“I truly didn’t care if I died that night,” Hall said, recalling the humiliation and terror she felt inside the endless cycle of bingeing, purging, and over-exercising she’d been ensnared by since high school. “I truly didn’t care if I died that night.”

Thoughts of suicide aren’t uncommon among women (and men) who suffer from eating disorders. Up to one-half of individuals struggling with bulimia, anorexia, or binge-eating disorder say they’ve considered ending their own lives. One analysis found that 245 out of 16,342 patients with anorexia followed through on their intent within 11 years as did four out of 1,768 patients with bulimia over seven years.

Psychologists have a few explanations for the profound risk of suicide among people with eating disorders. Chief among them: the daily misery courted by constant starvation, purging, excessive physical activity, or laxative abuse coupled with relentless and obsessive thoughts about food and appearance. (Some mental health professionals even consider eating disorders painfully slow suicides in and of themselves.)

“Oddly enough, it was at my very thinnest that I felt the most helpless,” Hall said. “After 10 years, I’d finally starved myself into a weight that I knew people ‘noticed,’ and yet I was paralyzed by it. That part of the eating disorder was the hardest for me. Not the 15-mile runs, the starvation, the purging, or drinking wine in place of food, but realizing that, even at this ‘goal’ weight, I was just as unhappy and obsessive as I had been before. There was always a reason to keep hating myself.”

An eating disorder’s agony is often made worse by the social isolation its sufferers typically experience — there’s a lot of secrecy surrounding their symptoms. (Can’t remember the last time you saw someone throw up a meal, put away two pizzas, or panic over how many calories are in a snack? It’s because these behaviors are typically hidden and shrouded in shame.)

Reflecting on how her symptoms impacted her closest relationships, Hall recalls “not ever really feeling ‘there’ or hearing what my family and friends were saying because all I could think of was what I’d eaten, when I could throw it up, or when I could exercise it all off.”

Angela Howell relates all too well. Not only did she feel enveloped by her eating disorder — which, like Hall’s, entailed both bulimia and anorexia, and drove her, at age 17, to consider taking her own life — but she knew it contributed to her difficulties making and keeping friends well beyond her teen years.

“Even in college, I remained isolated,” Howell, who is now 48, said. “I was so used to revolving my life around food and purging that I didn’t even know how to be present with people.”

Howell was plagued by a concern throughout her childhood that she was “troublesome” — and wanting nothing more than to become “as physically and emotionally small as possible.” As her eating disorder progressed over a decade, no one she knew seemed to pick up on any signs she was struggling. “No one knew what I was doing. I felt like I was a freak.”

Disconnection from others is a key risk for suicide — regardless of whether or not an eating disorder’s at play. As is the damning belief one is a burden to others, which a lack of belonging can corroborate. Well aware of this link, a team of researchers led by Miami University’s Lauren N. Forrest, M.A., and April R. Smith, Ph.D., sought to examine if these factors predicted how strongly women who regularly starved, binged, or purged entertained thoughts of killing themselves.

They found that the lower a woman’s satisfaction was with her body, the less she felt like she belonged in the world. (Body dissatisfaction was also linked with more severe eating disorder symptoms — think: worse bingeing, purging, over-exercising, and self-starvation.) Plus, the greater control disordered behaviors held over a woman’s life, the more isolated she felt, overall. And when it came to suicide, the seriousness with which a woman considered it depended largely on her belief that she was a burden.

It’s tricky to discern what comes first in the complicated loop of burdensomeness, lack of belonging, suicidal ideation, and eating disordered behavior. But all appear to feed into, and aggravate, one another.

“Studies haven’t examined whether thwarted belongingness or burdensomeness are presentbefore people develop eating disorders,” Smith explained to Cosmopolitan.com. But she says research has shown that having few social supports, perceiving poor quality of existing friendships, having low self-esteem, and experiencing high levels of shame are risk factors for their onset.

These issues pervaded Howell’s and Hall’s lives well before their eating disorders began. Howell, for one, says she felt starved for attention and praise from others, and split in half due to shoving a memory of assault during her childhood out of her awareness. Hall recollects being bullied for wearing a back brace and feeling painfully sure she was an outsider for most of her life.

“Everyone thought I was this happy-go-lucky girl with no issues,” Hall says. “But I didn’t feel like my friends really knew me. So much was going on inside of me. It was like I was one of the women in Mad Men — suffocating under who they’re supposed to be and how they’re supposed to present themselves.”

Both women used their eating disorders to control the chaos inside and around them — as well as gain approval from those whose positive regard they desperately craved. But as is the case for so many people who lose themselves inside eating disorders, their self-destructive coping mechanisms ended up walling them off from the authentic connections that could have kept them from drowning in an emotional deep-end.

Howell and Hall each eventually sought inpatient treatment to begin letting go of their eating disorders. It took Hall a tearful confrontation with her parents and soul-wrenching admission to her friends via Facebook that she’d been suffering in silence for so many years before checking into the Renfrew Center in Florida. Howell cycled through two different inpatient programs with little success during her 20s until finding a facility in Decatur, Georgia, where she felt safe enough to surrender her symptoms once and for all.

It took both women an impressive amount of therapy to change their fatal but deeply entrenched obsessions surrounding food and exercise. But beyond the months of intensive behavioral interventions and nutritional counseling they received in their respective programs, each credits the social ties they forged during their recoveries to keeping their life-threatening habits and suicidal thoughts at bay in the years that followed.

“I didn’t understand how many people cared about my well-being until I finally reached out to get help,” says Hall, whose point of no return entailed such a severe binge that she lost consciousness and awoke vomiting. “But once I began honestly connecting with others, I was finally able to look past my symptoms and see how many people actually loved me.”

Howell points to the network she grew while seeking support from 12-step programs during her recovery’s early stages. Bonding with people who understood her struggle and had bounced back into fulfilling lives proved to her she wasn’t the only one suffering and that there was a way out. “Connectedness — being around other people who could relate to me — was what saved my life,” she says.

Hall now lives in New York and works as a freelance writer. She’s deeply involved in the eating disorder recovery community and blogs about her experiences. Though she’s sometimes still tempted by urges to binge, purge, restrict food, or overdo it at the gym, she feels that being accountable to a vast network of on- and offline supporters helps her remain on a self-caring course.

Howell hasn’t binged or starved for 24 years. She currently lives in Tennessee with her husband, has a 20-year-old son who’s in college, recently polished off her first book, and has begun speaking about her story across the country.

WHAT YOU CAN DO TO HELP

It can be hard for those outside the mental health field to pick up on signs someone’s struggling with an eating disorder — or contemplating killing themselves. But Kelsey Latimer, Ph.D., lead psychologist at Dallas’s Center for Pediatric Eating Disorders at Children’s Health, points toward some key signs we can all keep in mind to discern whether something’s amiss.

Latimer suggests asking the following if you’re worried someone you know may have an eating disorder (yourself included):

• Are there changes in a person’s relationship with food? Are they often on a new diet, cutting out whole food groups, or frequently preoccupied with food? (Hiding food, cutting it into bits and pieces also count here.) Do they escape to the bathroom shortly after tucking away a meal?
• Have they changed the way they dress — say, by wearing bulkier clothing?
• Are they withdrawing from activities and social situations they used to enjoy — especially ones involving food?
• Are they engaging in more exercise than seems reasonable? (Think: canceling plans or showing up late to work repeatedly due to their lengthy gym routine?)
• Has there been a noticeable change in their energy levels or mood? Are they more irritable, tired, or anxious lately?

Significant weight loss isn’t always apparent in some eating disorders, Latimer adds: “Many individuals with bulimia, for instance, may appear relatively normal in weight but their health may be in a very dangerous state.”

If you’re worried someone may be suicidal, Latimer suggests these additional questions:

• Have they mentioned feeling like a burden to others? How about saying they “can’t do this” or “don’t want to be here” anymore?
• Has their mood shifted drastically upward or down? Depression can coincide with suicidal thoughts, says Latimer, but unexpected calmness may indicate someone has come up with a plan.
• Are they giving away things that used to be meaningful to them? Making good-bye calls or tying up loose ends?
• Are they engaging in reckless behaviors? Drinking or drugging themselves into states where they may be less able to curtail impulses to end their life?

The importance of reaching out to someone you suspect is struggling cannot be stressed enough, says Latimer. Inviting someone to open up about their suicidal thoughts will not plant any ideas in their heads nor condone this action as valid, she adds. Not only is there a lack of evidence to support this common fear but the very act of offering someone a nonjudgmental ear to discuss thoughts and feelings they’re plagued by offers them proof they aren’t as alone, nor as much of a burden, as they may think. Same goes for listening to someone’s issues with food or exercise: Only by breaking through another person’s isolation can you help alter their false beliefs.

If you or someone you know is struggling with an eating disorder or suicidal thoughts, don’t keep it to yourself. Reach out to a mental health professional and make use of the following resources.

National Eating Disorders Association

National Association of Anorexia Nervosa and Associated Disorders

National Suicide Prevention Lifeline: 1 (800) 273-TALK

American Foundation for Suicide Prevention

Samaritan’s 24-Hour Crisis Hotline – (212) 673-3000

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