© 2013 American Psychological Association 0021-843X/13/$l2.00 IX)I: 10.1037/a0034902

Journal of Abnormal Psychology 2013, Vol. 122, No. 4. 1042-1056

Suicide Attempts in Women With Eating Disorders Emily M. Pisetsky and Laura M. Thornton

Paul Lichtenstein and Nancy L. Pedersen

University of North Carolina at Chapel Hill

Karolinska Institutet

Cynthia M. Bulik University of North Carolina at Chapel Hill We evaluated whether the prevalence of lifetime suicide attempts/completions was higher in women with a lifetime history of an eating disorder than in women with no eating disorder and assessed whether eating disorder features, comorbid psychopathology, and personality characteristics were associated with suicide attempts in women with anorexia nervosa, restricting subtype (ANR), anorexia nervosa, bingepurge subtype (ANBP), lifetime history of both anorexia nervosa and bulimia nervosa (ANBN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD). Participants were part of the Swedish Twin study of Adults: Genes and Environment (N = 13,035) cohort. Lifetime suicide attempts were identified using diagnoses from the Swedish National Patient and Cause of Death Registers. General linear models were applied to evaluate whether eating disorder category (ANR, ANBP, ANBN, BN, BED, PD, or no eating disorder [no ED]) was associated with suicide attempts and to identify factors associated with suicide attempts. Relative to women with no ED, lifetime suicide attempts were significantly more common in women with all types of eating disorder. None of the eating disorder features or personality variables was significantly associated with suicide attempts. In the ANBP and ANBN groups, the prevalence of comorbid psychiatric conditions was higher in individuals with than without a lifetime suicide attempt. The odds of suicide were highest in presentations that included purging behavior (ANBN, ANBN, BN, and PD), but were elevated in all eating disorders. To improve outcomes and decrease mortality, it is critical to be vigilant for suicide and identify indices for those who are at greatest risk. Keywords: suicide, eating disorders, anorexia, bulimia, binge eating disorder

A companion analysis of 16 studies on BN comprising 1,768 patients, with a mean follow-up of 7.5 years, yielded an SMR = 7.5 (Preti et al., 2011). Only three studies examining suicide in individuals with binge eating disorder (BED) were available for inclusion in this meta-analysis. With only 246 patients, no completed suicides were identified and an SMR could not be calculated. Purging disorder (PD), characterized by purging in the absence of binge eating behavior, is described in depth by Keel and StriegelMoore (2009) and is included as a named condition in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) in the Other Specified Feeding and Eating Disorders section (American Psychiatric Association, 2013). To our knowledge, there are no published data on completed suicides in individuals with PD. Suicide attempts in individuals with AN are also common, with estimates of lifetime attempts ranging from 3.0% to 29.7% (Bulik et al., 2008; Forcano et al., 2011; Franko & Keel, 2006). Furthermore, these attempts are often serious and are associated with the intention to die. In a sample of 432 non-treatment-seeking participants with AN, of those who had attempted suicide, 78.3% wanted to die from their attempt(s), and 56.5% thought that they would die as a result of the attempt(s). Over half of these attempts required medical attention (Bulik et al., 2(X)8). In another study of a treatment-seeking sample, 79% of those who had attempted suicide endorsed "moderate or severe intent" to die (Bulik, Sullivan, & Joyce, 1999). Suicide attempts are also common in BN, with between 15% and 40% of individuals indicating a lifetime history of at least one suicide attempt (Bulik et al., 1999; Coreos et al., 2002; Favaro &

Eating disorders (EDs) are serious mental illnesses that occur in 1-5% of women (Hudson, Hiripi, Pope, & Kessler, 2007) and can have poor long-term outcomes (Berkman et al., 2006; Hudson et al., 2007). A comprehensive meta-analysis of mortality in EDs including 36 studies reported standardized mortality ratios (SMRs) of 5.86 (95% CI [4.17, 8.26]) for anorexia nervosa (AN) and 1.93 (95% CI [1.44, 2.59]) for bulimia nervosa (BN; Arcelus, Mitchell, Wales, & Nielsen, 2011), suggesting that individuals with either disorder are at increased risk of death compared with their age- and gender-matched peers. Suicide is a common cause of this elevated mortality in EDs. A meta-analysis by Preti, Rocchi, Sisti, Camboni, and Miotto (2011) analyzed data from 40 studies comprising 16,342 patients with AN followed over a mean of 11.1 years and yielded an SMR = 31.0.

Emily M. Pisetsky and Laura M. Thornton, Department of Psychiatry, University of North Carolina at Chapel Hill; Paul Lichtenstein and Nancy L. Pedersen, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Cynthia M. Bulik, Department of Psychiatry, University of North Carolina at Chapel Hill. This study was supported by Grants CA-085739 (P.I.: P. E. Sullivan) and AI-056014 (P.I.: P. F. Sullivan) from the National Institutes of Health. The Swedish Twin Registry is supported by grants from the Swedish Department of Higher Education and the Swedish Research Council. Correspondence conceming this article should be addressed to Cynthia Bulik, CB #7160, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599. E-mail: [email protected] 1042

SUICIDE ATTEMPTS IN WOMEN WITH EATING DISORDERS

Santonastaso, 1997; Forcano et al., 2009; Franko & Keel, 2006; Milos, Spindler, Hepp, & Schnyder, 2004). Of individuals with BN who attempted suicide, 34.1% had a "serious" or "extreme" first attempt; the proportion of "serious" or "extreme" attempts increased with the number of attempts. More than 60% of individuals with BN were hospitalized as a result of their fu^st suicide attempt, and 100% of those who endorsed an "extreme" suicide attempt were hospitalized (Coreos et al., 2002). Whether the risk of suicide attempts across ED subtypes differs remains a matter of some disagreement, with some studies reporting no difference in the prevalence of attempts (Bulik et al., 1999; Herzog et al., 1999; Milos et al., 2004), some reporting higher prevalence of suicide attempts in individuals with BN than in those with AN (Favaro & Santonastaso, 1996, 1997), and others reporting higher prevalence of suicide attempts in individuals with AN than in those with BN (Franko et al., 2004). The differences are likely attributable to differences in subtyping diagnostics, although one fairly consistent finding is higher risk among the binge-purge subtype of AN than individuals with the restricting subtype (Bulik et al., 2008; Favaro, Tenconi, & Santonastaso, 2006; Franko & Keel, 2006). However, most of the research has focused on differences in prevalence of suicide attempts across AN subtypes and BN. Research on the prevalence of suicide attempts in individuals with BED or PD is extremely limited. One recent study of patients with BED presenting for outpatient treatment found that 12.5% had a lifetime history of a suicide attempt, providing initial indication of elevated risk of suicide attempts in this population compared with individuals with no ED (Carano et al., 2012). PD has not been included in any of the large studies of suicide attempts in women with EDs. Additional studies are needed to further clarify the prevalence of suicide attempts in individuals with BED and individuals with PD and compare suicide risk in the other ED groups. Large population-based studies have the potential to clarify differences in suicide risk across the ED diagnostic categories, particularly in these understudied disorders, and inform risk assessment in treatment settings. Reports have been inconsistent when addressing whether specific patient profiles or characteristics are associated with suicide attempts in individuals with EDs. Factors identified as associated with suicide attempts in isolated studies of AN include older age, longer duration of illness, lower body mass index (BMI), depression, greater number of past treatments, antidepressant use, elevated phobic anxiety, and dmg and alcohol abuse (Favaro & Santonastaso, 1997; Forcano et al., 2009). For BN, associated factors include greater general psychopathology; greater number of past treatments; antidepressant use; lower education; lower minimum BMI; family history of alcohol abuse; increased impulsive behaviors including self-injury; lower self-directedness, cooperativeness, and reward dependence; and higher harm avoidance (Favaro & Santonastaso, 1997; Forcano et al., 2009). Current evidence suggests that suicidality is associated with anxious personality traits such as harm avoidance and neuroticism in various psychiatric and community samples of individuals with EDs (Bulik et al., 1999; Engström, Brandstrom, Sigvardsson, Cloninger, & Nylander, 2004; McGirr, Paris, Lesage, Renaud, & Turecki, 2007; Ruchkin, Schwab-Stone, Koposov, Vermeiren, & King, 2003; van Heeringen et al., 2003). Moreover, impulsivity, high novelty seeking, and low self-directedness have also been reported (Forcano et al., 2009; McGirr et al, 2007; Zouk, Tousignant, Seguin, Lesage,

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& Turecki, 2006). The coexistence of anxious and impulsive traits may converge to increase suicidal risk. Several comorbid psychiatric disorders have been associated with suicide attempts in individuals who have an ED, including a lifetime history of major depression (Anderson, Carter, Mclntosh, Joyce, & Bulik, 2002; Bulik et al., 2008; Coreos et al., 2002; Favaro & Santonastaso, 1997), with more than 80% of individuals with AN who attempted suicide reporting that their worst or only attempt occurred during an active episode of major depressive disorder (Bulik et al., 2008). In addition, anxiety disorders (e.g., posttraumatic stress disorder, panic disorder, and a broad diagnosis of "any anxiety disorder"; Bulik et al., 2008; Milos et al., 2004), substance abuse, and alcohol abuse (Anderson et al., 2002; Coreos et al., 2002; Franko et al., 2004) have been associated with suicide attempts in AN and BN. The present study clarifies and extends this body of research by employing data from the population-based Swedish Twin Registry in conjunction with the Swedish National Patient Register and the National Cause of Death Register. Conducting research with national registers is a valuable methodological approach, especially in Nordic countries (Allebeck, 2009) where data are reliable and participants are less likely to be lost to follow-up. Moreover, all deaths and hospitalizations in Sweden are captured in national registers (Ludvigsson et al., 2011; National Board of Health and Welfare, 2010). Using Swedish national registers, we evaluated whether suicide attempts/completions were more prevalent in individuals with AN subtypes, BN, lifetime history of both AN and BN (ANBN), BED, and PD than in individuals without EDs and explored whether there were specific psychopathological, temperament, and personality features that were associated with suicide attempts in individuals with EDs.

Method Participants Participants were female twins bom between 1959 and 1985 and assessed as part of the Swedish Twin study of Adults: Genes and Environment (STAGE; N = 13,035; Furberg et al., 2008; Lichtenstein et al., 2006). STAGE data were collected in 2005 using Webbased questionnaires and phone interviews (response rate for full STAGE data set = 59.6%). Questionnaires assessed demographic information; medical history; presence of psychiatric disorders including detailed information on EDs and alcohol and illicit substance use; and personality variables including neuroticism, extraversion, perfectionism, and self-directedness. Participants were between 20 and 47 years of age at the time of assessment. Determination of zygosity was based on responses to standard twin similarity questions, which were validated with a panel of 47 single-nucleotide polymorphisms in a random sample of 198 twin pairs. Ninety-flve percent (n = 188) were correctly classified. This zygosity algorithm has also previously been validated with similar results (Lichtenstein et al., 2002). Of the twins included in the present study, 42.4% were from monozygotic twin pairs, 30.2% were from same-sex dizygotic twin pairs, 25.2% were from opposite-sex twin pairs, and 2.3% were of unknown zygosity.

Identification of Attempted and Completed Suicide All Swedish citizens since 1947 and, therefore, all participants in STAGE, have an assigned unique personal identification num-

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ber (national registration number; Ludvigsson, OtterbladOlausson, Pettersson, & Ekbom, 2009). Via this number, the STAGE database can be linked to any Swedish national register. To identify all recorded suicide attempts and completions, STAGE was linked with following registers; National Patient Register. The National Board of Health and Welfare maintains the National Patient Register (National Board of Health and Welfare, 2010), which covers all public inpatient hospitalizations in Sweden. Each record contains admission and discharge dates, primary discharge diagnosis, and up to eight secondary diagnoses using the International Classification of Diseases (ICD)-8, ICD-9, or ICD-10 depending on the year of hospitalization (World Health Organization, 1967, 1978, 1992). The attending physician documented the diagnoses. This register captures all inpatient psychiatric care in Sweden since 1973. The register also routinely captures suicide attempts using ICD codes (codes E950-E959 in ICD-8 and ICD-9 and X60-X84 in ICD10). This register was searched for any discharge diagnoses indicating suicide attempts. Cause of Death Register. All deaths in Sweden from 1958 to 2009 are contained in the Cause of Death Register (National Board of Health and Welfare, 2010). The diagnoses and causes of death are coded according to ICD codes. The register routinely codes suicide as a cause of death. This database was searched to identify all cases of death by suicide (ICD-10 X60-X84 for years 20052009). Suicide attempts/completions. Information on suicide attempts was extracted from the National Patient Register for the years 1969-2009. Therefore, all suicide attempts not resulting in death prior to participation in STAGE and suicide attempts after participation in STAGE were captured. To participate in STAGE, individuals needed to be alive in 2005 and suicide information was available up to 2009. As such, information on completed suicides was available only for the interval between 2005 and 2009. Given the restricted interval to capture completed suicides, the number of completed suicides was hypothesized a priori to be too small to be adequately powered to conduct independent analyses across groups. Therefore, we created a composite variable that included suicide attempts and completions. In addition, the number of individuals with an initial suicide attempt subsequent to their participation in STAGE was hypothesized a priori to be too small to compose a sufficiently large group to be examined independently (i.e., suicide attempt prior to STAGE participation vs. after STAGE participation). For this reason, we identified the presence or absence of lifetime suicide attempts as the primary outcome variable.

ED Diagnosis Narrow. Two sets of diagnostic criteria were used to define EDs. The first reflected narrow definitions from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000). Specifically, AN was coded if a participant (a) indicated that she had a period of time when she weighed much less than other people thought she should weigh and reported a BMI < 17.55, (b) indicated being very or extremely afraid of gaining weight or becoming fat, and (c) indicated feeling very or extremely fat when at low weight. Amenorrhea was not required for the diagnosis as it is an unreliable

diagnostic criterion for AN (American Psychiatric Association, 1994; Bulik, Sullivan, & Kendler, 2000) and was ultimately eliminated in the DSM-5 (American Psychiatric Association, 2013). Information about binge eating (eating an unusually large amount of food in a short period of time with at least slight loss of control) and purging (defined as vomiting, diuretic use, or laxative use during the time when binge eating was occurring or at least weekly) was also collected and used to further classify women as AN, restricting subtype (ANR; absence of both lifetime binge eating and purging) or AN, binge-purge subtype, (ANBP; presence of lifetime binge eating and or purging). Narrow BN was defined as meeting DSM-IV Criteria A (binge eating), B (inappropriate compensatory behaviors), C (binge eating episodes occur at least eight times a month for at least 3 months), and D (body weight or shape are important or the most important factors in self-evaluation). Narrow BED was defined as meeting DSM-IV Criteria A (binge eating), B (endorsing at least three of the following symptoms; eating faster than usual, eating until uncomfortably full, eating large amounts of food when not hungry, eating alone due to embarrassment, and feeling disgusted/depressed/guilty after overeating), C (distress or upset over binge episodes), D (at least eight binge episodes a month for at least 3 months), and E (did not engage in inappropriate compensatory behaviors during the time when they were binge eating). A diagnosis of BED was not made if the participant had a history of either AN or BN. If a participant indicated that she engaged in vomiting, laxative use, or diuretic use at least weekly, indicated that body weight or shape are important or the most important factors in selfevaluation, had no history of binge eating, and did not have a lifetime history of AN, she was scored positive for narrow PD. In addition to the specific questions described above, participants were also asked the general prompt "Do you have or have you ever had any of the following problems?" and one of the listed problems was "anorexia/bulimia/eating disorders" as part of a medical checklist (n = 11,117). Participants responded "yes" or "no" to this question. This question was used in the present study only to identify agreement between the response on the medical checklist and ED diagnosis as established by the diagnostic algorithms (K = 0.40). Most individuals who responded yes to the checklist item were also given an ED diagnosis (n = 261). Of the 10,391 women who were not classified as meeting a narrow diagnosis for an ED, 642 (6.10%) self-identified as having an ED. There were 50 individuals who said no to the checklist item, but were classified as having an ED diagnosis by the algorithms. Broad. For the broad diagnoses, the criteria were modified for each disorder. Specifically, AN was coded if a participant (a) indicated that she had a period of time when she weighed much less than other people thought she should weigh and had a BMI < 18.55; (b) indicated being slightly, somewhat, very, or extremely afraid of gaining weight or becoming fat; and (c) indicated feeling slightly, somewhat, very, or extremely fat when at low weight. For broad BN, Criterion C was modified; A reduced frequency of binge eating of four or more times per month was required. In addition. Criterion D was defined as body weight or shape at least moderately influences self-evaluation. This definition has been used previously (Root et al., 2010) and has been shown to improve the detection of binge eating behavior without significantly increasing the prevalence of the disorder (Trace et al., 2012). Broad

SUICIDE ATTEMPTS IN WOMEN WITH EATING DISORDERS

BED was defined as meeting DSM-IV criteria with a reduced frequency of at least four binge eating episodes in a 1-month period (broadened Criterion D). For broad PD, vomiting, laxative use, or diuretic use had to occur at least weekly and body weight or shape at least moderately influenced self-evaluation. Agreement between those identified as having a broadly defined ED diagnosis from the above-described criteria and those who self-identified as having an ED on the medical checklist was calculated (K = 0.60). Many individuals identified by the algorithms as having an ED diagnosis also answered yes to the ED question on the medical checklist (n = 524). However, 202 women met criteria for an ED using the algorithms but responded no to the checklist item. Of those who were not classified as meeting a broad diagnosis for an ED, 407 self-identified as having an ED. The ED categories used in the analyses were nonoverlapping. For both the narrow and broad definitions, each person was classified as either having a lifetime diagnosis of ANR, lifetime diagnosis of ANBP (the respondent was scored as positive for binge eating, defined below, and/or indicated engaging in at least one purging behavior weekly or daily), lifetime diagnosis of BN, lifetime diagnosis of BED, lifetime diagnosis of PD, or no lifetime diagnosis of an ED (no ED). Any participant who had a lifetime history of both AN and BN (narrow definition, n = 23; broad definition, n = 103) was classified as ANBN. Participants who met broad criteria for an ED but not narrow criteria (n = 388) were excluded from the analyses for the narrow diagnoses, as those individuals could not be considered cases or controls. Therefore, the final sample size for the analyses of the broad definitions of illness was 13,035.

ED Features Binge eating. The main binge eating question was "Have you ever had binges when you ate what most people would regard as an unusually large amount of food in a short period of time?" with response options yes, no, and don't know/refuse. Positive responses were followed by "When you were having eating binges, did you feel your eating was out of control?" Response options were not at all, slightly, moderately, very much, extremely, and don't know/don't wish to answer. Binge eating was scored as present if the individual responded yes to the first question and indicated feeling slightly, moderately, very much, or extremely out of control. ED behaviors. Two questions evaluated weight control methods. Individuals who endorsed binge eating were asked whether they engaged in compensatory behaviors (vomiting, laxative use, diuretic use, diet pills) during the time of binge eating. Those who responded that they engaged in compensatory behaviors during the time of binge eating were scored as positive for the respective method. Individuals who did not endorse binge eating were asked whether they ever engaged in vomiting, laxative use, diuretic use, or diet pill use at any point in their lifetime to control shape or weight. Response options were never, once or twice, weekly, or daily. Those who engaged in any of the behaviors weekly or daily were scored as positive for the respective weight control method. Each participant was asked whether she ever fasted to control her shape or weight or had not eaten for 24 hr or more (present/ absent). Excessive exercise reflected exercising more than 2 hr per

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day to control shape and weight. Those who endorsed daily were scored positive for excessive exercise. Amenorrhea. Women were asked to recall age at menarche. Those who got their first period at age 16 or later, those who had not yet experienced menarche prior to AN onset, and those who reported missing three or more periods were classified as having amenorrhea. BMI. Each participant reported lowest weight in kilograms (kg) since age 18 and current height in meters (m). For women who did not have a history of AN, lowest adult BMI (kg/m^) was calculated. For women with a history of AN, lowest BMI was calculated from lowest weight during AN and height at the time of low weight. Current BMI was calculated using current height (m) and participant-reported current weight (kg). Highest BMI was calculated using current height (m) and participant-reported highest weight (not including pregnancy; kg). BMI difference was calculated by subtracting the lowest BMI value from the highest BMI value. Age of onset. Age of onset of ANR was defined as age at lowest illness-related weight. Age of onset of BN and of BED was defined as age at first binge. Age of onset of ANBP and ANBN was defined as age at first binge or age at lowest illness-related weight, which ever was younger. No age of onset information was provided for inappropriate compensatory behaviors, so these data are unavailable for participants with PD.

Psychiatric Comorbidity Other psychiatric disorders were assessed using detailed selfreport questionnaires based on the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 2002). Depression was coded as present if Criterion A (five symptoms of depression, including depressed mood and/or anhedonia, associated with a change of functioning) and Criterion C (significant impairment caused by the symptoms) were met. Participants needed to endorse the symptoms of depression for 2 or more weeks in a row and experience these symptoms all day long or mo.si ofthe day to be coded as meeting criteria for depression. Participants were also asked whether they "have or have ever had . .. depression" with a response option of yes or no. Agreement between those identified as having lifetime depression from the abovedescribed algorithm and those self-identified as having lifetime depression from the yes-no question was calculated (K = 0.56). Generalized anxiety disorder (GAD) was considered present if Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) Criteria A (excessive anxiety and worry) and C (at least three symptoms resulting from anxiety and worry) were met. Lifetime prevalence of specific phobias, obsessive-compulsive disorder (OCD), and panic disorder was assessed with the question "Have you ever had any of the following problems?" Each disorder was then listed and response options were "yes" and "no." A composite "any anxiety disorder" variable was also assessed: If the participant had a history of GAD, phobias, OCD, or panic disorder, she was scored positive for any anxiety disorder. Alcohol abuse/dependence was assigned based on DSM-IV criteria (American Psychiatric Association, 1994); participants were asked about the presence (and frequency where appropriate) of each abuse and dependence criterion. If a participant responded

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positively to one abuse criterion or three or more dependence criteria, she was given a positive diagnosis for alcohol abuse/ dependence. Substance use was defined as using marijuana/hash, opioids, stimulants, hallucinogens, sedatives, and/or hormones 10 times or more in 1 month.

Temperament and Personality Concem over mistakes (a = .82), personal standards (a = .81), and doubts about actions (a = .90) were each evaluated using four items from the subscales of the Frost Multidimensional Perfectionism Scale (Frost, Marten, Lahart, & Rosenblate, 1990). Extraversion was evaluated using nine items (a = .78) and neuroticism was evaluated using 18 items (a = .90) of the Eysenck Personality Inventory (Schapiro et al., 2001). Self-directedness was measured using five items (a = .84) from the Temperament and Character Inventory (Cloninger, 1994).

Statistical Analyses All data management and analyses were conducted using SAS 9.2. The STAGE database was first linked with the Swedish National Patient Register and the Swedish National Cause of Death Register. For each individual, the total number of lifetime suicide attempts resulting in hospitalization was based on the number of unique dates of hospital discharge entries into the Swedish National Patient Register with a suicide attempt code. Individuals who died as a result of a suicide attempt were identified from a cause of death code for suicide in the Swedish National Cause of Death Register. Identified completed suicides were added to the number of suicide attempts generated from the Swedish Hospital Discharge Register if the date of the death was different from the last Swedish National Patient Register entry. Each individual's age at first attempt was calculated from the date of discharge or death. ICD codes were used to categorize the method used for each attempt. Methods were classified as "violent" (e.g., stabbing, hanging, jumping from a high place) and "nonviolent" (see Table 1 for classification by ICD code). Any participant who had more than one suicide attempt with at least one attempt classified as violent was coded as having had a violent attempt. The prevalence of at least one lifetime suicide attempt and of a violent suicide attempt among those who had ever attempted suicide was computed for ANR, ANBP, ANBN, BN, BED, PD, and no ED groups by narrow and broad ED definitions. Means and standard deviations for number of attempts and age at first attempt were calculated for all groups. Logistic regression analyses (using PROC GENMOD in SAS) with generalized estimating equations (GEEs) were applied to assess differences in the prevalence of suicide attempts/completion across the ANR, ANBP, ANBN, BN, BED, PD, and no ED groups. GEE was used to account for the nesting of the data within twin pairs in this and all subsequent full-model analyses. GEE assumes a relationship within clusters (twin pairs), and this relationship is modeled and treated as a nuisance variable. For our analyses, the exchangeable correlation matrix was used to model the relationship for the analyses of the ANR, ANBP, ANBN, and PD groups and for the personality features for the BN and BED groups. The identity matrix was used for the analyses of the ED features and comorbidity in the BN groups because the models for these groups

would not converge. Models for the ED features and comorbidity for the BED group could not be applied. Age at assessment was entered as a covariate in all models. Type 3 score statistics were used to determine the significance of the independent variable in the models. Post hoc contrasts, which use adjusted means, were requested to assess pairwise group differences for the omnibus tests that were significant. The score statistics are presented as x^ for all analyses. We used the guidelines presented by Chen, Cohen, and Chen (2010); Odds ratios of 1.68, 3.47, and 6.71 are considered equivalent to Cohen's d = 0.2 (small), 0.5 (medium), and 0.8 (large), respectively. Therefore, odds ratios greater than 1.68 indicate a small effect size and are presented even if the model did not reach significance. Among those who ever attempted suicide, differences in the prevalence of violent suicide attempts and in age at first suicide attempt across ED category were assessed using general linear models with GEE corrections. To determine whether ED category was associated with the total number of lifetime suicide attempts, we conducted a Poisson regression with GEE corrections. Associations between suicide attempts and lifetime lowest BMI, age of onset of ED, specific ED features (including history of vomiting, laxative use, diet pill use, diuretic use, excessive exercise, fasting, other inappropriate compensatory behaviors, and amenorrhea), psychiatric comorbidity, and personality traits were evaluated for each ED group separately using general linear models with GEE corrections. All p values of omnibus tests were coiTected for multiple testing using the methods of false discovery (Pfa,) (Benjamini & Hochberg, 1995). In addition, sign tests were conducted to evaluate whether there was a systematic difference in reporting of comorbid conditions between individuals with a history of suicide attempts and those who had never attempted suicide. Specifically, we evaluated whether those with suicide attempts reported higher prevalences across a majority of comorbid conditions than those without suicide attempts. These analyses were stratified by ED group, were one-tailed, and were not corrected for multiple testing.

Results Demographics Narrow diagnostic groups. Demographic information is presented across the narrow ED categories in the top panel of Table 2. There were no differences in age at assessment across the ED groups. BMI at time of assessment differed across EDs (x'^ = 48.79, p < .0001). Post hoc analyses revealed that the BED group had a significantly higher mean BMI at assessment than all of the other ED categories. In addition, the mean BMIs at assessment for the ANR and ANBP groups were significantly lower than those for the BN, PD, and no ED groups. Education level differed across groups (x^ = 15.38, p < .02); post hoc analyses revealed that education levels differed between the BN and no ED groups. Civil status differed across groups (x^ = 13.83, p < .04). The prevalence of being married or cohabiting with a partner was lower in the BN and BED groups than the no ED group. Broad diagnostic groups. The bottom panel of Table 2 presents the demographic information across the broadly defined ED categories. There were no differences in age at assessment across the ED groups. BMI at time of assessment differed across ED

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Table 1 Intemational Classißcation of Diseases (¡CD) Codes Used to Identify Suicide Attempts and Completions and the Violence Categorization for Each Code Code ICD-8 and ICD-9 E950 E951 E952 E953 E954 E955 E956 E957 E958 E959 ICD-10 X60 X61 X62 X63 X64 X65 X66 X67 X68 X69 X70 X71 X72 X73 X74 X75 X76 X77 X78 X79 X80 X81 X82 X83 X84

Definition

Violence categorization

Suicide and self-inflicted poisoning by solid or liquid substances Suicide and self-inflicted poisoning by gases in domestic use Suicide and self-inflicted poisoning by other gases and vapors Suicide and self-inflicted injury by hanging, strangulation, and suffocation Suicide and self-inflicted injury by submersion (drowning) Suicide and self-inflicted injury by firearms, air guns, and explosives Suicide and self-inflicted injury by cutting and piercing instrument Suicide and self-inflicted injuries by jumping from high place Suicide and self-inflicted injury by other and unspecified means Late effects of self-inflicted injury

Nonviolent Nonviolent Nonviolent Violent Violent Violent Violent Violent Nonviolent Nonviolent

Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics, and antirheumatics Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, anti-Parkinsonism, and psychotropic drugs, not elsewhere classified Intentional self-poisoning by and exposure to narcotics and psychodysleptics Piallucinogens], not elsewhere classified Intentional self-poisoning by and exposure to other drugs acting on the autonomie nervous system Intentional self-poisoning by and exposure to other and unspecifled drugs, medicaments and biological substances Intentional self-poisoning by and exposure to alcohol Intentional self-poisoning by and exposure to organic solvents and halogenated hydrocarbons and their vapors Intentional self-poisoning by and exposure to other gases and vapors Intentional self-poisoning by and exposure to pesticides Intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances Intentional self-harm by hanging, strangulation, and suffocation Intentional self-harm by drowning and submersion Intentional self-harm by handgun discharge Intentional self-harm by rifle, shotgun, and larger firearm discharge Intentional self-harm by other and unspecified firearm discharge Intentional self-harm by explosive material Intentional self-harm by smoke, fire, and flames Intentional self-harm by steam, hot vapors, and hot objects Intentional self-harm by sharp object Intentional self-harm by blunt object Intentional self-harm by jumping from a high place Intentional self-harm by jumping or lying before moving object Intentional self-harm by crashing of motor vehicle Intentional self-harm by other specified means Intentional self-harm by unspecified means

Nonviolent Nonviolent

groups (x^ = 99.57, p < .0001). Post hoc analyses revealed that the BED group had a significantly higher mean BMI than all of the other ED categories and the mean BMI for the ANBN group was lower than those for the BN, PD, and no ED groups. Education level differed across groups (x^ = 19.89, p < .01), with post hoc analyses revealing differences between the BN group and both the PD and no ED groups. Civil status differed across groups (x^ = 19.32, p < .04). The prevalence of being married or cohabiting with a partner was lower in the BN group than the PD and no ED groups.

Prevalence of Suicide Attempts Narrow diagnostic groups. Suicide attempts were identified in 260 ofthe 12,647 (2.06%) individuals included in the analysis applying the narrow ED diagnoses, representing 11.99% of indi-

Nonviolent Nonviolent Nonviolent Nonviolent Nonviolent Nonviolent Nonviolent Nonviolent Violent Violent Violent Violent Violent Violent Violent Violent Violent Nonviolent Violent Violent Violent Nonviolent Nonviolent

viduals with EDs and 1.74% of the referent group. Three individuals died subsequent to their participation in STAGE as a result of a suicide attempt: One had a lifetime diagnosis of narrowly defined BN and two had no lifetime ED diagnosis. Table 3 presents the lifetime prevalence of suicide attempts across the ANR, ANBP, ANBN, BN, BED, PD, and no ED groups for narrow and broad definitions of illness. The prevalence of suicide attempts was significantly different across narrow ED groups (x^ = 31.39, ;>„, < .004). Suicide attempts were significantly more common in all ED groups than in the referent group (see Table 4). There were no other significant pairwise differences across the narrow ED groups. Characteristics of the suicide attempts among those with narrow diagnostic classifications who attempted suicide are presented in Table 5. No significant differences emerged across the narrow ED

PISETSKY ET AL.

1048 Table 2

Age and Body Mass Index (BMI) at Time of Swedish Twin study of Adults: Genes and Environment Assessment and Education and Relationship Status by Eating Disorder Variable

ANR

n Mean (SD) age at assessment (years) Mean (SD) BMI at assessment Education, n (%) Some secondary or secondary graduate University graduate Other (military, vocational, or folk) Civil status, n (%) Married or cohabiting Living alone

65 32.20 (7.78) 21.37(4.05)

n Mean (SD) age at assessment (years) Mean (SD) BMI at assessment Education, n (%) Some secondary or secondary graduate University graduate Other (military, vocational, or folk) Civil status, n (%) Married or cohabiting Living alone

242 31.93(7.52) 21.28(3.82)

ANBP

ANBN

BN

Narrow eating disorder defiition 124 23 75 32.59(7.14) 30.68 (7.32) 30.09 (6.09) 21.07(2.89) 22.94 (4.99) 22.76 (3.76)

BED

PD

No ED

22 33.09 (7.32) 28.72(7.18)

83 31.78(7.36) 23.07 (3.83)

12,255 33.59 (7.65) 23.17(3.90)

26 (40.63) 30 (46.88) 8 (12.50)

26 (34.67) 38 (50.67) 11 (14.67)

7 (30.43) 12(52.17) 4(17.39)

36 (29.27) 66 (53.66) 21 (17.07)

6 (27.27) 12 (54.55) 4(18.18)

36 (43.90) 29 (35.37) 17 (20.73)

5,113(42.16) 5,603 (46.20) 1,412(11.64)

39(61.90) 24(38.10)

41 (55.41) 33 (44.59)

12(52.17) 11 (47.83)

68 (54.84) 56(45.16)

10 (45.45) 12(54.55)

54 (66.67) 27 (33.33)

8,283 (68.40) 3,826(31.60)

Broad eating disorder defiition 127 103 251 32.10(7.40) 31.77(7.19) 30.96 (7.35) 23.46 (4.62) 21.57(3.47) 21.74 (3.75)

64 30.95 (7.59) 26.20 (6.02)

89 31.92(7.42) 23.49 (3.79)

12,159 33.67 (7.65) 23.18(3.87)

88 (37.29) 123(52.12) 25 (10.59)

50 (39.37) 61 (48.03) 16(12.60)

30(29.41) 54 (52.94) 18(17.65)

81 (32.40) 137(54.80) 32(12.80)

20(31.25) 34(53.13) 10(15.63)

41 (46.59) 31 (35.23) 16(18.18)

5,087 (42.33) 5,506(45.81) 1,425(11.86)

144 (60.76) 93 (39.24)

71 (56.80) 54 (43.20)

67 (65.05) 36 (34.95)

135 (53.78) 116(46.22)

34(53.13) 30 (46.88)

59 (67.05) 29 (32.95)

8,251 (68.77) 3,747(31.23)

Note. ANR = restricting subtype anorexia nervosa; ANBP = binge-purge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; No ED = no eating disorder.

groups and the referent group in terms of the percentage of individuals who experienced violent suicide attempts (see Table 5). The age at first attempt for individuals with at least one suicide attempt ranged from 13 to 50 years and did not differ across

Table 3 Lifetime Prevalence of at Least One Suicide Attempt by Eating Disorder Group for Narrow and Broad Eating Disorder Definitions No lifetime suicide attempt

Lifetime suicide attempt %)

60(92.31) 65 (86.67) 19(82.61) 108 (87.10) 19 (86.36) 74(89.16) 12,042(98.26)

5 (7.69) 10(13.33) 4(17.39) 16(12.90) 3(13.64) 9(10.84) 213(1.74)

232 (95.87) 116(91.34) 90 (87.38) 222 (88.45) 59(92.19) 77 (86.52) 11,969(98.44)

10(4.13) 11 (8.66) 13(12.62) 29(11.55) 5(7.81) 12(13.48) 190(1.56)

Group Narrow ANR (n = 65) ANBP (n = 75) ANBN (n = 23) BN (n = 124) BED (n = 22) PD (n = 83) No ED (« = 12,255) Broad ANR (n = 242) ANBP (n = 127) ANBN (« = 103) BN (n = 251) BED (n = 64) PD (« = 89) No ED (n = 12,159)

Note. ANR = restricting subtype anorexia nervosa; ANBP = bingepurge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; No ED = no eating disorder.

narrow ED and referent groups (see Table 5). The total number of suicide attempts ranged from one to 34 (see Table 5). Although the number of suicide attempts did not differ across groups, there was a small effect observed for the ANBN group (OR = 1.92, 95% CI [0.87, 2.98]) having a higher mean number of attempts than the referent group. Broad diagnostic groups. Suicide attempts were identified in 270 of 13,035 (2.07%) individuals included in the analyses when applying broad diagnoses, representing 9.13% of individuals with EDs and 1.56% of the referent group. The prevalence of suicide attempts was also significantly different across the broad ED groups (x^ = 51.88, Pf¿^ < .004). Post hoc pairwise comparisons (see Table 4) revealed that suicide attempts were significantly more common in all broad ED groups than in the referent group. In addition, suicide attempts were significantly more prevalent in the ANBN, BN, and PD groups than in the ANR group. No significant differences emerged across the broad ED groups and the referent group in terms of the percentage of individuals who experienced violent suicide attempts (see Table 5). The age at first attempt for all individuals with at least one suicide attempt ranged from 13 to 50 years and did not differ across broad ED and referent groups (see Table 5). The total number of suicide attempts ranged from 1 to 43 and also did not differ across all groups (see Table 5).

ED Features Associated With Suicide Attempts Narrow diagnostic groups. The top panel of Table 6 presents descriptive statistics for ED features by ED diagnosis for individuals with narrow EDs with and without suicide attempts. None of the ED features was significantly associated with suicide attempts

SUICIDE ATTEMPTS IN WOMEN WITH EATING DISORDERS

1049

Table 4 Results of Post Hoc Pairwise Comparison Evaluating Differences in Suicide Prevalence Between Eating Disorder Groups for Narrow and Broad Eating Disorder Definitions Narrow

Comparison eating disorder group

Referent group

OR [95% CI]

ANR ANBP ANBN BN BED PD ANBP ANBN BN BED PD ANBN BN BED PD BN BED PD BED PD PD

No ED No ED No ED No ED No ED No ED ANR ANR ANR ANR ANR ANBP ANBP ANBP ANBP ANBN ANBN ANBN BN BN BED

4.77 [1.94, 11.72] 7.92 [3.86, 16.20] 10.74 [3.70, 31.25] 8.12 [4.50, 14.65] 7.84 [2.08, 29.59] 6.59 [3.18, 13.65] 1.66 [0.54, 5.10] 2.26 [0.57, 8.97] 1.70 [0.59,4.90] 1.65 [0.33,8.08] 1.38 [0.44,4.31] 1.36 [0.38,4.83] 1.03 [0.42, 2.53] 0.99 [0.22, 4.40] 0.83 [0.31, 2.26] 0.76 [0.23, 2.52] 0.73 [0.13,3.98] 0.61 [0.17,2.20] 0.97 [0.23,4.03] 0.81 [0.32, 2.03] 0.84 [0.21, 3.44]

Broad

x'(p)

OR [95% CI]

x'(p)

11.56 (.001) 32.07 (.001) 19.03 (.001) 48.34 (.001) 9.25 (.003) 25.72 (.001) 0.79 (.376) 1.33 (.249) 0.98 (.324) 0.38 (.542) 0.31 (.577) 0.22 (.637) 0.00 (.956) 0.00 (.991) 0.13 (.719) 0.21 (.649) 0.13 (.716) 0.57 (.453) 0.00 (.963) 0.20 (.656) 0.06 (.809)

2.70 [1.40, 5.20] 5.79 [3.04, 10.95] 8.46 [4.53, 15.81] 7.83 [5.07, 12.09] 5.09 [1.99, 13.06] 9.16 [4.81, 17.45] 2.14 [0.88, 5.19] 3.14 [1.31,7.54] 2.90 [1.37,6.17] 1.89 [0.60, 5.93] 3.40 [1.40, 8.28] 1.47 [0.62, 3.48] 1.36 [0.65, 2.85] 0.88 [0.29, 2.71] 1.59 [0.66, 3.83] 0.93 [0.45, 1.90] 0.60 [0.20, 1.84] 1.08 [0.45,2.59] 0.65 [0.24, 1.79] 1.17 [0.55,2.47] 1.80 [0.62,5.25]

8.79 (.003) 28.81 (.001) 44.80 (.001) 86.41 (.001) 11.47 (.001) 45.46 (.001) 2.84 (.093) 6.53 (.011) 7.71 (.006) 1.19 (.277) 7.25 (.008) 0.75 (.387) 0.65 (.420) 0.05 (.827) 1.06 (.304) 0.04 (.833) 0.79 (.374) 0.03 (.858) 0.69 (.406) 0.17 (.682) 1.15 (.283)

Note. ANR = restricting subtype anorexia nervosa; ANBP = binge-purge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; No ED = no eating disorder.

in any of the ED groups. Although all of the models investigating the association between ED features and suicide attempts in each of the ED groups failed to reach statistical significance, several of the models produced medium and large effect sizes. The Cohen's d for BMI difference was 0.52 and for age of ED onset was 1.24 in the ANR group, with women with suicide attempts having a greater BMI difference and an older age of onset. For the ANBN group, women with suicide attempts had lower lowest BMI values (Cohen's d = 0.60), higher highest BMI values (Cohen's d 0.63), greater BMI differences (Cohen's d = 0.63), and an older age of ED onset (Cohen's d = 0.87). A greater BMI difference was also observed for women with suicide attempts in the BN group (Cohen's d = 0.57). In the BED group, women with suicide

attempts had higher lowest BMI values (Cohen's d = 1.04) and higher highest BMI values (Cohen's d - 0.75) than women who had no suicide attempts. In the PD group, those with suicide attempts had higher highest BMI values (Cohen's d = 0.74) and a greater BMI difference (Cohen's d = 0.84). The remaining models did not produce a remarkable effect size or did not converge. Models that did not converge are indicated in Table 6. Broad diagnostic groups. The bottom panel of Table 6 presents descriptive statistics for ED features by group for individuals with broad EDs with and without suicide attempts. None of the ED features was significantly associated with suicide attempts in any of the ED groups. Regarding effect sizes, results were similar to those for the narrow ED definitions: Cohen's d = 0.80 for age of

Table 5 Suicide Characteristics in Women Who Attempted Suicide by Eating Disorder and Results for Models Assessing Differences in These Features Across Eating Disorder for Both Narrow and Broad Eating Disorder Definitions Variable n Violent attempt, n {%) Mean (SD) age at first attempt (years) Mean {SD) total number of attempts

Definition Narrow Broad Narrow Broad Narrow Broad Narrow Broad

ANR

ANBP

ANBN

BN

BED

Results PD

No ED

X^ (Pfdr)

5 10 4 16 3 9 213 10 11 13 29 5 12 190 2 (40.00) 3 (30.00) 3(75.00) 3 (18.75) 0 (0.00) 1(11.11) 30(14.08) 12.33 (.147)' 3 (30.00) 2(18.18) 4 (30.77) 4(13.79) 1 (20.00) 3 (25.00) 27(14.21) 3.34 (.766) 30.40 (4.93) 22.90 (6.26) 25.25 (9.63) 24.20 (6.39) 28.00(10.82) 31.11 (10.41) 25.73 (8.48) 6.56 (.492) 28.90 (4.48) 20.55 (5.82) 25.77 (8.27) 24.11(6.75) 23.80 (9.73) 29.08 (9.89) 26.07 (8.64) 5.95 (.492) 2.60 (3.05) 5.80 (6.64) 15.50(18.95) 4.56 (5.50) 1.00(0.00) 2.33(1.41) 2.25 (3.78) 8.85 (.366) 2.20 (2.20) 4.00 (6.20) 6.85(11.63) 3.34 (4.53) 1.60(0.89) 2.50(1.93) 2.31(3.95) 6.33 (.492)

Note. ANR = restricting subtype anorexia nervosa; ANBP = binge-purge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; No ED = no eating disorder; Pf^, = p-value after correcting for multiple comparisons using the method of false discovery. " Model applied without correcting for nonindependence of the sample.

PISETSKY ET AL.

1050 Table 6

Lifetime Prevalence of Eating Disorder Features and Characteristics of Women With a Lifetime History of a Suicide Attempt by Eating Disorder Variable n Suicide attempt, n (%) Eating disorder features, n (%) Vomiting Laxative use Diuretic use Diet pill use Fasting Excessive exercise Amenorrhea Mean (SD) lowest BMI Mean (SD) highest BMI Mean (SD) BMI difference (highest -- lowest) Mean (SD) age of eating disorder onset (years)

ANBP

ANR

ANBN

Narrow •eating disorder definition 75 65 No: 60 (92.31) Yes: 5 (7.69) No: 65 (86.67) Yes: 10(13.33)

No: 19 (82.61)

Yes: 4 (17.39)

9 (90.00) 3 (30.00) 2 (20.00) 4 (40.00) 6 (66.67) 4 (40.00) 5 (55.56) 14.90(1.45) 24.88 (6.34) 9.86 (6.75) 19.30 (2.98)

17(89.47)» 6(31.58) 7 (36.84) 5 (26.32) 10(52.63)'' 13(68.42)" 15 (83.33) 15.69(1.26) 26.32 (6.95) 10.48(6.96) 17.26(3.23)

4(100.00)" 3 (75.00) 1 (25.00) 1 (25.00) 4(100.00)° 4(100.00)" 2 (66.67) 14.36(2.86) 31.44(9.20) 16.50(11.54) 20.75 (4.65)

127 No: 116(91.34) Yes: 11 (8.66)

No: 90 (87.38)

103 Yes: 13 (12.62)

68 (75.56) 24 (26.67) 15(16.67) 10(11.11) 48 (53.33) 56 (62.22) 53 (60.92) 16.36(1.82) 24.23(4.14) 7.84 (4.55) 17.48 (3.44)

12(92.31) 7 (53.85) 3 (23.08) 4 (30.77) 6 (50.00) 8(61.54) 5 (45.45) 15.01 (2.16) 26.84 (7.50) 11.90(7.79) 18.69(5.36)

NA NA NA 2 (3.33)" 20 (33.33) 17 (28.33) 31 (65.96) 15.09(1.91) 22.93 (3.58) 7.80 (3.98) 17.63 (4.06)

NA NA NA 0 (0.00)» 3 (60.00) 4 (80.00) 4 (80.00) 14.50 (2.42) 26.16(10.98) 11.66(9.60) 25.80 (8.35)

50 (76.92) 15 (23.08) 5 (7.69) 6 (9.23) 40(61.54) 46 (70.77) 37 (67.27) 15.20(1.74) 23.69 (3.64) 8.49(4.11) 17.71 (4.23)

23

Broad eating disorder definition n Suicide attempt, n (%) Eating disorder features, n (%) Vomiting Laxative use Diuretic use Diet pill use Fasting Excessive exercise Amenorrhea Mean (SD) lowest BMI Mean (SD) highest BMI Mean (SD) BMI difference (highest -- lowest) Mean (SD) age of eating disorder onset (years)

24; No: 232 (95.87) Yes: 10(4.13) NA NA NA 8 (3.45)" 44(18.97) 42(18.10) 88 (46.32) 16.45(1.89) 23.12(3.93) 6.64(4.12) 18.94(5.25)

NA NA NA 0 (0.00)° 4 (40.00) 5 (50.00) 5 (55.56) 15.55(2.37) 24.35(8.11) 8.56 (7.75) 24.10(7.43)

84 (72.41) 20 (17.24) 11 (9.48) 11 (9.48) 59 (50.86) 62 (53.45) 46 (52.27) 16.36(1.53) 24.39 (4.36) 8.05 (4.44) 18.69(4.16)

10(90.91) 3(27.27) 2(18.18) 4 (36.36) 8 (72.73) 3(27.27) 4 (40.00) 16.01(1.73) 25.43 (5.97) 9.20 (6.69) 20.18(4.75)

Note. ANR = restricting subtype anorexia nervosa; ANBP = binge-purge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; BMI = body mass index. " The model evaluating the association with the variable and suicide attempt for the specific group did not converge.

ED onset for the ANR group; Cohen's d = 0.68 for lowest BMI and Cohen's d = 0.64 for BMI difference for the ANBN group; Cohen's d = 0.52 for BMI difference for the BN group; Cohen's d = 0.71 for lowest BMI and Cohen's d = 0.68 for highest BMI for the BED group; and, for the PD group, Cohen's d = 0.62 for lowest BMI (those with suicide attempts had lower lowest BMI values), Cohen's d = 0.58 for highest BMI, and Cohen's d = 0.78 for BMI difference. The remaining models produced effect sizes less than 0.50 or did not converge. Models that did not converge are indicated in Table 6.

Psychiatric Comorbidity and Personality Features Associated With Suicide Attempts Narrow diagnostic groups. The top panel of Table 7 presents comorbid psychiatric disorders and personality variables across narrow ED groups by the presence or absence of suicide attempts. None of the comorbid psychiatric disorders was significantly associated with suicide attempts. None of the models yielded medium or large effect sizes. Models that did not converge are indicated in Table 7. Although there were no significant differences in the individual comorbid conditions, the sign test indicated that, in the ANBP and

ANBN groups, the prevalence of all seven conditions was significantly higher in the group with suicide attempts compared with the group without suicide attempts (ps < .008). None of the personality measures was significantly associated with suicide attempts in any ofthe ED groups. However, several of these measures had medium or large effect sizes. Specifically, concem over mistakes was greater in those with suicide attempts than those without attempts in the ANBP (Cohen's d = 0.73) and BN (Cohen's d = 0.85) groups, as were doubts about actions in the ANBP group (Cohen's d = 0.61) and neuroticism in the BED group (Cohen's d = 0.69). Personal standards was lower in those with suicide attempts than in those without attempts in the ANBN (Cohen's d = 0.66) and PD (Cohen's d = 0.70) groups. Extraversion was also lower in those with suicide attempts in the ANBP (Cohen's d = 0.58), ANBN (Cohen's d = 0.93), and BED (Cohen's d = 1.25) groups. Those with suicide attempts in the ANR, BED, and PD groups also had lower self-directedness (Cohen's d = 0.88, 1.26, and 0.56, respectively). Broad diagnostic groups. The bottom panel of Table 7 presents comorbid psychiatric disorders and personality variables across broad ED groups by the presence or absence of suicide attempts. None of the comorbid psychiatric disorders was signif-

SUICIDE ATTEMPTS IN WOMEN WITH EATING DISORDERS

1051

BN

BED

124

No: 74 (89.16)

Yes: 9 (10.84)

65 (87.84) 13 (17.57) 9(12.16)» 13(17.57) 19 (25.68) 23(31.08) 12(31.58) 19.10(2.26) 25.80 (5.04) 6.55 (4.71) NA

7 (77.78) 2 (22.22) 0 (0.00)» 5 (55.56) 3 (33.33) 1(11.11) 2 (66.67) 17.70 (4.30) 31.55(9.79) 13.84(11.39) NA

PD

No: 108(87.10)

Yes: 16(12.90)

Narrow eating; disorder definition 22 No: 19 (86.36) Yes: 3 (13.64)

93(86.11)' 22 (20.37) 8 (7.41) 18 (16.67) 47 (43.52) 46 (42.59) 30(46.15) 19.07 (2.69) 25.62 (4.03) 6.49 (3.59) 18.92(4.53)

16 (100.00)° 4 (25.00) 6 (37.50) 3(18.75) 10(62.50) 5(31.25) 4 (36.36) 19.06 (3.73) 27.66 (6.08) 8.60 (3.87) 20.94 (7.03)

NA NA NA 2(10.53)" 1 (5.26)» 0 (0.00)" 2 (33.33)» 21.97(3.13) 31.86(9.19) 8.33 (4.97) 19.78 (5.56)

Yes: 29 (11.55)

Broad eating disorder definition 64 No: 59 (92.19) Yes: 5 (7.81)

No: 77 (86.52)

Yes: 12 (13.48)

26 (89.66) 6 (20.69) 6 (20.69) 4(13.79) 16(55.17) 13 (44.83) 6 (33.33) 18.99(3.13) 27.81 (7.93) 8.83 (6.89) 20.14(6.64)

NA NA NA 3 (5.08)» 1 (1.69)» 0 (0.00)» 4(21.05)» 21.20(2.75) 28.61 (7.11) 6.88 (4.39) 19.98(5.16)

64(83.12) 11 (14.29) 11 (14.29)» 10(12.99) 17(22.08) 20 (25.97) 11(33.33) 19.68 (2.28) 25.90 (5.09) 6.15(4.63) NA

10 (83.33) 3 (25.00) 0 (0.00)» 5(41.67) 6 (50.00) 2 (16.67) 3 (75.00) 17.78 (3.65) 30.04 (8.62) 12.25 (9.97) NA

251 No: 222 (88.45) 170 (76.58) 32(14.41) 14(6.31) 31 (13.96) 81 (36.49) 80 (36.04) 39 (42.86) 20.04 (2.97) 26.06 (4.97) 5.94 (3.90) 18.72(4.35)

icantly associated with suicide attempts, and no medium or large effect sizes were observed. Models that did not converge are indicated in Table 7. The sign test indicated that, in the ANR, ANBP, and ANBN groups, the prevalence of all seven conditions was significantly higher in those with suicide attempts compared with those without suicide attempts (ps < .008). None of the personality measures was significantly associated with suicide attempts in any of the ED groups. Medium or large effect sizes were observed for each measure in at least one broadly defined ED group. Concem over mistakes was greater in those with suicide attempts than those without attempts in the ANR (Cohen's d = 0.55) and ANBP (Cohen's d = 0.76) groups, as was doubts about actions in the BED group (Cohen's d - 0.54) and neuroticism in the ANBP group (Cohen's d = 0.66). Similar to the narrowly defined ED groups, personal standards was lower in those with suicide attempts than in those without attempts in the PD group (Cohen's d = 0.88) and extraversion was lower in those with suicide attempts in the ANBN (Cohen's d = 0.75) and BED (Cohen's d = 1.25) groups. Those with suicide attempts in the ANR, ANBP, BED, and PD groups also had lower selfdirectedness (Cohen's d = 0.59, 0.59, 0.70, and 0.70, respectively).

NA NA NA 0 (0.00)» 0 (0.00)» 1 (33.33)» 0 (0.00)» 28.47 (8.25) 38.28(7.91) 9.81 (6.50) 20.00 (9.90)

NA NA NA 0 (0.00)» 0 (0.00)» 1 (20.00)» 0 (0.00)» 25.17(7.45) 33.96 (8.56) 8.79 (5.07) 20.75(6.13)

83

89

Discussion We shed further light on the risk for suicide in individuals with EDs by engaging the rich national registers in Sweden. Consistent with previous clinical reports, our results revealed significantly elevated prevalence of suicide attempts in individuals with all forms of eating disorders—ANR, ANBP, ANBN, BN, BED, and PD—with the highest odds relative to the referent being for individuals with narrow ANBN (OR = 10.74) and broad PD (OR = 9.16). In general, the prevalence estimates in this study are somewhat lower than published estimates from clinic-based investigations (Bulik et al, 1999; Coreos et al., 2002; Favaro & Santonastaso, 1997). This is as expected given that (a) ours represents a population-based sample of EDs, and (b) our definition of suicide attempts was rigorous insofar as an attempt had to be sufficiently severe as to be captured by the health care system and entered into the national registers. Chnic-based studies of EDs typically focus on a more severe subset of the ED population. Likewise, studies that estimate the prevalence of suicide attempts based on selfreport may also include attempts that do not come to the attention of the health care system. This supposition is supported by data from a non-treatment-seeking sample of individuals with AN, in which only approximately 50% of those who reported a suicide

PISETSKY ET AL.

1052

Table 7 Lifetime Prevalence of Comorbid Psychiatric Disorders and Temperament Characteristics by Eating Disorder and by Lifetime Suicide Attempt/Completion Status Variable n Suicide attempt/completion, n {%) Psychiatric comorbidity, n (%) Major depression Generalized anxiety disorder Specific phobia Obsessive-compulsive disorder Panic disorder Any anxiety disorder Alcohol abuse/dependence Substance use Mean (SD) personality features Concern over mistakes (MPS) Doubts about actions (MPS) Personal standards (MPS) Extraversion (EPI) Neuroticism (EPI) Self-directedness (TCI)

ANBN

ANBP

äiNR

Narrow eating disorder definition 75 65 No: 65 (86.67) Yes: 10(13.33) No: 60(92.31) Yes: 5 (7.69) 27 (50.94) 2(5.41) 5 (12.82) 7(13.46)" 18 (34.62)» 21 (56.76)° 7(11.67) 6(10.00) 12.05 (4.02) 8.77(3.15) 14.38 (2.90) 5.43(2.10) 6.92 (4.23) 19.25(2.88)

3 (60.00) 1 (50.00) 1 (50.00) 0 (0.00)' 0 (0.00)° 2(100.00)" 2 (40.00) 2 (40.00) 11.50(2.89) 10.00(1.82) 14.25 (3.50) 5.50(1.73) 7.25 (5.50) 16.00 (4.36)

39 (63.93)° 10 (25.00) 8(18.18) 12 (23.08) 17 (32.69) 29 (70.73)° 10(15.38) 4(6.15) 11.51 (4.47) 9.34 (3.76) 13.57(3.24) 5.07(2.19) 8.88(5.15) 17.65 (3.28)

10(100.00)° 3 (42.86) 3 (60.00) 2 (25.00) 7 (77.78) 7(100.00)° 4 (40.00) 6 (60.00) 14.67(4.18) 11.78(4.24) 13.78(2.68) 3.88(1.89) 10.57 (5.88) 16.00(4.15)

No: 19(82.61) 12(70.59)° 4 (33.33) 3(23.08) 3 (20.00) 6 (40.00) 10 (76.92) 5 (27.78) 3 (15.79) 15.20(2.86) 12.60(4.14) 17.40(1.72) 5.29(1.90) 10.62(4.96) 15.40(2.75)

23 Yes: 4 (17.39) 4(100.00)» 2 (66.67) 2 (66.67) 1 (33.33) 2 (66.67) 3 (75.00) 2 (50.00) 2 (50.00) 15.33(1.15) 11.33(2.08) 15.75(3.10) 3.00 (2.94) 12.00(6.08) 15.75(3.10)

Broad eating disorder definition n Suicide attempt/completion, n (%) Psychiatric comorbidity, n (%) Major depression Generalized anxiety disorder Specific phobia Obsessive-compulsive disorder Panic disorder Any anxiety disorder Alcohol abuse/dependence Substance use Mean (SD) personality features Concern over mistakes (MPS) Doubts about actions (MPS) Personal standards (MPS) Extraversion (EPI) Neuroticism (EPI) Self-directedness (TCI)

242 No: 232 (95.87) Yes: 10(4.13) 94 (44.98) 24(14.63) 21 (12.73) 19(9.18) 57 (27.67) 83 (53.55)" 24(10.53) 21 (9.05) 11.42(3.98) 8.95 (3.66) 13.46(3.59) 5.07 (2.28) 7.60 (4.53) 18.48(3.14)

7 (70.00) 3 (60.00) 1 (20.00) 1 (14.29) 4(57.14) 6(100.00)= 2 (20.00) 2 (20.00) 13.50(3.51) 10.38 (2.72) 13.86 (3.24) 5.29(1.60) 9.71 (5.82) 16.67(3.01)

127 No: 116(91.34) Yes: 11 (8.66) 59(55.14)° 14(18.92) 18(21.95) 17(17.89) 28 (29.79) 47 (62.67)° 13(11.40) 9 (7.76) 11.14(4.28) 8.99 (3.59) 13.39 (3.41) 4.92 (2.29) 8.30 (4.72) 17.92(3.28)

11 (100.00)° 4 (50.00) 1 (25.00) 2 (22.22) 8 (88.89) 8 (100.00)» 4 (36.36) 6 (54.55) 14.14(3.63) 10.29(3.59) 13.00(1.73) 4.29 (2.56) 11.43(4.76) 15.57(4.54)

103 No: 90 (87.38) Yes: 13(12.62) 43 (53.75) 13 (22.41) 13 (20.97) 13(17.81) 30 (40.54) 40 (64.52) 18(20.22) 8 (8.89) 12.96(4.26) 10.66(4.11) 14.36(3.21) 5.01 (2.26) 9.28 (5.06) 16.49 (3.02)

12(92.31) 5 (55.56) 4(57.14) 3 (30.00) 7(63.64) 9 (90.00) 6(46.15) 7 (53.85) 13.18(4.38) 12.09(3.33) 13.83(3.38) 3.45 (1.86) 10.22(6.12) 15.25 (2.83)

Note. ANR = restricting subtype anorexia nervosa; ANBP = binge-purge subtype anorexia nervosa; ANBN = lifetime diagnosis of both anorexia nervosa and bulimia nervosa; BN = bulimia nervosa; BED = binge eating disorder; PD = purging disorder; MPS = Frost Multidimensional Perfectionism Scale; EPI = Eysenck Personality Inventory; TCI = Temperament and Character Inventory. ° The model evaluating the association with the variable and suicide attempt/completion for the specific group did not converge. attempt had ever sought medical treatment for the attempt (Bulik et al., 2008). However, the percentage of individuals seeking treatment for a suicide attempt was only slightly higher in a treatment-seeking sample of individuals with EDs (60%; Coreos et al., 2002). Our results underscore the value of the recommendation of Franko and Keel (2006), who emphasized the importance of subtyping AN into ANR and ANBP when assessing the prevalence of suicide attempts. Risk is elevated in both AN subtypes, narrowly and broadly defined, compared with the no ED group. Although there was no significant difference in prevalence of suicide attempts between the ANR and ANBP groups, either narrowly or broadly defined, the broad ANR group had a significantly lower prevalence of suicide attempts than the broad ANBN, BN, and PD groups. It has long been known that diagnostic crossover is a common occurrence in individuals with AN, with around 50% of those with

initial ANR migrating to a bulimic presentation at some point during the course of their illness (Bulik, Sullivan, Fear, & Pickering, 1997; Eddy et al., 2008; Eichter & Quadfiieg, 2007; Tozzi et al., 2005). Suicide risk may fluctuate as the clinical presentation migrates between restricting and binge-purge forms. It is noteworthy that the highest prevalence of suicide attempts (17.39%) and the highest mean number of lifetime suicide attempts (15.50) in the present sample were in the narrow ANBN group, indicating that individuals who experience diagnostic crossover may be at particularly elevated risk. More granular investigations of longitudinal risk are required to confirm whether suicide risk fluctuates with symptom evolution or is more strongly related to trait factors. We further extend our understanding of suicide and EDs by demonstrating significantly elevated risk for suicide in individuals with BED. Although the number of cases of BED was smaller than would have been expected on the basis of U.S. population data

SUICIDE ATTEMPTS IN WOMEN WITH EATING DISORDERS

BN

BED

124 No: 108(87.10)

Yes: 16(12.90)

66 (65.35) 19 (29.69) 14 (22.58)" 21 (25.30) 40 (47.62)° 55 (78.57)° 29 (27.88) 12(11.11)

14 (93.33) 8 (66.67) 0 (0.00)° 4 (36.36) 11 (100.00)" 15 (100.00)° 5(31.25) 8 (50.00)

12.39 (4.39) 10.76(4.14) 13.19(3.24) 4.53 (2.20) 10.61 (4.70) 16.31 (2.83)

15.54 (2.84) 12.67(4.96) 14.17(3.97) 4.09 (2.26) 12.83 (4.22) 14.92 (3.20) 251

No: 222 (88.45) 117(57.92) 29(20.71) 27(19.71) 27(15.17) 60 (33.52) 91 (65.00) 48 (22.43) 16(7.21) 11.41(4.16) 9.39(4.21) 12.52(3.40) 4.83 (2.26) 9.48 (4.85) 16.83(3.30)

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Yes: 29 (11.55) 23(85.19) 8(47.06) 2(15.38) 4 (19.05) 14 (66.67) 19 (95.00) 5 (17.24) 9(31.03) 13.14(4.05) 10.65 (4.62) 13.22(3.70) 3.90 (2.43) 10.61 (4.15) 16.17(2.71)

PD

Narrow eating disorder definition 22 No: 19 (86.36) Yes: 3 (13.64) 12 (66.67)° 4 (33.33)° 2(18.18)° 1 (6.67)° 6 (40.00)° 8(57.14)° 5 (26.32)° 3(15.79) 12.44 (5.20) 9.25 (3.64) 12.25 (4.60) 4.75 (2.77) 9.00 (4.43) 16.56 (4.03)

3 (100.00)° 2 (100.00)° 0 (0.00)° 0 (0.00)° 2 (100.00)° 2(100.00)° 0 (0.00)° 2 (66.67) 12.50(0.71) 10.00 (2.83) 10.50 (3.54) 2.00(1.41) 12.00(4.24) 12.50(2.12)

Broad eating disorder definition 64 No: 59 (92.19) Yes: 5 (7.81) 30 (53.57)° 8 (18.60)° 5 (12.82) 6(12.24)° 15 (30.61)° 22 (53.66)° 9(15.52) 4 (6.78) 11.90(4.42) 9.29 (3.83) 12.26 (3.62) 4.70 (2.55) 9.07 (4.59) 16.27 (3.34)

(Hudson et al., 2007), suicide risk was significantly elevated in individuals with both narrow and broad BED diagnoses. As adjustments are made worldwide secondary to BED being a bona fide diagnostic category in DSM-5, clinicians should remain vigilant for suicide risk in individuals with this disorder. An additional extension of the knowledge base is the observation that individuals with broadly defined PD had elevated risk for suicide attempts relative to individuals with no ED (OR = 9.16) and ANR (OR = 3.40). These initial results are consistent with observations that, within those with AN and those with BN, individuals who purge are at greater risk for suicide attempts than those who do not purge (Favaro & Santonastaso, 1997) and highlight the need for additional research to better understand this high-risk yet understudied population. Unlike previous investigations, we did not identify specific features of EDs that were associated with suicide attempts. The

5(100.00)° 2(100.00)» 1 (50.00) 0 (0.00)° 3(100.00)° 3(100.00)° 1 (25.00) 3 (60.00) 11.50(5.45) 11.75(5.19) 11.50(4.36) 3.75 (2.22) 10.00 (5.29) 14.25 (2.36)

83 No: 74 (89.16)

Yes: 9 (10.84)

37 (56.06)° 15 (28.30) 10(20.41)° 4 (6.56)» 16 (26.67) 29 (64.44) 10(13.70) 11(14.86)

9(100.00)° 1 (20.00) 0 (0.00)° 0 (0.00)° 5 (62.50) 5(71.43) 2 (25.00) 4 (44.44)

11.15(4.16) 8.12(3.75) 12.96 (3.24) 5.25(1.99) 7.76 (4.05) 17.63 (3.65)

9.50 (4.28) 9.17(4.49) 10.00(5.06) 5.80(1.30) 9.57(3.31) 15.33 (4.46) 89

No: 77 (86.52) 40 (57.97) 13 (24.07) 10(18.87)° 3 (4.48)° 20 (29.85) 30 (60.00) 12(15.79) 9(11.69) 10.75 (4.48) 8.23 (3.78) 12.95(3.08) 5.26 (2.09) 7.65 (4.34) 17.85(3.67)

Yes: 12(13.48) 9(81.82) 1 (20.00) 0 (0.00)° 0 (0.00)° 6 (60.00) 6 (75.00) 2(18.18) 5(41.67) 9.62 (3.26) 8.25(4.17) 9.62 (4.34) 5.43(1.51) 9.25 (3.20) 15.25(3.81)

small cell sizes for some of the suicide groups most likely precluded the detection of significant effects. However, the overall pattern of results indicates that the highest odds ratios for suicide were observed in presentations that included purging (ANBP, ANBN, ANBP, and PD). This observation is consistent with findings that individuals who engage in purging behavior are at particularly elevated risk for suicide attempts. Also consistent with previous reports, our results confirm that greater comorbid psychiatric burden (i.e., increased prevalence across seven comorbid conditions) is associated with elevated risk for suicide in individuals with ANBP and ANBN (Franko & Keel, 2006). By nature of having an ED presentation with both AN and BN features, these individuals already experience elevated comorbidity burden. Individuals who present with a clinical picture of both low weight plus binge eating and/or purging are at increased risk for adverse medical out-

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PISETSKY ET AL.

comes (Takakura et al., 2006) and psychiatrie comorbidity (Peat, Mitchell, Hoek, & Wonderlich, 2009). Our results reveal that this pattern holds in population-based samples as well clinical samples. In aggregate, these results underscore the critical importance of flagging these individuals in the clinical setting as high risk for an array of adverse outcomes, including suicide attempts. Unlike previous studies of women who sought treatment for EDs, we did not find clear differences in personality measures between those who did and did not attempt suicide. This may be an artifact of the fact that the personality measures in STAGE were not necessarily completed contemporaneously with the suicide attempts, whereas measurements in treatment-seeking samples capture extremes of personality evident during the acute phase of illness (Perkins et al., 2005). Moreover, some of the personality measures assessed in the STAGE cohort are not ones commonly associated with suicide risk (e.g., perfectionism). Our sample is uniquely informative by referencing a population-based register to identify ED cases. This approach eliminates the biases inherent in relying on samples of individuals seeking treatment for an ED, which skews observations toward the extreme. By coupling this population-based sample with hospital and cause of death registers, we were able to capture those suicide attempts that were sufficiently severe to warrant medical attention. This methodology yields a clear picture of risk of suicide attempts individuals with EDs in the general population. As there is no evidence of elevated risk of suicide in twins (Statham et al., 1998), our results from the STAGE sample are likely to generalize to the nontwin population.

Swedish twins. Although twin registers are often used to conduct research about the general population, twins may differ from the general population in significant ways. The population of Sweden is also fairly homogeneous in terms of racial and ethnic demographics. Therefore, results must be interpreted within the context of limited generalizability. By estimating the prevalence of suicide attempts via the hospital register, we were unable to identify those suicide attempts that did not warrant medical attention. This yields a conservative estimate; thus, the findings of this study may apply primarily to individuals with more severe suicide attempts. STAGE was chosen for this study because of the large sample size and detailed information about ED behaviors. However, we were nonetheless faced with fairly small cell sizes—especially in ANR and BED—which left us underpowered for some comparisons. In addition, as only the lifetime presence of ED behaviors and diagnoses were assessed, we did not have information on ilhiess duration or status of illness (currently ül or recovered) at the time of assessment. The STAGE assessment covers a wide range of physical and psychological variables. Unfortunately, given the large number of variables being assessed, not all of the constructs were assessed in depth. For example. Criterion B of GAD, difficulty controlling worry, was not assessed and therefore not required for participants to receive a diagnosis of GAD. Specific phobia, OCD, and panic disorder were assessed with a single yes-no self-report item, limiting the validity of these diagnoses. Age of onset and status of illness (currently ill or recovered) at the time of assessment were not assessed for any of the comorbid diagnoses, which precluded the investigation of temporal precedence of eating disorders, comorbid disorders, and suicide attempts. Furthermore, personality disorders were not assessed.

Strengths One strength of this study is the sample, which was large and population-based. Such a sample decreases the biases inherent in using treatment-seeking populations that are likely to have a more severe ED and be more psychologically distressed. EDs, particularly BN, often go undetected in the community (Hoek, 1991; Hudson et al., 2007). Therefore, a woman is likely to seek treatment if (a) her disorder is sufficiently severe to be noticed by others who encourage treatment, (b) she is highly distressed by her disorder, (c) she has a comorbid disorder for which she is seeking treatment, or (d) she is hospitalized for a suicide attempt and then referred for treatment of her ED. Therefore, the previous reliance on samples of individuals seeking treatment for an ED may have Inflated the estimates of the prevalence of suicide attempts. By estimating the prevalence of suicide attempts from hospital discharge registers and cause of death registers, we opted for a conservative estimate not subject to self-report bias. Furthermore, the use of the cause of death register, albeit for a restricted interval, allowed for the identification of completed suicides. A longer observation period would allow for direct comparisons of those individuals who completed assessments at a point in time after a suicide attempt with individuals who attempted suicide after completing assessments.

Limitations Although this study makes a significant contribution to the literature, several limitations should be noted. First, the study is of

Conclusion Suicide attempts in women with EDs in the general population are concemingly common. Suicide risk is elevated in all EDs studied here—ANR, ANBP, ANBN, BN, PD, and BED. To improve outcomes and decrease mortality, it is critical to identify individuals who, within this patient population, experience psychological suffering so intense that they feel compelled to take their own lives.

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New Editors Appointed, 2015-2020 The Publications and Communications Board of the American Psychological Association announces the appointment of 6 new editors for 6-year terms beginning in 2015. As of January 1, 2014, manuscripts should be directed as follows: • Behavioral Neuroscience (http://www.apa.org/pubs/joumals/bne/), Rebecca Burwell, PhD, Brown University • Joumal of Applied Psychology (http://www.apa.org/pubs/joumals/apl/), Gilad Chen, PhD, University of Maryland • Joumal of Educational Psychology (http://www.apa.org/pubs/joumals/edu/), Steve Graham, EdD, Arizona State University • JPSP: Interpersonal Relations and Group Processes (http://www.apa.org/pubs/joumals/psp/), Kerry Kawakami, PhD, York University, Toronto, Ontario, Canada • Psychological Bulletin (http://www.apa.org/pubs/joumals/bul/), Dolores Albarracin, PhD, University of Pennsylvania • Psychology of Addictive Behaviors (http://www.apa.org/pubs/joumals/adb/), Nancy M. Petry, PhD, University of Connecticut School of Medicine Electronic manuscript submission: As of January 1, 2014, manuscripts should be submitted electronically to the new editors via the joumal's Manuscript Submission Portal (see the website listed above with each joumal title). Current editors Mark Blumberg, PhD, Steve Kozlowski, PhD, Arthur Graesser, PhD, Jeffry Simpson, PhD, Stephen Hinshaw, PhD, and Stephen Maisto, PhD, wiU receive and consider new manuscripts through December 31, 2013.

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