Suicidality and Eating Disorders:

Suicidality and Eating Suicidality and Eating Disorders:Disorders:

What you don’t want to know, What you don’t want to know, but need to ask….but need to ask….

Melissa Freizinger, Ph.D.Melissa Freizinger, Ph.D.

Caroline Balz, MA, LMHCCaroline Balz, MA, LMHC

Who we are…Who we are…

Melissa Freizinger, Ph.D. Melissa Freizinger, Ph.D. Caroline Balz, LMHCCaroline Balz, LMHC

French philosopher Albert Camus (1913-1960) perhaps best French philosopher Albert Camus (1913-1960) perhaps best explains the divergent views philosophers and theologians hold explains the divergent views philosophers and theologians hold concerning suicide when he said, concerning suicide when he said,

““What is called a reason for living is also an excellent reason for What is called a reason for living is also an excellent reason for dying.”dying.”

Objectives for TodayObjectives for TodayExplore the factsExplore the facts

Experiential exercise: Experiential exercise: What is your inner dialogueWhat is your inner dialogue??

Review risk factors and protective factorsReview risk factors and protective factors

Case studies: Tanya and KellyCase studies: Tanya and Kelly– Group DiscussionGroup Discussion

Theory to practiceTheory to practice– Commonly used interventionsCommonly used interventions– Tools for Practice:Tools for Practice:

Assessing safetyAssessing safetyEmergency plans for your practiceEmergency plans for your practiceRisk management for TherapistsRisk management for TherapistsSelf care for TherapistsSelf care for Therapists

Q&AQ&A

Exploring the facts:Exploring the facts:

In 2007 there were 34,598 suicides in the U.S.

900,875 annual attempts in U.S. in 2009

Every day, approximately 99 Americans take their own life

Suicide ranks 10th as a cause of death; Homicide ranks 15th

Rates of SI have increased 60% in the last Rates of SI have increased 60% in the last 50 years50 years

Exploring the Facts Exploring the Facts Suicide is the most frequent mental health Suicide is the most frequent mental health emergencyemergency

Four out of five people who commit suicide Four out of five people who commit suicide have attempted to kill themselves at least have attempted to kill themselves at least once previouslyonce previously

1 out of 5 psychologists will lose a patient 1 out of 5 psychologists will lose a patient to suicideto suicide

Suicide is a frequent cause of malpractice Suicide is a frequent cause of malpractice suitssuits

Exploring the Facts Exploring the Facts

Clinicians are Clinicians are not not expected to expected to predict or prevent suicidepredict or prevent suicide

Clinicians Clinicians areare expected to expected to identify elevated suicide risks identify elevated suicide risks and take protective steps where and take protective steps where possiblepossible

Exploring the facts: Exploring the facts: Patients Patients w/EDw/ED

Suicide mortality rates among pts. with Suicide mortality rates among pts. with AN/BN are 23 times higher than that of the AN/BN are 23 times higher than that of the general populationgeneral population

Suicide is the dominant cause of death in ED Suicide is the dominant cause of death in ED patients who die from non-natural causespatients who die from non-natural causes

– Is more likely than medical complicationsIs more likely than medical complications

AN has the highest mortality rate of all AN has the highest mortality rate of all psychiatric disorderspsychiatric disorders

Exploring the facts:Exploring the facts:

Rate of suicide in pt. with ED’s are Rate of suicide in pt. with ED’s are 5757 times times the expected rate of a healthy woman the expected rate of a healthy woman (Herzog & Luczaj)(Herzog & Luczaj)Women suffering from anorexia are 12 Women suffering from anorexia are 12 times more likely to die from suicide than times more likely to die from suicide than any other cause of death. any other cause of death. AN patients use extremely lethal means: AN patients use extremely lethal means: burning, hanging, jumping in front of trains.burning, hanging, jumping in front of trains.Suicide occurs not only more often in the Suicide occurs not only more often in the late stages of the disease, but also during late stages of the disease, but also during periods of symptom remission.periods of symptom remission.

Exploring the FactsExploring the Facts

Lifetime Prevalence RatesLifetime Prevalence Rates::

– 3-20% AN3-20% AN– 25-35% BN25-35% BN– 13.5% General population13.5% General population

In a recent study of 342 AN patients, 38% had suicidal In a recent study of 342 AN patients, 38% had suicidal ideation, & 10% had hx of suicide attempt by the age ideation, & 10% had hx of suicide attempt by the age of 23. The majority (62%) of patients reporting prior of 23. The majority (62%) of patients reporting prior attempts report making more than one (Vervaet et al., attempts report making more than one (Vervaet et al., 2008). 2008). 6 to 10% of those who attempt suicide will 6 to 10% of those who attempt suicide will succeedsucceed

Naming our Resistance and Naming our Resistance and DenialDenial

50% of clinicians do not ask their 50% of clinicians do not ask their clients about suicide and do not clients about suicide and do not effectively assess suicidal ideationeffectively assess suicidal ideation

We all have some stress around We all have some stress around suicidalitysuicidality

Some denial may be functionalSome denial may be functional

Experiential Exercise:Experiential Exercise:What is your inner dialogue?What is your inner dialogue?

Take a moment to write down responses to Take a moment to write down responses to the following questions:the following questions:– Are you asking clients questions about Are you asking clients questions about

their thoughts/intentions about suicide?their thoughts/intentions about suicide?– If not, what might be getting in the way?If not, what might be getting in the way?

Proceed to sign which best represents Proceed to sign which best represents your internal dialogueyour internal dialogueLet’s discuss the context of your Let’s discuss the context of your explorationexploration

Risk Factors for Risk Factors for Attempts:Attempts:

Patients with AN and BEDPatients with AN and BED– Mixed AN/BN, AN-PTMixed AN/BN, AN-PT– Co-morbidity: Mood disorders, PTSD, OCDCo-morbidity: Mood disorders, PTSD, OCD

Bingeing/purging symptomatology – using Bingeing/purging symptomatology – using more than one method to compensatemore than one method to compensate

Impulse control disorderImpulse control disorder

More extensive treatment history More extensive treatment history Earlier onset of symptomsEarlier onset of symptoms

More dissociative symptomsMore dissociative symptoms

AN pts: older, lower weightAN pts: older, lower weight

Risk Factors for Risk Factors for Attempts:Attempts:

History of Major Depressive Disorder and History of Major Depressive Disorder and higher severity of depressive symptomshigher severity of depressive symptoms

Characteristics correlated with attempts: Characteristics correlated with attempts: sexual abuse history, laxative use and sexual abuse history, laxative use and drug, alcohol or tobacco usedrug, alcohol or tobacco use

Character traits: impulsivity, Character traits: impulsivity, perfectionism, low self-directednessperfectionism, low self-directedness

BN pts: co-morbid symptoms, sexual BN pts: co-morbid symptoms, sexual abuse historyabuse history

Hopelessness with regards to recoveryHopelessness with regards to recovery

Risk Factors for Risk Factors for CompletionCompletion::

Alcohol abuse – correlated w/completed Alcohol abuse – correlated w/completed deathsdeaths

Cluster B Personality disorders– high Cluster B Personality disorders– high risk for completed suicidesrisk for completed suicidesCharacteristics which are correlated with Characteristics which are correlated with death: duration of illness, spiritual death: duration of illness, spiritual acceptance, alcohol abuse and social acceptance, alcohol abuse and social isolationisolation

The more severe the ED: the higher the The more severe the ED: the higher the risk for suiciderisk for suicide

Case Presentation: Kelly Case Presentation: Kelly

Background:Background: 32 y/o female, 15 yr hx ED, co-morbid ADHD, 32 y/o female, 15 yr hx ED, co-morbid ADHD,MDD recurrent/severe, 2 previous suicide attempts, MDD recurrent/severe, 2 previous suicide attempts, inpatient ED admissions, medical admissions for IV inpatient ED admissions, medical admissions for IV fluids. Incomplete master’s degree, a strained fluids. Incomplete master’s degree, a strained relationship with her parents, close relationship with her relationship with her parents, close relationship with her sister, no local supportssister, no local supports

Symptoms:Symptoms: restricting – below usual hospital admission restricting – below usual hospital admission weight, orthostatic, fainting, alcohol abuse, driving drunk, weight, orthostatic, fainting, alcohol abuse, driving drunk, medicine non-compliance, therapy interfering behaviors, medicine non-compliance, therapy interfering behaviors, meal plan non-compliance, missing work, abusing meal plan non-compliance, missing work, abusing psychotropic meds, endorsing urges to purgepsychotropic meds, endorsing urges to purge

Kelly’s fiancé recently cancelled their wedding leaving Kelly’s fiancé recently cancelled their wedding leaving her $10K in debt. He also informed her he is moving out her $10K in debt. He also informed her he is moving out in one month. Kelly is devastated and feels hopeless.in one month. Kelly is devastated and feels hopeless.

Case Presentation: TanyaCase Presentation: Tanya26 26 year old college student who lives at home year old college student who lives at home with her parents. Seven year hx of ED-NOS, co-with her parents. Seven year hx of ED-NOS, co-morbid BDD, depression with psychotic features morbid BDD, depression with psychotic features beginning to emergebeginning to emergeTanya recently celebrated her 21 birthday with a Tanya recently celebrated her 21 birthday with a good high school friend, the friends’ boyfriend good high school friend, the friends’ boyfriend and a boy whom they were setting her up with and a boy whom they were setting her up with (who “friend-ed” her on Facebook). The night (who “friend-ed” her on Facebook). The night was a flop b/c Tanya felt the boy didn’t like herwas a flop b/c Tanya felt the boy didn’t like herTanya suspects her mother has disordered Tanya suspects her mother has disordered eating and she is refusing psychotropic meds eating and she is refusing psychotropic meds and family therapy citing she cannot afford itand family therapy citing she cannot afford it

Case PresentationsCase Presentations

Who are you more worried Who are you more worried about?about?

Why?Why?

Case Presentation: Case Presentation: DiscussionDiscussion

What do I do? How do I know?What do I do? How do I know?

Holding hopeHolding hope

Felt senseFelt sense

Ask the questionsAsk the questions

Opening the dialogueOpening the dialogue

Validate their feelingsValidate their feelings

Be there in the pain with your patientBe there in the pain with your patient

Understand the role suicide plays in the Understand the role suicide plays in the context of their value systems and context of their value systems and experiences experiences

Be curious about the meaning they Be curious about the meaning they attribute to ending one’s lifeattribute to ending one’s life

Protective FactorsProtective Factors

Skills in problem solving and a nonviolent way Skills in problem solving and a nonviolent way of handling disputes of handling disputes

Cultural and religious beliefs that discourage Cultural and religious beliefs that discourage suicide and support instincts for self-suicide and support instincts for self-preservationpreservation

Family support, friends, and other significant Family support, friends, and other significant relationshipsrelationships

Protective FactorsProtective FactorsCommunity involvementCommunity involvement

A satisfying social lifeA satisfying social life

Pet ownershipPet ownership

Social integration e.g.. through employment, Social integration e.g.. through employment, constructive use of leisure timeconstructive use of leisure time

Access to mental health care and servicesAccess to mental health care and services

Commonly Used Interventions:Commonly Used Interventions:

Safety Contracts: Safety Contracts:

No empirical evidence supports the No empirical evidence supports the effectiveness in preventing suicide effectiveness in preventing suicide Reliance on contract alone not a good Reliance on contract alone not a good practicepracticeDoubtful value when pt. is impulsive, Doubtful value when pt. is impulsive, substance abuser, or prone to disassociationsubstance abuser, or prone to disassociationTherapist must be available 24/7Therapist must be available 24/7Does not work if pt. isn’t attached to Does not work if pt. isn’t attached to therapisttherapistDoes not protect therapists from malpracticeDoes not protect therapists from malpractice

Crisis InterventionsCrisis Interventions

Sole focus on treatment – safetySole focus on treatment – safetyRemove lethal methodsRemove lethal methodsDelay of pt.’s suicidal impulsesDelay of pt.’s suicidal impulsesIncreased sessions/check insIncreased sessions/check insFocus on solving the immediate Focus on solving the immediate problemproblemInstruct pt. not to commit suicideInstruct pt. not to commit suicideGet a commitment to a plan of actionGet a commitment to a plan of action

Assessing Safety:Assessing Safety:

Assess immediate risk factors – find out Assess immediate risk factors – find out what methods they plan to use – the what methods they plan to use – the higher the risk, the more active the higher the risk, the more active the therapist’s responsetherapist’s responseDetermine whether pt. has written a Determine whether pt. has written a note, has any plans for isolating self, or note, has any plans for isolating self, or taken precautions against discoverytaken precautions against discoveryHow available other people are to her How available other people are to her now and over next several days?now and over next several days?Assess deepening depressive Assess deepening depressive affect/panic attacksaffect/panic attacks

Theory to PracticeTheory to Practice

Have up to date crisis planning sheetHave up to date crisis planning sheet

Know protective factorsKnow protective factors

Know risk factorsKnow risk factors

Monitor pt. in between sessionsMonitor pt. in between sessions

Check with a medical professional to Check with a medical professional to understand the lethality of their understand the lethality of their medications medications

Theory to PracticeTheory to PracticeCrisis ManagementCrisis Management

See: Crisis Template in handoutsSee: Crisis Template in handouts

Handout AHandout A

Handout BHandout B

Handout CHandout C

Sometimes getting really concrete helps us get unstuck from seemingly insurmountable concepts

Risk Management for Risk Management for Therapist:Therapist:

1.1. Involve the family and pt.’s Involve the family and pt.’s support systemsupport system

2.2. Consultation with other Consultation with other professionals is necessary professionals is necessary

3.3. 24/7 List of 24/7 List of colleagues/supervisioncolleagues/supervision

Risk Management for Therapist:Risk Management for Therapist:

1.1. Self-assessment of technical and Self-assessment of technical and personal competencepersonal competence

2.2. Meticulous and timely documentation Meticulous and timely documentation is required – maintain records per is required – maintain records per legal requirementslegal requirements

3.3. Involve managed care company and Involve managed care company and treatment team members in the treatment team members in the discussionsdiscussions

4.4. Previous medical and psychotherapy Previous medical and psychotherapy records must be obtained for each pt.records must be obtained for each pt.

Self-Care for the Therapist:Self-Care for the Therapist:

Consultation is necessary/essentialConsultation is necessary/essential

Be mindful about your caseloadBe mindful about your caseload

Raise your own awareness to Raise your own awareness to countertransferencecountertransference

Know your own limits and beliefsKnow your own limits and beliefs

Healing……Healing……The Om is also often referred to as the sound of the The Om is also often referred to as the sound of the

Earth…creation...the heart of existence.  Earth…creation...the heart of existence.  

To become one with the sound of the Om allows one to To become one with the sound of the Om allows one to become one with the source of all energy. become one with the source of all energy. 

Q & AQ & A

Thank you for your time!Thank you for your time!

RESOURCE LISTRESOURCE LISTCognitive-Behavioral Treatment of Borderline Personality Disorder. Marsha Cognitive-Behavioral Treatment of Borderline Personality Disorder. Marsha

Linehan. The Guilford Press. (May 14, 1993). http://behavioraltech.orgLinehan. The Guilford Press. (May 14, 1993). http://behavioraltech.orgSarah Luczaj, "Just How Strong is the Link between Anorexia and Sarah Luczaj, "Just How Strong is the Link between Anorexia and

Suicide?"(March 10, 2008, Counselling Resource.com, website)Suicide?"(March 10, 2008, Counselling Resource.com, website)Skills Training Manual for Treating Borderline Personality Disorder. Marsha Skills Training Manual for Treating Borderline Personality Disorder. Marsha

M. Linehan. The Guilford Press. (May 14, 1993)M. Linehan. The Guilford Press. (May 14, 1993)Dialectical Behavior Therapy in Clinical Practice: Applications across Dialectical Behavior Therapy in Clinical Practice: Applications across

Disorders and Settings. Linda A. Dimeff, Kelly Koerner. Marsha M. Linehan Disorders and Settings. Linda A. Dimeff, Kelly Koerner. Marsha M. Linehan (Foreword). The Guilford Press. (August 14, 2007)(Foreword). The Guilford Press. (August 14, 2007)

Dialectical Behavior Therapy with Suicidal Adolescents. Alec L. Miller, Jill H. Dialectical Behavior Therapy with Suicidal Adolescents. Alec L. Miller, Jill H. Rathus, Marsha M. Linehan. The Guilford Press; (November 16, 2006) Rathus, Marsha M. Linehan. The Guilford Press; (November 16, 2006)

Helping Teens Who Cut: Understanding and Ending Self-Injury. Michael Helping Teens Who Cut: Understanding and Ending Self-Injury. Michael Hollander. The Guilford Press. (June 10, 2008)Hollander. The Guilford Press. (June 10, 2008)

Dialectical Behavior Therapy for Binge Eating and Bulimia Debra L. Safer, Dialectical Behavior Therapy for Binge Eating and Bulimia Debra L. Safer, Christy F. Telch, and Eunice Y. Chen. The Guilford Press. (May 2009)Christy F. Telch, and Eunice Y. Chen. The Guilford Press. (May 2009)

No-Harm Contracts: A Review of What We Know. Lisa McConnell Lewis, No-Harm Contracts: A Review of What We Know. Lisa McConnell Lewis, Suicide and Life-Threatening Behavior 37(1) February 2007, The American Suicide and Life-Threatening Behavior 37(1) February 2007, The American Association of SuicidologyAssociation of Suicidology

Suicide and Eating Disorders. The American Association of Suicidology. Suicide and Eating Disorders. The American Association of Suicidology. www.suicidology.org/c/document_library/www.suicidology.org/c/document_library/