked with depression (Greening, Stoppelbein, Luebbe, & Fite, 2010; Gvion & Apter, 2011), Attention Deficit Hyperactivity Disorder (ADHD; Hinshaw et al., 2012; Hurtig, Taanila, Moilanen, Nordstrom, & Ebeling, 2012), autism (Mayes, Gorman, Hillwig-Garcia, & Syed, 2013), and oppositional defiant disorder (ODD) and conduct disorder (Agosti, Chen, & Levin, 2011; Address correspondence to Susan Dickerson Mayes, Department of Psychiatry H073, Hershey Medical Center, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA. E-mail: [email protected] 352
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Cho et al., 2008; James, Lai, & Dahl, 2004). For some disorders (e.g., depression, ODD, and conduct disorder), the relationship with suicide behavior is direct and independent of other variables, whereas for other disorders (e.g., ADHD and autism), the relationship between these disorders and suicide behavior exists in large part because of comorbid depression and conduct problems associated with both (Agosti et al., 2011; Impey & Huen, 2012; Mayes, Calhoun et al., 2013; Mayes, Gorman et al., 2013). Suicide in adults with anorexia nervosa is eight times more common than in the general population (Bulik et al., 2008). Adults with bulimia nervosa do not differ from the norm in suicides (Franko & Keel, 2006), but they have more attempts across studies (25–30%) than do adults with anorexia nervosa (3–20%; Franko & Keel, 2006). Adults with bulimia nervosa are also more likely to have suicide ideation (32%) than adults with anorexia nervosa (22%; Favaro & Santonastaso, 1997). Studies of the frequency of suicide behavior in adolescents with eating disorders are sorely lacking, and two small studies report strikingly different frequencies (Fennig & Hadas, 2010; Ruuska, Kaltiala-Heino, Rantanen, & Koivisto, 2005). A self-report survey of 1,000 adolescents in Italy found that adolescents with suicide ideation had higher scores on measures of eating disorders than adolescents without suicide ideation (Miotto, De Coppi, Frezza, & Preti, 2003). Suicide ideation and attempts in adolescents and adults with anorexia nervosa and bulimia nervosa are associated with purging and binging, but not restricting (Bulik et al., 2008; Favaro & Santonastaso, 1997; Stein, Lisa, Lilenfeld, Wildman, & Marcus, 2004); longer duration of the eating disorder and older age (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010); depression (Corcos et al., 2002; Fennig & Hadas, 2010; Franko et al., 2004; Milos, Spindler, Hepp, & Schnyder, 2004; Nickel et al., 2006; Ruuska et al., 2005); conduct problems such as stealing, lying, aggression, and substance use (Bulik et al., 2008; Corcos et al., 2002; Favaro & Santonastaso, 1997; Franko et al., 2004; Stein et al., 2004); panic and posttraumatic stress disorders (Bulik et al., 2008); and history of physical or sexual abuse (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010; Nickel et al., 2006). Despite the fact that sleep disturbances (e.g., insomnia symptoms and nightmares) have been associated with suicide ideation, attempts, and completions in psychiatric and general population studies (Barbe et al., 2005; Cukrowicz et al., 2006; Liu, 2004; Nadorff, Nazem, & Fiske, 2011, 2013; Pigeon, Pinquart, & Connor, 2012; Sjostrom, Hetta, & Waern, 2009; Tanskanen et al., 2001), sleep disturbances have not typically been included in studies of suicide behavior in individuals with eating disorders. Only two recent studies analyzed sleep disturbances and found that insomnia symptoms were greater in women with bulimia nervosa who attempted suicide than in those who did not (Corcos et al., 2002; Nickel et al., 2006). The goals of our study are to investigate the frequency and correlates of suicide ideation and attempts in children and adolescents with anorexia
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nervosa and bulimia nervosa. Our study is unique in that our sample is younger than all other studies reviewed and uses a wide variety of sleep, psychological, and demographic variables relevant to children and adolescents to determine which of these variables are significantly and independently related to suicide behavior.
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Sample The sample consists of 90 children and adolescents referred to our eating disorder program who were diagnosed with anorexia nervosa or atypical anorexia nervosa (n = 69) or bulimia nervosa (n = 21) by a board certified child and adolescent psychiatrist using DSM-5 criteria. Diagnoses were confirmed through a chart review by a licensed Ph.D. psychologist. The children are 7–18 years (M = 13.8). In all, 96.7% are female, 95.6% are White, and 57.8% have a parent with a professional or managerial occupation. Children with anorexia nervosa were classified with atypical anorexia nervosa if their weight was “within or above the normal range,” as specified by the DSM-5. The CDC definition for underweight (Body Mass Index [BMI] < 5th percentile) was used to determine which children were below the normal range. BMI percentiles were calculated based on CDC norms for age and gender.
Dependent Variables Mothers rated their children on a 4-point scale (not at all, sometimes, often, and very often a problem) on the 165-item Pediatric Behavior Scale (PBS; Lindgren & Koeppl, 1987). Dependent variables are suicide ideation (“talks about harming or killing self”) and suicide attempts (“deliberately harms self or attempts suicide”). The latter item was not scored as an attempt if the child engaged in cutting or other forms of self-harm but did not attempt suicide.
Independent Variables Independent variables are (a) demographic data (age, IQ, gender, race, and parent occupation), (b) eating disorder types and symptoms (BMI percentile and degree of restricting, self-induced vomiting, and binging), (c) comorbid diagnoses (depression, anxiety disorder, ADHD, and ODD), (d) sexually or physically abused or bullied by other children, and (e) maternal ratings on the PBS. These ratings include (a) sleep disturbances (e.g., sleeps less than most other children, trouble falling asleep, wakes during the night, and nightmares), (b) externalizing behavior problems (e.g., bullies other children, explosive, defiant, aggressive, and impulsive), (c) internalizing problems
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(e.g., anxious, sad, and feels worthless), and (d) somatic symptoms (e.g., lacks energy, headaches, and stomachaches). Internal consistency for the PBS subscale scores is high, with a median coefficient of .91 (Lindgren & Koeppl, 1987). Validity studies show that the PBS differentiates diagnostic groups, and the PBS has been used to diagnose and measure psychological symptoms and sleep disturbances in several published studies (Mayes & Calhoun, 2009; Mayes, Calhoun, Bixler, & Vgontzas, 2009; Nichols et al., 2000; Wolraich et al., 1994).
Data Analysis The significance of differences in continuous scores between groups was determined with independent t-tests. The linear relationship between ideation and attempt scores and PBS psychological scores and age was calculated using Pearson correlations and explained variance. A Bonferroni correction was made to control for the number of comparisons made. The independent variables were entered in stepwise binary and linear logistic regression analyses to determine the combination of variables that was most significant in identifying children who had versus did not have suicide ideation and attempts (at least sometimes vs. not at all) and to determine the variables that were independently and significantly correlated with ideation and attempt scores (rated on a 4-point scale from never to very often).
RESULTS Eating Disorder Types and Symptoms Children with bulimia nervosa had higher ideation and attempt scores than children with anorexia nervosa (t = 2.3, p = .03, t = 3.3, p = .004). Suicide ideation was 2.1 times more common in bulimia nervosa (42.9%) than in anorexia nervosa (20.3%), and attempts were 14.8 times more common in bulimia nervosa (42.9%) than in anorexia nervosa (2.9%). All children with bulimia nervosa who had ideation also had attempts. Severity of suicide behavior was greater in bulimia nervosa than in anorexia nervosa. For children with anorexia nervosa, all cases of ideation and attempts were only “sometimes” a problem. In contrast, ideation was “often to very often” a problem for 44.4% of children with bulimia nervosa who had ideation, and attempts were “often to very often” a problem for 66.7% who had attempts. Suicide ideation and attempt scores did not differ significantly between children with anorexia nervosa and atypical anorexia nervosa and between the restricting and binge eating-purging types (t = 0.4 to 2.0, Bonferroni p > .05). In regression analysis, greater binging and BMI percentile were significant correlates of suicide ideation scores (R = .46, F = 11.6, p < .0001), and bulimia nervosa and greater self-induced vomiting were significant correlates
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of attempt scores (R = .58, F = 21.7, p < .0001). Restricting frequency was not significant and was the only variable negatively correlated with ideation and attempt scores (r = –.11 and –.23, Bonferroni p > .05).
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Comorbid Diagnoses All children who had suicide ideation or attempts had comorbid depression (major depression or dysthymic disorder), anxiety disorder (generalized anxiety disorder, obsessive-compulsive disorder, social anxiety disorder, and/or panic disorder), ODD, and/or ADHD. Conversely, none of the 16 children without one or more of these comorbid diagnoses had ideation or attempts. Using these comorbid diagnoses in regression analysis, only ODD and anxiety disorder plus depression were significant correlates of ideation scores (R = .52, F = 16.1, p < .0001). Ideation was present in 64.7% of children with ODD (vs. 16.4% without) and in 40.0% of those with anxiety plus depression (vs. 7.5% without). For attempts, only anxiety plus depression was a significant correlate (R = .27, F = 6.7, p = .01). Children with both anxiety and depression were 8.0 times more likely to have attempts (20.0%) than children who did not have both anxiety and depression (2.5%).
Externalizing Behavior Problems Externalizing behavior problems were present in less than half of children with eating disorders, with the exception of defiant and angry-irritable. Ideation and attempts were more common in children who had any of the externalizing behavior problems than in children who did not. For several problems (bullies, steals, aggressive, does not get along with peers, and substance use), ideation was present in the majority of children who had any of these problems. For the remaining externalizing behaviors (explosive, defiant, impulsive, lies or cheats, and angry-irritable), ideation was present in 28.9% to 50.0% of the children. The majority of children with substance abuse (57.1%) had attempts, whereas attempts ranged from 13.2% to 33.3% in all other behavior problems groups. Using regression analysis, the strongest correlates of ideation scores were explosive, lies or cheats, and impulsive (R = .67, F = 23.4, p < .0001). Lies or cheats, substance use, and does not get along with peers were the most significant independent correlates of attempt scores (R = .51, F = 9.8, p < .0001).
Internalizing Problems All of the internalizing problems (anxious, sad, lonely, feels worthless, low self-confidence, apathetic, and withdrawn) were present in most children and were far more common than externalizing problems. Mothers rated 91.1% of children as sad and 88.9% as anxious. Unlike the externalizing
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problem groups, ideation and attempts were not present in the majority of children with any of the internalizing problems. Ideation was present in less than 38% and attempts in less than 18% of children in any of the internalizing groups. For ideation scores, lonely was the only significant correlate in regression analysis (R = .45, F = 22.2, p < .0001). For attempts, feels worthless was the only significant correlate (R = .33, F = 11.0, p = .001). Although internalizing problems were not strong predictors of suicide behavior, many of these problems were necessary (but not sufficient) for ideation and attempts. All children with ideation and attempts were sad and anxious, whereas no child without anxiety or sadness had ideation or attempts. Furthermore, all with attempts felt worthless and had low self-confidence, whereas no child who did not feel worthless or have low self-confidence had attempts.
Sleep Disturbances Sleep disturbances were common, especially trouble falling asleep which was reported for half of the children. Frequencies for sleeping less than normal, waking during the night, restless sleep, nightmares, and daytime sleepiness ranged from 31.1% to 37.8%, whereas 21.1% woke early and 14.4% talked or walked in their sleep. Suicide ideation was present in the majority of children who had nightmares, talked or walked in their sleep, and slept less than other children. Attempts were present in less than 24% of children in any of the sleep disturbance groups. When the sleep disturbance scores were entered in regression analyses, sleeps less than most children and wakes often during the night were significant correlates of ideation scores (R = .58, F = 22.2, p < .0001), and wakes often during the night and nightmares were significant correlates of attempt scores (R = .42, F = 9.4, p < .0001).
Abused and Bullied The seven children who had been sexually or physically abused had significantly higher ideation and attempt scores than children not abused (t = 3.8 and 2.5, p < .05). History of abuse explained 14.3% of the variance in ideation scores (R = .38, F = 14.7, p < .0001) and explained 27.9% of the variance in attempt scores (R = .53, F = 34.1, p < .0001). Correlations between bullied (never to very often) and ideation and attempt scores were nonsignificant (r = .20 and .02, p > .05).
Somatic Symptoms Correlations between somatic symptom scores (headaches, stomach aches, muscle and body pain, feels “sick,” and tires easily) and ideation and attempt
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scores were all nonsignificant at .05 (r = –.06 to .20) and explained less than 5% of the variance.
Demographics
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Age was not significantly related to ideation or attempt scores (r = .05 and .24) and ideation and attempt scores did not differ significantly between males and females (t = 1.0 and 1.2), Whites and nonwhites (t = 1.4 and 1.6), and professional and nonprofessional families (t = 0.1 and 1.1), with Bonferroni p values ranging from .08 to 1.00.
Combined Correlates and Relative Significance The independent variables significant in one or more of the preceding analyses were entered in stepwise regression analyses to determine the strength of their independent association with suicide behavior. The most powerful combination of variables classifying children with or without suicide ideation in binary regression analysis was explosive, sleeps less than most children, and substance use (87.8% overall classification accuracy, χ 2 = 46.0, p < .0001). Together these variables identified 69.6% of children with ideation and 94.0% without ideation. The remaining variables did not contribute significantly more to the identification of children with and without ideation. The strongest combined correlates of ideation scores (never to very often) in linear regression analysis also comprised sleep disturbances and externalizing problems and were explosive, sleeps less than most children, lies or cheats, and wakes during the night (explained variance 61.8%, R = .79, F = 34.4, p < .0001). The most powerful combination of variables predicting the presence or absence of suicide attempts was self-induced vomiting and bulimia nervosa (91.1% overall classification accuracy, χ 2 = 29.4, p < .0001), which together identified 45.5% with attempts and 97.5% without attempts. The strongest correlates of attempt scores (never to very often) were abused, bulimia nervosa, and nightmares (explained variance 46.3%, R = .68, F = 24.7, p < .0001).
DISCUSSION Suicide ideation and attempts were highly prevalent in our clinical sample of children and adolescents with eating disorders. The novel findings of our study are that externalizing behavior problems and sleep disturbances are both strongly and independently associated with suicide ideation, while a diagnosis of bulimia nervosa, self-induced vomiting, nightmares, and history of physical or sexual abuse are strong independent correlates of suicide
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attempts in children with eating disorders. Our data suggest that children and adolescents with eating disorders should not only be screened for suicide ideation and attempts, particularly those with bulimia nervosa, but also for sleep disturbances, externalizing behavior problems, and physical or sexual abuse, which should be treatment targets because of their association with suicide behavior.
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Eating Disorder Types Suicide ideation and attempts were more common in children with bulimia nervosa than in anorexia nervosa, which is consistent with adult eating disorder studies (Favaro & Santonastaso, 1997; Franko & Keel, 2006). Only 3% of children in our study with anorexia nervosa had attempts, and, for the 20% who had ideation, ideation only occurred “sometimes.” In contrast, for half of the 43% of children with bulimia nervosa who had ideation, their ideation occurred “often to very often.” All children with bulimia nervosa who had ideation also had attempts, indicating that those who talk about killing themselves are very likely to make an attempt. Adults with the binging-purging type of anorexia nervosa have a higher frequency of suicide attempts than those with the restricting type (Favaro & Santonastaso, 1997). In our young sample, the two types did not differ in ideation or attempts. Age may be an explanatory factor. Studies of adults with anorexia nervosa show that those who attempt suicide are older and have been ill longer than those who have not attempted suicide (Favaro & Santonastaso, 1997) and that switching from the restricting to bingingpurging type is associated with an increase in attempts (Foulon et al., 2007). Therefore, by young adulthood, some of our children with anorexia nervosa may have suicide attempts because of switching, increasing age, and longer illness duration.
Depression and Anxiety Ideation and attempts were absent in the eight children who were not sad and in the 10 who were not anxious. Furthermore, none of the 28 children who did not feel worthless had attempts. Conversely, all children with ideation and attempts were sad and anxious (at least sometimes), and all children with attempts felt worthless. Although these features may be necessary for ideation or attempts, they alone were not predictive, and most children with these traits did not have ideation or attempts.
Clinical Correlates Our study demonstrates high classification accuracies for suicide ideation and attempts. The most significant correlates of suicide ideation were
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externalizing behavior problems (explosive, lies or cheats, and substance use) and sleep disturbances (sleeps less than other children and wakes during the night), which identified children with and without ideation with 70% and 94% accuracy. Significant correlates of attempts were eating disorder symptoms (bulimia nervosa and self-induced vomiting), nightmares, and history of physical or sexual abuse, which identified children with and without attempts with 46% and 98% accuracy. Similar to other studies, accuracy in identifying individuals with suicide behavior was lower than identifying those without suicide behavior (Gvion & Apter, 2011). Our finding that externalizing behavior problems, bulimia nervosa, selfinduced vomiting, and history of physical or sexual abuse are correlates of suicide behavior in young children and adolescents is consistent with findings from adolescent and adult studies showing that purging (not restricting) is associated with suicide attempts (Bulik et al., 2008; Favaro & Santonastaso, 1997; Stein et al., 2004), that conduct problems in psychiatric and general population samples are linked with suicide ideation and attempts (Agosti et al., 2011; Bulik et al., 2008; Cho et al., 2008; Corcos et al., 2002; Favaro & Santonastaso, 1997; Franko et al., 2004; Goldston et al., 2009; James et al., 2004; Mayes, Gorman et al., 2013; Stein et al., 2004), and that suicide behavior is associated with a history of physical or sexual abuse (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010; Nickel et al., 2006). Our study identified novel and specific aspects of sleep disturbances associated with suicide behavior in young patients with eating disorders. Specifically, sleeping less than other children and waking during the night were highly correlated with suicide ideation, while nightmares were associated with suicide attempts. Why are these three symptoms particularly important, even after considering other sleep variables (i.e., trouble falling asleep, restless sleep, talks or walks in sleep, wakes early, and daytime sleepiness)? It has long been recognized that insomnia symptoms and nightmares in adults are linked with psychopathology (Bixler, Kales, Soldatos, Kales, & Healey, 1979), and nightmares in particular are associated with increased mental stress (Kales et al., 1980). In fact, insomnia symptoms and nightmares are independently associated with suicide ideation, attempts, and completions in psychiatric and general population studies (Barbe et al., 2005; Nadorff et al., 2011, 2013; Pigeon et al., 2012; Singareddy et al., 2013; Sjostrom et al., 2009; Tanskanen et al., 2001). In children with eating disorders, sleeping less than other children may result in children feeling poorly physically and mentally, increasing their overall mental distress. If children with eating disorders wake often during the night, they may spend more time lying in bed obsessing about their weight and feeling miserable. When they do sleep, nightmares may create additional psychological distress. Alternatively, nightmares may be a marker of psychological distress, thereby correlating with suicide behavior. Although some (Tanskanen et al., 2001) postulate that trauma may explain the link between nightmares and
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suicide behavior, Nadorff et al. (2011) found nightmares are correlated with suicide behavior independent of posttraumatic stress disorder in a nonclinical sample. Consistent with the latter, our study showed that nightmares and a history of sexual or physical abuse were both correlates of suicide attempts independent of each other in a clinical sample of patients with eating disorders. As in previous studies, the strong relationship between sleep disturbances and suicide behavior is not explained by associated psychopathology, because sleep disturbance is a significant correlate of suicide behavior even after controlling for anxiety, depression, and other psychological problems. This strong relationship is also not explained by daytime sleepiness, lack of energy, or poor stamina, which may result from disturbed sleep and may affect coping ability and how people feel physically and mentally. In fact, these variables had low correlations with suicide ideation and attempts in our study. Pigeon et al. (2012) speculated that several pathways may explain the association between sleep disturbances and suicide, from the neurobiology of insomnia which shares a number of features with that of depression, including hypothalamic-pituitary-adrenal (HPA) axis alterations (Vgontzas et al., 2001), elevations in pro-inflammatory cytokines (Vgontzas et al., 2002), and decreased serotonergic tone (Sjostrom et al., 2009; Singareddy & Balon, 2001) to cognitive-behavioral factors, such as rumination, cognitive arousal, and maladaptive coping skills (Fernandez-Mendoza et al., 2010; Vgontzas, Fernandez-Mendoza, Liao, & Bixler, 2013).
Comparison With Correlates in Other Diagnostic Groups Our findings have similarities and differences compared to studies of children with autism and children with ADHD, which used the same measures of suicide ideation and attempts as in the current study (Mayes, Calhoun et al., 2013; Mayes, Gorman et al., 2013). The most significant independent correlates of ideation and attempts in children with autism and in children with ADHD were explosive, angry, aggressive, oppositional, and sad. Therefore, in all three disorders (eating disorders, autism, and ADHD), traits associated with conduct problems are significant correlates independent of other variables. Sadness was an independent correlate in autism and ADHD, but not in eating disorders, most likely because sadness was far more common in eating disorders (occurring in 91%). Correlations between sleep disturbance and ideation and attempts in autism and ADHD were small, in contrast to large correlations in eating disorders. This was the case even though sleep disturbance is common in all three disorders (Mayes et al., 2009). However, the etiology of the sleep problems may differ between the groups, explaining why sleep is associated with ideation and attempts in eating disorders but not in autism and ADHD. Sleep disturbance in ADHD and autism may be related to behavioral factors and hyperactivity, resulting in difficulty settling
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and maintaining sleep, whereas sleep disturbances in individuals with eating disorders may be more related to psychological distress and neurophysiological alterations (e.g., HPA axis activation). Further, the autism and ADHD samples were predominantly male and much younger than the eating disorder sample. It remains to be determined if differences in correlates are diagnosis specific or related to other differences between the groups.
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Limitations and Directions for Future Research Our single site study needs to be replicated with larger samples of children in other settings. Larger samples would permit determining correlates of suicide behavior for bulimia nervosa and anorexia nervosa separately and exploring gender and racial differences in the correlates of suicide behavior. Our study is also limited because it is a cross sectional analysis, and not a prospective longitudinal study of predictors of suicide behavior. Moreover, our study relied on maternal report of suicide ideation and attempts and other variables, which is important in young samples like ours, but has definite limitations. It is possible that the lack of association between internalizing problems (e.g., anxiety and depression) and suicide behavior could be attributed to maternal unawareness of anxiety, sadness, and other internal states in their children. Parents are more likely to be aware of observable externalizing behaviors than their child’s internal thoughts and feelings. However, mothers rated 91% of our sample as sad and 89% as anxious, suggesting that mothers were aware of these problems and that the lack of association with suicide behavior may be because almost all children with eating disorders are sad and anxious. In contrast, most externalizing behavior problems were present in a minority of our sample. Regardless of possible explanations for the findings, parent report needs to be supplemented with self-report in future studies.
Conclusions In our study, 43% of children with bulimia nervosa had suicide ideation, as did 20% with anorexia nervosa. These percentages are 86 and 41 times higher than percentages for typical children reported in a study using the same measure of suicide ideation and attempts (Mayes, Gorman et al., 2013). Furthermore, all children with bulimia nervosa who had ideation also had attempts. Our data reinforce the importance of assessing and treating anxiety and depression in children with eating disorders because all children who had ideation and attempts were depressed and anxious. However, externalizing behavior problems were strong independent correlates of suicide behavior whereas internalizing problems were not. Less than one-third of sad or anxious children had ideation, whereas the majority of children who
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were explosive, aggressive, or bullies or who stole or used substances had suicide ideation, and they had more attempts than children who were sad or anxious. Therefore, it is critical not to neglect externalizing problems when assessing risk of suicide behavior in patients with eating disorders. Likewise, sleep disturbances cannot be ignored. The majority of children who slept less than other children and the majority who had nightmares also had suicide ideation, and they had more suicide attempts than children who were sad or anxious. Sleep problems combined with other clinical factors are highly correlated with suicide behavior. For example, all children with bulimia nervosa who had self-induced vomiting and nightmares had attempts. Sleep disturbance is amenable to treatment, possibly more so than other clinical problems. Decreasing sleep disturbances may reduce psychological distress and improve coping ability, which might decrease an individual’s likelihood of considering or attempting suicide. Effective cognitive behavioral treatments and medication are available to reduce the specific sleep disturbances associated with suicide behavior in our study (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013).
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Stein, D., Lisa, R. R., Lilenfeld, L. R., Wildman, P. C., & Marcus, M. D. (2004). Attempted suicide and self-injury in patients diagnosed with eating disorders. Comprehensive Psychiatry, 45, 447–451. Tanskanen, A., Tuomilehto, J., Viinamaki, H., Vartiainen, E., Lehtonen, J., & Puska, P. (2001). Nightmares as predictors of suicide. Sleep, 24, 844–847. Vgontzas, A. N., Bixler, E. O., Lin, H. M., Prolo, P., Mastorakos, G., Vela-Bueno, A. . . . Chrousos, G. P. (2001). Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: Clinical implications. Journal of Clinical Endocrinology and Metabolism, 86, 3787–3794. Vgontzas, A. N., Fernandez-Mendoza, J., Liao, D., & Bixler, E. O. (2013). Insomnia with objective short sleep duration: The most biologically severe phenotype of the disorder. Sleep Medicine Reviews, 17, 241–54. Vgontzas, A. N., Zoumakis, M., Papanicolaou, D. A., Bixler, E. O., Prolo, P., Lin, H. M. . . . Chrousos, G. P. (2002). Chronic insomnia is associated with a shift of interleukin-6 and tumor necrosis factor secretion from nighttime to daytime. Metabolism, 51, 887–92. Wolraich, M. L., Lindgren, S. D., Stumbo, P. J., Stegink, L. D., Appelbaum, M. I., & Kiritsy, M. C. (1994). Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. New England Journal of Medicine, 330, 301–307.
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders a
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Susan Dickerson Mayes , Julio Fernandez-Mendoza , Raman Baweja , a
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Susan Calhoun , Fauzia Mahr , Richa Aggarwal & Mariah Arnold
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Department of Psychiatry, Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA Published online: 19 May 2014.
To cite this article: Susan Dickerson Mayes, Julio Fernandez-Mendoza, Raman Baweja, Susan Calhoun, Fauzia Mahr, Richa Aggarwal & Mariah Arnold (2014) Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders, Eating Disorders: The Journal of Treatment & Prevention, 22:4, 352-366, DOI: 10.1080/10640266.2014.915694 To link to this article: http://dx.doi.org/10.1080/10640266.2014.915694
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Eating Disorders, 22:352–366, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.915694
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Correlates of Suicide Ideation and Attempts in Children and Adolescents With Eating Disorders SUSAN DICKERSON MAYES, JULIO FERNANDEZ-MENDOZA, RAMAN BAWEJA, SUSAN CALHOUN, FAUZIA MAHR, RICHA AGGARWAL, and MARIAH ARNOLD Department of Psychiatry, Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7–18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.
Almost all individuals who die by suicide have a psychiatric disorder (Gvion & Apter, 2011), and most psychiatric disorders are associated with increased risk of suicide attempts (Goldston et al., 2009). Suicide behavior in children and adults is linked with depression (Greening, Stoppelbein, Luebbe, & Fite, 2010; Gvion & Apter, 2011), Attention Deficit Hyperactivity Disorder (ADHD; Hinshaw et al., 2012; Hurtig, Taanila, Moilanen, Nordstrom, & Ebeling, 2012), autism (Mayes, Gorman, Hillwig-Garcia, & Syed, 2013), and oppositional defiant disorder (ODD) and conduct disorder (Agosti, Chen, & Levin, 2011; Address correspondence to Susan Dickerson Mayes, Department of Psychiatry H073, Hershey Medical Center, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA. E-mail: [email protected] 352
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Cho et al., 2008; James, Lai, & Dahl, 2004). For some disorders (e.g., depression, ODD, and conduct disorder), the relationship with suicide behavior is direct and independent of other variables, whereas for other disorders (e.g., ADHD and autism), the relationship between these disorders and suicide behavior exists in large part because of comorbid depression and conduct problems associated with both (Agosti et al., 2011; Impey & Huen, 2012; Mayes, Calhoun et al., 2013; Mayes, Gorman et al., 2013). Suicide in adults with anorexia nervosa is eight times more common than in the general population (Bulik et al., 2008). Adults with bulimia nervosa do not differ from the norm in suicides (Franko & Keel, 2006), but they have more attempts across studies (25–30%) than do adults with anorexia nervosa (3–20%; Franko & Keel, 2006). Adults with bulimia nervosa are also more likely to have suicide ideation (32%) than adults with anorexia nervosa (22%; Favaro & Santonastaso, 1997). Studies of the frequency of suicide behavior in adolescents with eating disorders are sorely lacking, and two small studies report strikingly different frequencies (Fennig & Hadas, 2010; Ruuska, Kaltiala-Heino, Rantanen, & Koivisto, 2005). A self-report survey of 1,000 adolescents in Italy found that adolescents with suicide ideation had higher scores on measures of eating disorders than adolescents without suicide ideation (Miotto, De Coppi, Frezza, & Preti, 2003). Suicide ideation and attempts in adolescents and adults with anorexia nervosa and bulimia nervosa are associated with purging and binging, but not restricting (Bulik et al., 2008; Favaro & Santonastaso, 1997; Stein, Lisa, Lilenfeld, Wildman, & Marcus, 2004); longer duration of the eating disorder and older age (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010); depression (Corcos et al., 2002; Fennig & Hadas, 2010; Franko et al., 2004; Milos, Spindler, Hepp, & Schnyder, 2004; Nickel et al., 2006; Ruuska et al., 2005); conduct problems such as stealing, lying, aggression, and substance use (Bulik et al., 2008; Corcos et al., 2002; Favaro & Santonastaso, 1997; Franko et al., 2004; Stein et al., 2004); panic and posttraumatic stress disorders (Bulik et al., 2008); and history of physical or sexual abuse (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010; Nickel et al., 2006). Despite the fact that sleep disturbances (e.g., insomnia symptoms and nightmares) have been associated with suicide ideation, attempts, and completions in psychiatric and general population studies (Barbe et al., 2005; Cukrowicz et al., 2006; Liu, 2004; Nadorff, Nazem, & Fiske, 2011, 2013; Pigeon, Pinquart, & Connor, 2012; Sjostrom, Hetta, & Waern, 2009; Tanskanen et al., 2001), sleep disturbances have not typically been included in studies of suicide behavior in individuals with eating disorders. Only two recent studies analyzed sleep disturbances and found that insomnia symptoms were greater in women with bulimia nervosa who attempted suicide than in those who did not (Corcos et al., 2002; Nickel et al., 2006). The goals of our study are to investigate the frequency and correlates of suicide ideation and attempts in children and adolescents with anorexia
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nervosa and bulimia nervosa. Our study is unique in that our sample is younger than all other studies reviewed and uses a wide variety of sleep, psychological, and demographic variables relevant to children and adolescents to determine which of these variables are significantly and independently related to suicide behavior.
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Sample The sample consists of 90 children and adolescents referred to our eating disorder program who were diagnosed with anorexia nervosa or atypical anorexia nervosa (n = 69) or bulimia nervosa (n = 21) by a board certified child and adolescent psychiatrist using DSM-5 criteria. Diagnoses were confirmed through a chart review by a licensed Ph.D. psychologist. The children are 7–18 years (M = 13.8). In all, 96.7% are female, 95.6% are White, and 57.8% have a parent with a professional or managerial occupation. Children with anorexia nervosa were classified with atypical anorexia nervosa if their weight was “within or above the normal range,” as specified by the DSM-5. The CDC definition for underweight (Body Mass Index [BMI] < 5th percentile) was used to determine which children were below the normal range. BMI percentiles were calculated based on CDC norms for age and gender.
Dependent Variables Mothers rated their children on a 4-point scale (not at all, sometimes, often, and very often a problem) on the 165-item Pediatric Behavior Scale (PBS; Lindgren & Koeppl, 1987). Dependent variables are suicide ideation (“talks about harming or killing self”) and suicide attempts (“deliberately harms self or attempts suicide”). The latter item was not scored as an attempt if the child engaged in cutting or other forms of self-harm but did not attempt suicide.
Independent Variables Independent variables are (a) demographic data (age, IQ, gender, race, and parent occupation), (b) eating disorder types and symptoms (BMI percentile and degree of restricting, self-induced vomiting, and binging), (c) comorbid diagnoses (depression, anxiety disorder, ADHD, and ODD), (d) sexually or physically abused or bullied by other children, and (e) maternal ratings on the PBS. These ratings include (a) sleep disturbances (e.g., sleeps less than most other children, trouble falling asleep, wakes during the night, and nightmares), (b) externalizing behavior problems (e.g., bullies other children, explosive, defiant, aggressive, and impulsive), (c) internalizing problems
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(e.g., anxious, sad, and feels worthless), and (d) somatic symptoms (e.g., lacks energy, headaches, and stomachaches). Internal consistency for the PBS subscale scores is high, with a median coefficient of .91 (Lindgren & Koeppl, 1987). Validity studies show that the PBS differentiates diagnostic groups, and the PBS has been used to diagnose and measure psychological symptoms and sleep disturbances in several published studies (Mayes & Calhoun, 2009; Mayes, Calhoun, Bixler, & Vgontzas, 2009; Nichols et al., 2000; Wolraich et al., 1994).
Data Analysis The significance of differences in continuous scores between groups was determined with independent t-tests. The linear relationship between ideation and attempt scores and PBS psychological scores and age was calculated using Pearson correlations and explained variance. A Bonferroni correction was made to control for the number of comparisons made. The independent variables were entered in stepwise binary and linear logistic regression analyses to determine the combination of variables that was most significant in identifying children who had versus did not have suicide ideation and attempts (at least sometimes vs. not at all) and to determine the variables that were independently and significantly correlated with ideation and attempt scores (rated on a 4-point scale from never to very often).
RESULTS Eating Disorder Types and Symptoms Children with bulimia nervosa had higher ideation and attempt scores than children with anorexia nervosa (t = 2.3, p = .03, t = 3.3, p = .004). Suicide ideation was 2.1 times more common in bulimia nervosa (42.9%) than in anorexia nervosa (20.3%), and attempts were 14.8 times more common in bulimia nervosa (42.9%) than in anorexia nervosa (2.9%). All children with bulimia nervosa who had ideation also had attempts. Severity of suicide behavior was greater in bulimia nervosa than in anorexia nervosa. For children with anorexia nervosa, all cases of ideation and attempts were only “sometimes” a problem. In contrast, ideation was “often to very often” a problem for 44.4% of children with bulimia nervosa who had ideation, and attempts were “often to very often” a problem for 66.7% who had attempts. Suicide ideation and attempt scores did not differ significantly between children with anorexia nervosa and atypical anorexia nervosa and between the restricting and binge eating-purging types (t = 0.4 to 2.0, Bonferroni p > .05). In regression analysis, greater binging and BMI percentile were significant correlates of suicide ideation scores (R = .46, F = 11.6, p < .0001), and bulimia nervosa and greater self-induced vomiting were significant correlates
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of attempt scores (R = .58, F = 21.7, p < .0001). Restricting frequency was not significant and was the only variable negatively correlated with ideation and attempt scores (r = –.11 and –.23, Bonferroni p > .05).
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Comorbid Diagnoses All children who had suicide ideation or attempts had comorbid depression (major depression or dysthymic disorder), anxiety disorder (generalized anxiety disorder, obsessive-compulsive disorder, social anxiety disorder, and/or panic disorder), ODD, and/or ADHD. Conversely, none of the 16 children without one or more of these comorbid diagnoses had ideation or attempts. Using these comorbid diagnoses in regression analysis, only ODD and anxiety disorder plus depression were significant correlates of ideation scores (R = .52, F = 16.1, p < .0001). Ideation was present in 64.7% of children with ODD (vs. 16.4% without) and in 40.0% of those with anxiety plus depression (vs. 7.5% without). For attempts, only anxiety plus depression was a significant correlate (R = .27, F = 6.7, p = .01). Children with both anxiety and depression were 8.0 times more likely to have attempts (20.0%) than children who did not have both anxiety and depression (2.5%).
Externalizing Behavior Problems Externalizing behavior problems were present in less than half of children with eating disorders, with the exception of defiant and angry-irritable. Ideation and attempts were more common in children who had any of the externalizing behavior problems than in children who did not. For several problems (bullies, steals, aggressive, does not get along with peers, and substance use), ideation was present in the majority of children who had any of these problems. For the remaining externalizing behaviors (explosive, defiant, impulsive, lies or cheats, and angry-irritable), ideation was present in 28.9% to 50.0% of the children. The majority of children with substance abuse (57.1%) had attempts, whereas attempts ranged from 13.2% to 33.3% in all other behavior problems groups. Using regression analysis, the strongest correlates of ideation scores were explosive, lies or cheats, and impulsive (R = .67, F = 23.4, p < .0001). Lies or cheats, substance use, and does not get along with peers were the most significant independent correlates of attempt scores (R = .51, F = 9.8, p < .0001).
Internalizing Problems All of the internalizing problems (anxious, sad, lonely, feels worthless, low self-confidence, apathetic, and withdrawn) were present in most children and were far more common than externalizing problems. Mothers rated 91.1% of children as sad and 88.9% as anxious. Unlike the externalizing
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problem groups, ideation and attempts were not present in the majority of children with any of the internalizing problems. Ideation was present in less than 38% and attempts in less than 18% of children in any of the internalizing groups. For ideation scores, lonely was the only significant correlate in regression analysis (R = .45, F = 22.2, p < .0001). For attempts, feels worthless was the only significant correlate (R = .33, F = 11.0, p = .001). Although internalizing problems were not strong predictors of suicide behavior, many of these problems were necessary (but not sufficient) for ideation and attempts. All children with ideation and attempts were sad and anxious, whereas no child without anxiety or sadness had ideation or attempts. Furthermore, all with attempts felt worthless and had low self-confidence, whereas no child who did not feel worthless or have low self-confidence had attempts.
Sleep Disturbances Sleep disturbances were common, especially trouble falling asleep which was reported for half of the children. Frequencies for sleeping less than normal, waking during the night, restless sleep, nightmares, and daytime sleepiness ranged from 31.1% to 37.8%, whereas 21.1% woke early and 14.4% talked or walked in their sleep. Suicide ideation was present in the majority of children who had nightmares, talked or walked in their sleep, and slept less than other children. Attempts were present in less than 24% of children in any of the sleep disturbance groups. When the sleep disturbance scores were entered in regression analyses, sleeps less than most children and wakes often during the night were significant correlates of ideation scores (R = .58, F = 22.2, p < .0001), and wakes often during the night and nightmares were significant correlates of attempt scores (R = .42, F = 9.4, p < .0001).
Abused and Bullied The seven children who had been sexually or physically abused had significantly higher ideation and attempt scores than children not abused (t = 3.8 and 2.5, p < .05). History of abuse explained 14.3% of the variance in ideation scores (R = .38, F = 14.7, p < .0001) and explained 27.9% of the variance in attempt scores (R = .53, F = 34.1, p < .0001). Correlations between bullied (never to very often) and ideation and attempt scores were nonsignificant (r = .20 and .02, p > .05).
Somatic Symptoms Correlations between somatic symptom scores (headaches, stomach aches, muscle and body pain, feels “sick,” and tires easily) and ideation and attempt
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scores were all nonsignificant at .05 (r = –.06 to .20) and explained less than 5% of the variance.
Demographics
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Age was not significantly related to ideation or attempt scores (r = .05 and .24) and ideation and attempt scores did not differ significantly between males and females (t = 1.0 and 1.2), Whites and nonwhites (t = 1.4 and 1.6), and professional and nonprofessional families (t = 0.1 and 1.1), with Bonferroni p values ranging from .08 to 1.00.
Combined Correlates and Relative Significance The independent variables significant in one or more of the preceding analyses were entered in stepwise regression analyses to determine the strength of their independent association with suicide behavior. The most powerful combination of variables classifying children with or without suicide ideation in binary regression analysis was explosive, sleeps less than most children, and substance use (87.8% overall classification accuracy, χ 2 = 46.0, p < .0001). Together these variables identified 69.6% of children with ideation and 94.0% without ideation. The remaining variables did not contribute significantly more to the identification of children with and without ideation. The strongest combined correlates of ideation scores (never to very often) in linear regression analysis also comprised sleep disturbances and externalizing problems and were explosive, sleeps less than most children, lies or cheats, and wakes during the night (explained variance 61.8%, R = .79, F = 34.4, p < .0001). The most powerful combination of variables predicting the presence or absence of suicide attempts was self-induced vomiting and bulimia nervosa (91.1% overall classification accuracy, χ 2 = 29.4, p < .0001), which together identified 45.5% with attempts and 97.5% without attempts. The strongest correlates of attempt scores (never to very often) were abused, bulimia nervosa, and nightmares (explained variance 46.3%, R = .68, F = 24.7, p < .0001).
DISCUSSION Suicide ideation and attempts were highly prevalent in our clinical sample of children and adolescents with eating disorders. The novel findings of our study are that externalizing behavior problems and sleep disturbances are both strongly and independently associated with suicide ideation, while a diagnosis of bulimia nervosa, self-induced vomiting, nightmares, and history of physical or sexual abuse are strong independent correlates of suicide
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attempts in children with eating disorders. Our data suggest that children and adolescents with eating disorders should not only be screened for suicide ideation and attempts, particularly those with bulimia nervosa, but also for sleep disturbances, externalizing behavior problems, and physical or sexual abuse, which should be treatment targets because of their association with suicide behavior.
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Eating Disorder Types Suicide ideation and attempts were more common in children with bulimia nervosa than in anorexia nervosa, which is consistent with adult eating disorder studies (Favaro & Santonastaso, 1997; Franko & Keel, 2006). Only 3% of children in our study with anorexia nervosa had attempts, and, for the 20% who had ideation, ideation only occurred “sometimes.” In contrast, for half of the 43% of children with bulimia nervosa who had ideation, their ideation occurred “often to very often.” All children with bulimia nervosa who had ideation also had attempts, indicating that those who talk about killing themselves are very likely to make an attempt. Adults with the binging-purging type of anorexia nervosa have a higher frequency of suicide attempts than those with the restricting type (Favaro & Santonastaso, 1997). In our young sample, the two types did not differ in ideation or attempts. Age may be an explanatory factor. Studies of adults with anorexia nervosa show that those who attempt suicide are older and have been ill longer than those who have not attempted suicide (Favaro & Santonastaso, 1997) and that switching from the restricting to bingingpurging type is associated with an increase in attempts (Foulon et al., 2007). Therefore, by young adulthood, some of our children with anorexia nervosa may have suicide attempts because of switching, increasing age, and longer illness duration.
Depression and Anxiety Ideation and attempts were absent in the eight children who were not sad and in the 10 who were not anxious. Furthermore, none of the 28 children who did not feel worthless had attempts. Conversely, all children with ideation and attempts were sad and anxious (at least sometimes), and all children with attempts felt worthless. Although these features may be necessary for ideation or attempts, they alone were not predictive, and most children with these traits did not have ideation or attempts.
Clinical Correlates Our study demonstrates high classification accuracies for suicide ideation and attempts. The most significant correlates of suicide ideation were
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externalizing behavior problems (explosive, lies or cheats, and substance use) and sleep disturbances (sleeps less than other children and wakes during the night), which identified children with and without ideation with 70% and 94% accuracy. Significant correlates of attempts were eating disorder symptoms (bulimia nervosa and self-induced vomiting), nightmares, and history of physical or sexual abuse, which identified children with and without attempts with 46% and 98% accuracy. Similar to other studies, accuracy in identifying individuals with suicide behavior was lower than identifying those without suicide behavior (Gvion & Apter, 2011). Our finding that externalizing behavior problems, bulimia nervosa, selfinduced vomiting, and history of physical or sexual abuse are correlates of suicide behavior in young children and adolescents is consistent with findings from adolescent and adult studies showing that purging (not restricting) is associated with suicide attempts (Bulik et al., 2008; Favaro & Santonastaso, 1997; Stein et al., 2004), that conduct problems in psychiatric and general population samples are linked with suicide ideation and attempts (Agosti et al., 2011; Bulik et al., 2008; Cho et al., 2008; Corcos et al., 2002; Favaro & Santonastaso, 1997; Franko et al., 2004; Goldston et al., 2009; James et al., 2004; Mayes, Gorman et al., 2013; Stein et al., 2004), and that suicide behavior is associated with a history of physical or sexual abuse (Favaro & Santonastaso, 1997; Fennig & Hadas, 2010; Nickel et al., 2006). Our study identified novel and specific aspects of sleep disturbances associated with suicide behavior in young patients with eating disorders. Specifically, sleeping less than other children and waking during the night were highly correlated with suicide ideation, while nightmares were associated with suicide attempts. Why are these three symptoms particularly important, even after considering other sleep variables (i.e., trouble falling asleep, restless sleep, talks or walks in sleep, wakes early, and daytime sleepiness)? It has long been recognized that insomnia symptoms and nightmares in adults are linked with psychopathology (Bixler, Kales, Soldatos, Kales, & Healey, 1979), and nightmares in particular are associated with increased mental stress (Kales et al., 1980). In fact, insomnia symptoms and nightmares are independently associated with suicide ideation, attempts, and completions in psychiatric and general population studies (Barbe et al., 2005; Nadorff et al., 2011, 2013; Pigeon et al., 2012; Singareddy et al., 2013; Sjostrom et al., 2009; Tanskanen et al., 2001). In children with eating disorders, sleeping less than other children may result in children feeling poorly physically and mentally, increasing their overall mental distress. If children with eating disorders wake often during the night, they may spend more time lying in bed obsessing about their weight and feeling miserable. When they do sleep, nightmares may create additional psychological distress. Alternatively, nightmares may be a marker of psychological distress, thereby correlating with suicide behavior. Although some (Tanskanen et al., 2001) postulate that trauma may explain the link between nightmares and
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suicide behavior, Nadorff et al. (2011) found nightmares are correlated with suicide behavior independent of posttraumatic stress disorder in a nonclinical sample. Consistent with the latter, our study showed that nightmares and a history of sexual or physical abuse were both correlates of suicide attempts independent of each other in a clinical sample of patients with eating disorders. As in previous studies, the strong relationship between sleep disturbances and suicide behavior is not explained by associated psychopathology, because sleep disturbance is a significant correlate of suicide behavior even after controlling for anxiety, depression, and other psychological problems. This strong relationship is also not explained by daytime sleepiness, lack of energy, or poor stamina, which may result from disturbed sleep and may affect coping ability and how people feel physically and mentally. In fact, these variables had low correlations with suicide ideation and attempts in our study. Pigeon et al. (2012) speculated that several pathways may explain the association between sleep disturbances and suicide, from the neurobiology of insomnia which shares a number of features with that of depression, including hypothalamic-pituitary-adrenal (HPA) axis alterations (Vgontzas et al., 2001), elevations in pro-inflammatory cytokines (Vgontzas et al., 2002), and decreased serotonergic tone (Sjostrom et al., 2009; Singareddy & Balon, 2001) to cognitive-behavioral factors, such as rumination, cognitive arousal, and maladaptive coping skills (Fernandez-Mendoza et al., 2010; Vgontzas, Fernandez-Mendoza, Liao, & Bixler, 2013).
Comparison With Correlates in Other Diagnostic Groups Our findings have similarities and differences compared to studies of children with autism and children with ADHD, which used the same measures of suicide ideation and attempts as in the current study (Mayes, Calhoun et al., 2013; Mayes, Gorman et al., 2013). The most significant independent correlates of ideation and attempts in children with autism and in children with ADHD were explosive, angry, aggressive, oppositional, and sad. Therefore, in all three disorders (eating disorders, autism, and ADHD), traits associated with conduct problems are significant correlates independent of other variables. Sadness was an independent correlate in autism and ADHD, but not in eating disorders, most likely because sadness was far more common in eating disorders (occurring in 91%). Correlations between sleep disturbance and ideation and attempts in autism and ADHD were small, in contrast to large correlations in eating disorders. This was the case even though sleep disturbance is common in all three disorders (Mayes et al., 2009). However, the etiology of the sleep problems may differ between the groups, explaining why sleep is associated with ideation and attempts in eating disorders but not in autism and ADHD. Sleep disturbance in ADHD and autism may be related to behavioral factors and hyperactivity, resulting in difficulty settling
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and maintaining sleep, whereas sleep disturbances in individuals with eating disorders may be more related to psychological distress and neurophysiological alterations (e.g., HPA axis activation). Further, the autism and ADHD samples were predominantly male and much younger than the eating disorder sample. It remains to be determined if differences in correlates are diagnosis specific or related to other differences between the groups.
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Limitations and Directions for Future Research Our single site study needs to be replicated with larger samples of children in other settings. Larger samples would permit determining correlates of suicide behavior for bulimia nervosa and anorexia nervosa separately and exploring gender and racial differences in the correlates of suicide behavior. Our study is also limited because it is a cross sectional analysis, and not a prospective longitudinal study of predictors of suicide behavior. Moreover, our study relied on maternal report of suicide ideation and attempts and other variables, which is important in young samples like ours, but has definite limitations. It is possible that the lack of association between internalizing problems (e.g., anxiety and depression) and suicide behavior could be attributed to maternal unawareness of anxiety, sadness, and other internal states in their children. Parents are more likely to be aware of observable externalizing behaviors than their child’s internal thoughts and feelings. However, mothers rated 91% of our sample as sad and 89% as anxious, suggesting that mothers were aware of these problems and that the lack of association with suicide behavior may be because almost all children with eating disorders are sad and anxious. In contrast, most externalizing behavior problems were present in a minority of our sample. Regardless of possible explanations for the findings, parent report needs to be supplemented with self-report in future studies.
Conclusions In our study, 43% of children with bulimia nervosa had suicide ideation, as did 20% with anorexia nervosa. These percentages are 86 and 41 times higher than percentages for typical children reported in a study using the same measure of suicide ideation and attempts (Mayes, Gorman et al., 2013). Furthermore, all children with bulimia nervosa who had ideation also had attempts. Our data reinforce the importance of assessing and treating anxiety and depression in children with eating disorders because all children who had ideation and attempts were depressed and anxious. However, externalizing behavior problems were strong independent correlates of suicide behavior whereas internalizing problems were not. Less than one-third of sad or anxious children had ideation, whereas the majority of children who
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were explosive, aggressive, or bullies or who stole or used substances had suicide ideation, and they had more attempts than children who were sad or anxious. Therefore, it is critical not to neglect externalizing problems when assessing risk of suicide behavior in patients with eating disorders. Likewise, sleep disturbances cannot be ignored. The majority of children who slept less than other children and the majority who had nightmares also had suicide ideation, and they had more suicide attempts than children who were sad or anxious. Sleep problems combined with other clinical factors are highly correlated with suicide behavior. For example, all children with bulimia nervosa who had self-induced vomiting and nightmares had attempts. Sleep disturbance is amenable to treatment, possibly more so than other clinical problems. Decreasing sleep disturbances may reduce psychological distress and improve coping ability, which might decrease an individual’s likelihood of considering or attempting suicide. Effective cognitive behavioral treatments and medication are available to reduce the specific sleep disturbances associated with suicide behavior in our study (Augedal, Hansen, Kronhaug, Harvey, & Pallesen, 2013).
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