Q&A: A Patient Who Takes Extreme Risks

Q: I hope you can help. One of our patients, in her mid-20s, seems to be on a path of ever-riskier behaviors, from restrictive eating to anorexia nervosa, depression, anxiety, self-injury, and now to suicidal thoughts. Do you have any suggestions about how we can intercept and/or stop this dangerous trend?  (J.R., Greensboro, NC)

A: Your concern is well placed. Patients with eating disorders face significant medical complications, some of which are irreversible and potentially life-endangering (J Adolesc Health. 2003; 33:418). It is well known that AN is associated with the highest mortality rate among all mental disorders (Arch Gen Psychiatry. 2011, 68: 724). Perhaps the most dangerous symptom, of course, is attempted suicide. A recent article by Daniel Stein and colleagues (Front Psychiatry. 2020, 11:89) specifically investigates extreme risk-taking among 4 very different female patients. One was an adolescent with type 1 diabetes, one was in her mid-20s, one in her late 30s, and one was a 23-yr-old pregnant patient with AN.

The authors note that many factors are involved with the increased suicide risk in patients with AN, including disturbances in body image and body dissatisfaction. Another self-destructive behavior is non-suicidal self-injury, which is associated with an increased risk of suicide, according to the authors. As many as two-thirds of persons with eating disorders may engage in non-suicidal self-injury.

The 4 patients had very different presentations, but they had several things in common.  First, they all were diagnosed with AN with binge-purge pathology.  Next, 3 of the 4 women showed evidence of more than one purging behavior, including self-induced vomiting and laxative abuse, which suggested considerable impulsivity connected to the purging. Third, several behaviors had signs of non-ED-related impulsive behaviors. Most of the women had other comorbidities and multiple vulnerabilities.

The authors suggest that the most important finding that the women had in common was that multiple co-occurring non-ED motivations and faulty emotional handling might have been at the core of the extreme endangering behaviors the women exhibited.  In all cases, the women seemed to be indifferent to the potential harm that their extreme risk-taking behavior caused. Such indifference might be related to the patients’ deficient emotional, mentalization and theory of mind capacities, as well as their lack of attraction to life; they had no immediate or long-term goals.

What treatment approach makes sense?  A logical fit would be dialectic behavior therapy (DBT). Developed by Marcia Linchan for patients with borderline personality disorder, it is highly useful for treatment of multiple co-occurring problems, as in the case described here. And, there is evidence that DBT is beneficial for ED symptoms.

– SC

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