Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa

Edward A. Selby, April R. Smith, Cynthia M. Bulik, Marion P. Olmsted, Laura Thornton, Traci L. McFarlane, Wade H. Berrettini, Harry A. Brandt, Steve Crawford, Manfred M. Fichter, Katherine A. Halmi, Georg E. Jacoby, Craig L. Johnson, Ian Jones, Allan S. Kaplan, James E. Mitchell, Detlev O. Nutzinger, Michael Strober, Janet Treasure, D. Blake WoodsideWalter H. Kaye, Thomas E. Joiner

Research output: Contribution to journalArticlepeer-review

70 Scopus citations


Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.

Original languageEnglish (US)
Pages (from-to)634-645
Number of pages12
JournalBehaviour Research and Therapy
Issue number7
StatePublished - Jul 2010
Externally publishedYes

All Science Journal Classification (ASJC) codes

  • Experimental and Cognitive Psychology
  • Clinical Psychology
  • Psychiatry and Mental health


  • Anorexia
  • Purging
  • Restricting
  • Self-injury
  • Suicide


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