Reprinted from "Suicide" issue of Visions Journal, 2005, 2 (7), p. 11, 14
D. is a 17-year-old grade 12 student who has been hospitallized for the fourth time over the past three years. She has been struggling for the past six years with anorexia nervosa. Unlike her previous admissions, her mood is depressed and she has shared thoughts about suicide with some staff. She has been banging her head against the wall on oc- casion. When I asked her about her change in mood, she said, “I’m so scared to put any weight on… One reason why I lose weight is, I think, because I am trying to punish myself. I have created a wall between myself and my family and I can’t break it down any more. I used to be able to escape by not eating, but now even that does not work. Sometimes, I want to get better, get on with school and friends, but I am afraid I’ll never be able to get over this. Living like this is all I know. Before, I used to pretend I could control it and I could get better any time. I have no more friends. I have hurt and let down my family so many times. I feel so guilty. I do not think I want to kill myself, but it would be simpler if I was gone and my family would not have to worry anymore!”
One has to take these situations seriously, since suicide can account for up to 50% of the mortality encountered with patients who suffer from eating disorders (ED). Mortality rates increase with age. Sometimes patients also suffer from mood disorders, drug abuse and/or poor psychosocial functioning, which further compound the risk. Tragically, up to onethird of adults with eating disorders have experienced physical, emotional, or sexual abuse. Lastly, suicidal thoughts and attempts are quite common among adolescents in BC (up to one-third of youth have considered suicide in the past2). The lifetime prevalence of anorexia nervosa for women ranges from 0.5% to 3.0%, and 1.1% to 4.2% for bulimia nervosa. The male–female prevalence ratio is 1:10.
During the early stages of a disordered eating condition, when denial is strong, the person often feels in control and enjoys the beneﬁts the condition brings socially and personally. These include improved self-esteem, sense of control, and praise from peers for their appearance. However, the consequences of starvation background and compensatory behaviour, such as binge eating and purging, eventually become a burden and create personal social loss. Over a period of time, the person becomes more isolated, helpless and hopeless as friends and family distance themselves. Performance in school and other activities, such as sport, start becoming impaired. And hospitalizations are sometimes necessary. The person becomes exhausted from battling the eating disordered thoughts and behaviours. They realize that recovery will be hard, and a lengthy process.
It is important to reach out for help in the early stages of this condition; however, for some there are barriers. The person with an eating disorder often feels they are undeserving of help or that accepting help is a weakness. They may have learned from their family and culture to value control and to avoid conﬂict and expression of feelings. This can be due partly to malnutrition, but also to a lack of learned ability to be assertive and to express one’s voice.
There may also be ambivalence about getting better. There is a fear of losing beliefs and rituals that have helped with coping in the past. Sometimes the health care provider is not trusted, may be viewed as someone ‘forcing’ the client to do something he or she does not want to do.
This is a time when self-harming behaviours and suicidal ideation may become a way of coping with this turmoil—and a time when the support of friends and family is critical. Friends and family can help by providing empathetic listening and by acknowledging the ambivalence and the confusion. It is an important time to keep believing in recovery and supporting selfefﬁcacy. However, the person always needs to be kept safe; when danger is imminent, use of professional emergency services may be needed.
A consistent, hopeful and future-oriented approach is crucial to the healing process. Open communication facilitates this, although it can be sometimes demanding for helpers. They need to recognize that they must manage their own feelings of frustration: it can be challenging to encourage someone to express their feelings and then to hear their sadness, anger and despair, while not being able to ‘ﬁx’ it for them. Being honest and direct, while being compassionate, remains critical.
Help from their peers is sometimes easier for people with disordered eating to accept. In their despair, they struggle with thoughts of self-punishment and use the ED behaviours for relief from these thoughts. Feelings of shame tend to lead to further negative behaviours and further guilt. But, amidst the despair, they often also search for meaning and a better understanding of their purpose in life. Self-help groups and peer support can often help individuals manage these feelings and focus on personal values to good effect.
Ultimately, it bodes well for health care providers and signiﬁcant others to help these young people “construct a sense of hopefulness that they can ultimately enjoy a life without the eating disorder.
About the Authors
Dr. Leichner is Psychiatric Director of the Eating Disorders Program at BC Children’s Hospital and Clinical Professor with UBC’s Department of Psychiatry
Dr. Manley is Clinical Director of the Eating Disorders Program at BC Children’s Hospital and Clinical Assistant Professor, UBC Department of Psychiatry
Fictionalized vignette based on what patients have reported.
McCreary Centre Society. (2000). Mirror images: Weight issues among BC youth, results from the Adolescent Health Survey. Burnaby, BC: Author
American Psychiatric Association. (2000). Practice guideline for the treatment of patients with eating disorders (Revision). American Journal of Psychiatry 157(1)
Manley, R.S. & Leichner, P. (2003). Anguish and despair in adolescents with eating disorders. Crisis, 24(1), 32-36