Pet Attachment and the Interpersonal Theory of Suicide.

Background: Pet ownership is often assumed to have mental health benefits, but the effect of pets on suicide risk has a scant literature. Aims: Using the interpersonal theory of suicide, we examined the relationships between perceived burdensomeness (PB), thwarted belongingness (TB), overall attachment to one's pet, pet attachment avoidance or anxiety, and suicide risk. The following three hypotheses were investigated: (1) Higher attachment would be indirectly associated with lower suicide risk via lower TB and lower PB; (2) attachment would be associated with higher suicide risk, as conditioned on attachment avoidance/anxiety; and (3) attachment avoidance/anxiety would be associated with higher suicide risk via higher TB/PB. Method: Undergraduates (N = 187) completed surveys, and indirect effect and conditional effect analyses were utilized. Results: Overall attachment was associated with lower PB, which was associated with lower suicide risk. The relationship between overall attachment and suicide risk was not conditional upon attachment anxiety/avoidance. Attachment avoidance was associated with increased levels of TB, which was associated with increased suicide risk. Attachment anxiety was associated with increased suicide risk via TB and PB. Limitations: We used a university sample that had limited access to pets. Conclusions: Findings suggest that pet ownership may provide mixed associations with suicide risk.

Borderline personality disorder symptoms as mediational mechanisms linking childhood trauma and nonsuicidal self-injury among women with bulimia nervosa.

OBJECTIVE: Nonsuicidal self-injury (NSSI) frequently co-occurs with eating disorders, especially bulimia nervosa (BN). Theoretical models and empirical evidence show many overlapping risk factors for the onset and maintenance of NSSI and BN. However, among those with BN, it remains unclear what distinguishes those who do versus do not engage in NSSI. The primary objective of the present study was to identify factors predicting NSSI among women with BN. Specifically, we tested four domains of borderline personality disorder as mediators between childhood trauma and NSSI. METHOD: Using structural equation modeling we tested a parallel mediation model to predict NSSI among women with BN (N = 130). Childhood trauma (measured by the Childhood Trauma Questionnaire at baseline) was the independent variable. The four parallel mediators (measured at baseline via the Diagnostic Interview for Borderlines, Revised) were lifetime negative affect, impulsive actions, atypical cognitions (e.g., odd thinking, unusual perceptual experiences, quasi-psychotic thinking), and interpersonal problems. The dependent variable was instances of NSSI during a subsequent two-week ecological momentary assessment protocol. RESULTS: Childhood trauma was significantly associated with all four mediators (all p values < .01), but only atypical cognitions predicted NSSI (p = .03). The indirect path from childhood trauma to NSSI, through atypical cognitions was significant (path coefficient = .001, SE < .001, p = .01). DISCUSSION: Among women with BN, childhood trauma was associated with atypical cognitions, which in turn predicted NSSI. Atypical cognitions may be a mechanism for NSSI in this population.

Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery.

BACKGROUND: Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative. OBJECTIVES: To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery. SETTING: Five academic medical centers. METHODS: Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]age = 17 yr, Mbody mass index[BMI] = 52 kg/m2) and nonsurgical comparators (n = 70; 80% female, 54% white, Mage = 16 yr, MBMI = 47 kg/m2) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [MBMI = 38 kg/m2], n = 56 nonsurgical [MBMI = 48 kg/m2]). RESULTS: For the surgical group, rates of STBs were low (year 2 [1.3%-4.6%]; year 4 [2.6%-7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides. CONCLUSIONS: The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.

The interaction of sociocultural attitudes and gender on disordered eating.

OBJECTIVE: The Tripartite Influence Model posits that social agents emphasize a thin ideal for women and a muscularity ideal for men. There is a gap in the literature of how sociocultural body ideal internalization affects overall disordered eating symptoms in men and specifically drive for muscularity in women. METHOD: The sample consisted of 1,929 participants (44.2% men) who completed online surveys. It was predicted that internalization would be a stronger predictor for overall disordered eating in women and for muscularity in men. RESULTS: Women with high internalization had increased disordered eating symptoms in comparison to men, whereas for men, increased internalization was linked to more drive for muscularity, as compared with women. CONCLUSIONS: It is important to emphasize, however, that men still exhibited higher rates of disordered eating symptoms when they had increased internalization and women exhibited an increased drive for muscularity when they had higher internalization.

A longitudinal examination of suicide-related thoughts and behaviors among bariatric surgery patients.

BACKGROUND: Past research suggests self-harm/suicidality are more common among adults who have undergone bariatric surgery than the general population. OBJECTIVES: To compare prevalence of self-harm/suicidal ideation over time and identify presurgery risk factors for postsurgery self-harm/suicidal ideation. SETTING: The Longitudinal Assessment of Bariatric Surgery-2 is a cohort study with presurgery and annual postsurgery assessments conducted at 10 U.S. hospitals. METHODS: Adults with severe obesity undergoing bariatric surgery between March 2006 and April 2009 (n = 2458). Five-year follow-up is reported. Self-reported history of suicidality assessed retrospectively via the Suicide Behavior Questionnaire-Revised (SBQ-R) and self-reported self-harm/suicidal ideation assessed prospectively via the Beck Depression Inventory-Version 1 (BDI-1). RESULTS: The SBQ-R was completed by 1540 participants; 2217 completed the BDI-1 pre- and postsurgery. Over 75% of participants were female, with a median age of 46 years and body mass index of 45.9 kg/m2. Approximately one fourth of participants (395/1534) reported a presurgery history of suicidal thoughts or behavior (SBQ-R). The prevalence of self-harm/suicidal ideation (BDI-1) was 5.3% (95% confidence interval [CI], 3.7-6.8) presurgery and 3.8% (95% CI, 2.5-5.1) at year 1 postsurgery (P = .06). Prevalence increased over time postsurgery to 6.6% (95% CI, 4.6-8.6) at year 5 (P = .001) but was not significantly different than presurgery (P = .12). CONCLUSIONS: A large cohort of adults with severe obesity who underwent bariatric surgery had a prevalence of self-harm/suicidal ideation that may have decreased in the first postoperative year but increased over time to presurgery levels, suggesting screening for self-harm/suicidality is warranted throughout long-term postoperative care. Several risk factors were identified that may help with enhanced monitoring.

Emotions before and after loss of control eating.

Our study examined momentary mood and emotional instability pre- and post-loss of control (LOC) eating on non-LOC and LOC eating days, using randomly timed assessments. Community and university participants (n = 45) who endorsed LOC eating at least once per week completed 2 weeks of ecological momentary assessment. All negative moods and emotional instability were elevated on LOC eating days, but trajectories between days did not differ. Guilt exhibited an increasing trajectory prior to a LOC eating episode, but remained elevated after LOC eating episodes. Additional analyses revealed that size of the LOC eating episode did not change these results dramatically.

An examination of the relationships between acculturative stress, perceived discrimination, and eating disorder symptoms among ethnic minority college students.

Empirical evidence suggests the importance of considering acculturative stress and perceived discrimination in understanding the mental health of ethnic minority groups, including their eating behaviors and associated psychopathology. The current study examined the effect of acculturative stress and perceived discrimination on eating disorder symptoms among ethnic minority undergraduate students. A total of 187 ethnic minority undergraduate students (41.2% men) completed this cross-sectional study by completing self-report questionnaires on a secure online system. Regression analyses revealed a main effect of acculturative stress on eating concern, shape concern, weight concern, drive for thinness, and bulimia but not restraint or body dissatisfaction. Gender moderated the effect of acculturative stress on drive for muscularity, suggesting that this effect was only significant in women, but not men. The main effect of perceived discrimination was significant for restraint, eating concern, shape concern, weight concern, and drive for muscularity but not drive for thinness, bulimia, or body dissatisfaction. Acculturative stress and perceived discrimination are important factors to consider in understanding the development and maintenance of eating disorder symptoms among ethnic minority populations. Targeting these two factors may improve the effectiveness of intervention programs for eating disorder symptoms among ethnic minority undergraduate students.

Empirically derived classes of eating pathology in male and female college students.

BACKGROUND: The empirical structure of eating disorder (ED) pathology has often been studied in female, clinical samples, leaving questions about the structure of ED pathology in males and nonclinical samples. METHOD: A latent class analysis was performed on data combined from two different studies (N = 1,751) using the behavioral items in the Eating Disorder Examination Questionnaire (EDE-Q; binge eating, self-induced vomiting, laxative use, and excessive exercise), with the addition of an item representing restraint. Validation analyses examined weight, shape, and eating concern among the classes. RESULTS: Three similar classes emerged for both the men and women's models: very low ED behaviors, binge eating, and high ED behaviors. DISCUSSION: These results suggest that binge eating occurs within the context of lower symptom and higher symptom presentations, and that the empirical structure of ED symptoms does not differ in men and women in the nonclinical population. Further research is needed to clarify whether ED phenotypes differ in men and women.

"I don't want to grow up, I'm a [Gen X, Y, Me] kid": Increasing maturity fears across the decades.

The current studies examined the hypothesis that maturity fears are increasing among undergraduate men and women from the United States over time. Study 1 used a time-lag method to assess generational effects of maturity fears among a large sample (n = 3,291) of undergraduate men and women assessed in 1982, 1992, 2002, and 2012. Results revealed that both men and women reported significantly higher rates of maturity fears across time. Study 2 replicated these findings, and used a more restricted time frame to more closely examine the rate of change. Undergraduate women (n = 554) were assessed in 2001, 2003, 2009, and 2012. Maturity fears were again found to increase from 2001 to 2012. Recent cohorts of emerging adults seem more reluctant to mature than previous cohorts. Many contributing factors may be at play, including challenging economic times, social pressures to remain youthful, and/or internal fears of assuming increased responsibility.

Bulimic symptoms and interpersonal functioning among college students.

Integrating interpersonal theory and the stress generation hypothesis, two studies investigated the association between bulimic symptoms and interpersonal distress and the mechanism underlying this association. In Study 1, 36 pairs of female roommates completed self-report questionnaires in a laboratory while Study 2 recruited 539 undergraduate men and women to participate in a longitudinal online study by completing self-report measures at two time points. Multilevel modeling revealed that targets' bulimic symptoms predicted roommates' intention to continue living with them in Study 1. Greater bulimic symptoms predicted lower intention. In Study 2, bulimic symptoms had a direct and an indirect effect on interpersonal distress, with reassurance-seeking as a mediator in the indirect effect. Findings replicated previous studies showing that bulimic symptoms generate further distress and, in our studies, interpersonal distress specifically. Moreover, reassurance-seeking was a newly identified mechanism underlying this association. These findings provide support for the usefulness of interpersonal theory and the stress generation hypothesis as a framework for understanding bulimic symptomatology. Clinicians may find it useful to target reassurance-seeking behaviors during the treatment of bulimic symptoms in order to improve treatment outcomes.

An Examination of the Connections Between Eating Disorder Symptoms, Perceived Burdensomeness, Thwarted Belongingness, and Suicide Risk Among Undergraduate Students.

Suicide attempts and premature mortality due to suicide are elevated in people with eating disorders. Informed by the interpersonal theory of suicide, two studies examined the role of perceived burdensomeness and thwarted belongingness in explaining the association between eating disorder symptoms and suicide risk. Results indicated that various eating disorder symptoms had an indirect effect on suicide risk through perceived burdensomeness and thwarted belongingness. Targeting perceived burdensomeness and thwarted belongingness may be useful for decreasing suicide risk among undergraduates with eating disorder symptoms.

The effects of social support and stress perception on bulimic behaviors and unhealthy food consumption.

Two studies tested a model where perceived stress was the proposed mediator for the relationship between perceived social support and bulimic behaviors, and between perceived social support and unhealthy food consumption among undergraduate students. Study 1 was a longitudinal, online study in which undergraduate students completed the Multidimensional Scale of Perceived Social Support and the Bulimia Test-Revised at the Time 1 assessment, and the Perceived Stress Scale and the Eating Disorder Examination Questionnaire at the Time 2 assessment, approximately four weeks later. Study 2 was an experimental study in which female participants were randomly assigned into a group with or without social support. Stress was induced with a speech task, followed by a bogus taste task paradigm designed to assess unhealthy food consumption. Bootstrap analyses revealed an indirect effect of perceived social support on bulimic behaviors and unhealthy food consumption through perceived stress. Perceived social support was associated with lower perceived stress in both studies. Lower perceived stress was associated with less self-reported bulimic behaviors in Study 1 and greater consumption of unhealthy foods in Study 2. The negative association between perceived stress and calorie consumption in Study 2 was moderated by dietary restraint. Findings suggest that stress perception helps to explain the relationship between perceived social support and bulimic behaviors, and between perceived social support and calorie consumption. Stress perception may be an important treatment target for eating disorder symptoms among undergraduate students.

An examination of the prospective impact of bulimic symptoms and dietary restraint on life hassles and social support.

BACKGROUND: The stress generation hypothesis posits that individuals with psychopathology engage in maladaptive behaviors that create stress. Although extensively researched in the depression literature, few studies have investigated whether the stress generation hypothesis applies to eating disorders. This study examined whether bulimic symptoms and dietary restraint predict future life hassles and low social support among undergraduate students. METHODS: Three hundred seventy-four undergraduate students participated in this two-part prospective study through a secure online system. They completed questionnaires assessing depressive symptoms, bulimic symptoms, dietary restraint, life hassles, and social support. RESULTS: Regression analyses revealed that baseline bulimic symptoms predicted greater life hassles but not lower social support one month later, after statistically controlling for baseline measures. Baseline dietary restraint did not predict future life hassles or social support. LIMITATIONS: Limitations include use of self-report measures, suboptimal response rates at the follow-up assessment, and use of a non-clinical sample with primarily White participants. CONCLUSIONS: These results provide preliminary support for the stress generation hypothesis in relation to bulimic symptoms. Individuals with bulimic symptoms may generate stressors similar to those experiencing depressive symptoms. Our findings suggest that emphasizing stress management in the treatment of individuals with bulimic symptoms could potentially improve treatment outcomes.

Emotion Dysregulation and Affective Intensity Mediate the Relationship Between Childhood Abuse and Suicide-Related Behaviors Among Women with Bulimia Nervosa.

Self-harm and suicide attempts occur at elevated rates among individuals with bulimia nervosa, particularly among those who have experienced childhood abuse. This study investigated the potential mediating roles of emotion dysregulation and affective intensity in the relationship between these variables in 125 women with bulimia nervosa. Analyses revealed that emotion dysregulation mediated the relationship between sexual and emotional abuse with both self-harm and suicide attempts. Negative affective intensity mediated the relationship between abuse and suicide attempts. The findings may advance the understanding of mechanisms underlying suicide-related behaviors in women with bulimia nervosa who experienced abuse and suggest potential clinical targets.

Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature.

Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer's (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.

A test of an interactive model of binge eating among undergraduate men.

Past research has shown that a combination of high perfectionism, high body dissatisfaction, and low self-esteem is predictive of binge eating in college women (Bardone-Cone et al., 2006). In the current study, we examined whether this triple interaction model is applicable to men. Male undergraduate college students from a large Midwestern university (n=302) completed self-report measures online at two different time points, a minimum of eight weeks apart. Analyses revealed a significant interaction between the three risk factors, such that high perfectionism, high body dissatisfaction, and low self-esteem at Time 1 were associated with higher levels of Time 2 binge eating symptoms. The triple interaction model did not predict Time 2 anxiety or depressive symptoms, which suggests model specificity. These findings offer a greater understanding of the interactive nature of risk factors in predicting binge eating symptoms among men.

Gender differences in coping responses and bulimic symptoms among undergraduate students.

This prospective study examined the predictive role of three types of coping responses (i.e., voluntary disengagement, involuntary engagement, and involuntary disengagement) in response to social stress on bulimic symptoms among undergraduate women and men. A total of 883 (308 men; 35%) participants completed the Response to Stress Questionnaire, the Beck Depression Inventory, and the Eating Disorder Inventory (EDI) at baseline assessment and the EDI at follow-up assessment 8-12 weeks later. After controlling for baseline bulimic symptoms, depression, and body dissatisfaction, involuntary disengagement predicted bulimic symptoms at follow-up among men (b=.21, p<.001), but not among women (b=.06, p>.05). Results indicated that men who responded to social stress through involuntary disengagement (e.g., emotional numbing, inaction) had higher risk for increased bulimic symptoms. Future studies are needed to replicate these findings and to further understand the role of these coping responses on bulimic symptoms.

Fearlessness about death: the psychometric properties and construct validity of the revision to the acquired capability for suicide scale.

The Interpersonal Theory of Suicide proposes that suicidal behavior is so frightening that in order for an individual to engage in suicidal behavior, desire for suicide must be accompanied by the capability to do so. The capability for suicide is characterized by both a sense of fearlessness about death and elevated physiological pain tolerance. The primary aim of the current project was to reevaluate and revise the Acquired Capability for Suicide Scale (ACSS; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and offer a revision to the scale. Expert review of the scale items resulted in retaining 7 items assessing fearlessness about death. The recommendation is made to refer to the revised scale as the ACSS-Fearlessness About Death (ACSS-FAD) to reflect its content more specifically. A model with the 7 retained items provided good fit to the data across 3 independent samples of young adults. Multiple-group analyses examining measurement invariance across men and women found that the latent structure of the scale is comparable across gender. Data are also presented demonstrating convergent and discriminant validity for the scale in young adults and an inpatient psychiatric sample. Findings support the viability of the ACSS-FAD, indicating the scale has a replicable factor structure that generalizes across males and females and is substantively related to the construct of fearlessness about death. Taken together, the present work extends knowledge of the psychometrics of the ACSS-FAD in particular and the nature of fearlessness about death in general.

Post-therapy functional impairment as a treatment outcome measure in non-suicidal self-injury disorder using archival data.

There have been calls for the creation of a non-suicidal self-injury (NSSI) disorder, and a recent DSM-5 work group has delineated potential diagnostic criteria for the proposed disorder. Preliminary research comparing NSSI disorder to Axis I disorders and its closest diagnostic 'neighbor', borderline personality disorder (BPD), suggests that impairment at intake, patient history of associated features and diagnostic co-occurrence rates set NSSI disorder apart from existing DSM-IV-TR disorders. However, few studies have examined the treatment course of NSSI disorder relative to other disorders. The purpose of this study was to distinguish potential treatment outcome differences between a potential NSSI disorder, BPD and Axis I. Archival data (N = 571), which included ratings of functioning at therapy intake and termination, were analysed to determine between-group differences. Although no significant differences in the number of months in therapy or number of sessions attended were found, findings suggest that the NSSI group made strong gains in therapy, as evidenced by improvements in clinician ratings of functional impairment from intake to termination. These findings suggest that NSSI disorder may have a positive prognosis with treatment.

The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion.

The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full Diagnostic and statistical manual of mental disorders (4th ed.) criteria or subthreshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a 2-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. In addition, we used two analytic approaches to compare affect before and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly after LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach, we also found negative affect to decrease significantly after the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased before LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased after the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.