Common and differential risk factors behind suicidal behavior in patients with impulsivity- related disorders: The case of bulimic spectrum eating disorders and gambling disorder Journal of Behavioral Addictions EDUARDO VALENCIANO-MENDOZA1,2 , 11 (2022) 4, 963–978 FERNANDO FERNÁNDEZ-ARANDA1,2,3,4pp , DOI: ROSER GRANERO4,5 , CRISTINA VINTRÓ-ALCARAZ1,2,4 , 10.1556/2006.2022.00072 © 2022 The Author(s) BERNAT MORA-MALTAS1,2 , SUSANA VALERO-SOLÍS1,2 , ISABEL SÁNCHEZ1,2,4 , JESSICA JIMENEZ-DE TORO1,2, MÓNICA GÓMEZ-PEÑA1,2 , LAURA MORAGAS1,2 and SUSANA JIMÉNEZ-MURCIA1,2,3,4p FULL-LENGTH REPORT 1 Department of Psychiatry, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain 2 Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain 3 Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain 4 Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain 5 Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain Received: November 18, 2021 • Revised manuscript received: May 23, 2022; August 8, 2022 • Accepted: September 3, 2022 Published online: October 25, 2022 ABSTRACT Background and aims: Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD. Methods: A total of 6,077 adults who sought treatment and met criteria either for BSED (n 5 2,391) or GD (n 5 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated. Results: The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher p harm avoidance were associated with GD. Discussion: Patients with GD and BSED share certain Corresponding author. vulnerability factors although certain factors are exclusive to each disorder. Conclusions: Interventions E-mail: sjimenez@bellvitgehospital.cat need to pay special attention to both common and specific vulnerability factors to mitigate the risk of pp Corresponding author. suicidal acts in these disorders. E-mail: ffernandez@bellvitgehospital. cat KEYWORDS suicidal behavior, bulimic spectrum eating disorders, gambling disorder, impulsivity, risk factors 964 Journal of Behavioral Addictions 11 (2022) 4, 963–978 INTRODUCTION premeditation and perseverance compared to patients with anorexia nervosa (AN) restricting type, while those in- Suicide constitutes a major health concern given that it ac- dividuals with AN binge/purge (AN-BP) type have been counts for 1.4% of all deaths worldwide (World Health described to be situated in between (Claes, Vandereycken, & Organization, 2019) and in most Western countries it has Vertommen, 2005). become one of the first causes of non-natural death (World GD is characterized by a loss of control over gambling Health Organization, 2014). Numerous suicides are related which becomes the individual’s only interest, causing serious to mental disorders (Chesney, Goodwin, & Fazel, 2014; Too harmful consequences at social, family and financial levels et al., 2019) and impulsivity as a personality trait has been (American Psychiatric Association, 2013). The lifetime identified as a risk factor for suicidal behavior (Costanza prevalence of the disorder is estimated to be around 0.4– et al., 2020; Gvion, Levi-Belz, Hadlaczky, & Apter, 2015). 1.0% of the population (American Psychiatric Association, Impulsivity is defined as a predisposition to perform rapid 2013) although wide variations in past-year problem unplanned reactions to internal or external stimuli that often gambling rates across different countries in the world have cause adverse consequences (Moeller, Barratt, Dougherty, been described ranging from 0.12 to 5.8% (Calado & Grif- Schmitz, & Swann, 2001). Therefore, those mental disorders fiths, 2016). GD is associated with severe consequences that are characterized by high levels of impulsivity, such as including suicidal behavior (Karlsson & Håkansson, 2018). gambling disorder (GD) (Black et al., 2014; Hodgins & Manning et al. (2015) reported that 11.2% of patients with Holub, 2015; Ioannidis, Hook, Wickham, Grant, & Cham- GD who sought treatment had attempted suicide in their berlain, 2019; Rømer Thomsen et al., 2018) and bulimic lifetime. Likewise, eating disorders (ED) with a bulimic spectrum eating disorders (BSED) (Lavender & Mitchell, component are those in which there is presence of binging 2015; Mallorquí-Bagué et al., 2020; Waxman, 2009), deserve and/or purging episodes (i.e., “binge/purge type,” including greater attention when studying suicidal behavior. Although BN, binge-eating disorder (BED), and AN-BP). Lifetime and from a categorical point of view these disorders are clearly 12-month prevalence of BSED range from 1.68 to 2.15% and differentiated, from a dimensional approach these disorders 0.23–1.03% respectively (Micali et al., 2017). These ED are situated in the impulsive pole of the impulsive- subtypes show greater prevalence of impulsive behaviors compulsive spectrum (Del Pino-Gutiérrez et al., 2017). In (Mallorquí-Bagué et al., 2020) as well as higher rates of fact, this group of disorders share not only high levels of suicidal behavior compared to the rest of the ED subtypes impulsivity but also other transdiagnostic clinical features (Bodell, Joiner, & Keel, 2013; Foulon et al., 2007; Mandelli, such as difficulties in emotional regulation and inhibitory Arminio, Atti, & De Ronchi, 2019; Krug et al., 2021). Udo, control (Dalgleish, Black, Johnston, & Bevan, 2020; Munguía Bitley, and Grilo (2019) found that the prevalence estimates et al., 2021; Vintró‐Alcaraz et al., 2022). It has also been of suicide attempts in AN-BP, BN and BED were 44.1%, argued that GD and BSED may have similar risk and 31.4%, and 22.9% respectively showing that the highest maintenance factors. Following this idea, perfectionistic prevalence of suicide attempts were found in patients with tendencies and overvalued ideas constitute risk and main- BN and AN-BP (Forcano et al., 2009, 2011; Krug taining factors for BSED and may also explain GD (Tabri, et al., 2021). Werner, Milyavskaya, & Wohl, 2021). Due to the shared The fact that both BSED and GD have been classified as clinical characteristics and high prevalence of these disorders disorders in which impulsivity is crucial has led to the as well as their serious consequences -including suicidal proposal that these two types of disorders may show com- behavior-, it becomes clinically relevant to investigate both mon clinical correlates and a high shared comorbidity (Del groups of disorders from a transdiagnostic approach. Pino-Gutiérrez et al., 2017). In other words, it could indicate Impulsivity is a multidimensional construct (Sperry, that both types of disorders share impulsivity-related Lynam, Walsh, Horton, & Kwapil, 2016) and previous vulnerability factors (Davis et al., 2017; Munguía et al., studies have examined which facets of the construct are 2021). Not surprisingly, GD and BSED may co-occur more predominant in each disorder (Lavender & Mitchell, (Jiménez-Murcia et al., 2013, 2015; Kim, von Ranson, 2015; Mestre-Bach et al., 2020). There is a multiplicity of Hodgins, McGrath, & Tavares, 2018; Mestre-Bach, Fernán- models on impulsivity (Sperry et al., 2016). One of the most dez-Aranda, Jiménez-Murcia, & Potenza, 2020). In a sample studied is the UPPS-P, which proposes five factors of trait of treatment seeking patients with GD, 11.5% of the in- impulsivity: (lack of) perseverance, (lack of) premeditation, dividuals met criteria for a BSED. The prevalence of co- positive and negative urgency, and sensation-seeking occurring GD and BSED was higher in patients with BED (Whiteside & Lynam, 2001; Whiteside, Lynam, Miller, & and BN, and specifically among women (Kim et al., 2018). Reynolds, 2005). Higher lack of perseverance, and positive When approaching the phenomenon of suicidal and negative urgency are the most distinctive components behavior, it is important to differentiate between suicidal that distinguish patients with GD compared to healthy ideation (thoughts of engaging in behavior intended to end controls (Billieux et al., 2012; Michalczuk, Bowden-Jones, one’s life) and suicide attempts (any non-fatal self-destruc- Verdejo-Garcia, & Clark, 2011). Regarding BSED, patients tive act that includes a certain degree of intention to end with bulimia nervosa (BN) are more prone to report one’s life) (Gómez-Expósito et al., 2016; Mallorquí-Bagué higher levels of urgency and sensation seeking and less et al., 2018; Nock et al., 2008). Journal of Behavioral Addictions 11 (2022) 4, 963–978 965 Suicidal risk in the clinical population has been linked, METHODS besides biological vulnerabilities (van Heeringen, Bijttebier, & Godfrin, 2011), to a set of socio-demographic and psy- Participants and procedure chological factors. Socio-demographic factors include un- employment, family history of suicide, social isolation and The total sample consisted of 6,077 adults who sought the occurrence of adverse life events during childhood treatment and met criteria either for BSED (n 5 2,391) or (especially sexual and physical abuse) (Blakely, Collings, & GD (n 5 3,686). In our sample, patients with BSED included Atkinson, 2003; Cano-Montalbán & Quevedo-Blasco, 2018), individuals with a formal diagnosis of AN-BP (n 5 326), BN while psychological factors include hopelessness, impul- (n 5 1,440), BED (n 5 361) or Other Specified Feeding or sivity, fearlessness and pain insensitivity, as well as diffi- Eating Disorders (OSFED) with binge and purge episodes culties in problem solving and coping (O’Connor & Nock, (n 5 264). All patients were diagnosed according to DSM-5 2014). Specifically, in the case of GD, the literature has criteria (American Psychiatric Association, 2013). Patients identified a set of factors associated with suicide attempts, were recruited via consecutive referrals to the Eating Dis- namely psychological distress or depressive symptom- orders Unit and Behavioral Addictions Unit at Bellvitge atology, female gender, older age, financial debts and University Hospital, a tertiary care center highly specialized problem gambling severity (Carr, Ellis, & Ledgerwood, 2018; in the diagnosis and treatment of these mental disorders and Giovanni et al., 2017; Husky, Michel, Richard, Guignard, & other psychiatric disorders. All diagnoses were made by Beck, 2015; Ronzitti et al., 2017), as well as high scores in experienced clinical psychologists in the assessment and personality traits such as novelty seeking (propensity to be treatment of these two types of disorders. No compensation excited in response to novel stimuli) and harm avoidance for being part of the study was given. (tendency to inhibit responses to signals of aversive stimuli that lead to avoidance of punishment) (Guillou-Landreat Measures et al., 2016). Similarly, regarding suicide attempts in patients with BSED, factors such as psychological distress, comorbid Lifetime suicidal ideation and suicide attempts. The pres- psychiatric disorders -including affective, substance use and ence of lifetime suicidal ideation and a history of suicide anxiety disorders-, greater levels of psychopathology and attempts were assessed during a face-to-face structured severity of the disorder (Corcos et al., 2002; Gómez-Expósito clinical interview in which participants were asked about et al., 2016; Milos, Spindler, Hepp, & Schnyder, 2004) have past, recent, and present suicidal ideation and suicide been identified. In addition, personality traits such as high attempts. scores in persistence (propensity to persevere in spite of frustration and difficulties) and self-transcendence (incli- Diagnostic questionnaire for gambling disorder (according nation to conceive oneself as an integral part of the universe to DSM criteria) (Stinchfield, 2003). This is a self-report as a whole) and low scores in self-directedness (lack of a questionnaire designed to identify the presence of GD using tendency to be goal-oriented and self-confident) (Bulik, 19 items based on the DSM criteria [diagnoses are available Sullivan, & Joyce, 1999; Forcano et al., 2009) have been re- for the DSM-IV-TR (American Psychiatric Association, ported as well. 2000) and the DSM-5 versions (American Psychiatric As- However, even though BSED and GD share vulnerability sociation, 2013). To answer affirmatively to each item, the factors and clinical manifestations, to the best of the authors’ patient must have experienced the symptom for at least the knowledge there are no studies investigating common and last year. The psychometrical Spanish adaptation of this tool differential factors between these two types of disorders achieved adequate properties (Cronbach’s alpha α 5 0.81 for regarding suicide attempts. Improved knowledge of de- a population-based sample and α 5 0.77 for a clinical mographic, psychological and behavioral risk factors sample) (Jiménez-Murcia et al., 2009). The internal consis- behind suicidal behavior in impulsivity-related disorders can tency achieved in this study was good (α 5 0.70). inform appropriate harm reduction efforts and treatment approaches. Eating disorders Inventory-2 (EDI-2) (Garner, 1991); The aim of the present study was to identify common Spanish validation (Garner, 1998). This instrument was and differential risk factors behind suicide attempts in a used to assess different ED-related psychopathological sample of patients diagnosed with GD and in a sample of characteristics: drive for thinness, body dissatisfaction, patients diagnosed with BSED. It was hypothesized that, bulimia, ineffectiveness, perfectionism, interpersonal considering psychological factors, both BSED and GD pa- distrust, interoceptive awareness, maturity fears, asceticism, tients who attempt suicide share general risk factors such as impulse regulation, and social insecurity. The internal con- comorbid depressive symptomatology and unemployment. sistency in the present study was excellent (α 5 0.94). However, specific factors may differ according to the dis- order. Regarding socio-demographic factors, in the case of Symptom checklist-revised (SCL-90-R) (Derogatis, 1994). This patients with BSED, being young would be a greater risk for is a self-report questionnaire used to assess general psychopa- suicide attempts. As regards patients with GD, we hypoth- thology by means of 90 items factorized into nine primary di- esized that it would be vice versa. mensions (somatization, obsessive-compulsive, interpersonal 966 Journal of Behavioral Addictions 11 (2022) 4, 963–978 sensitivity, depression, anxiety, hostility, phobic anxiety, para- size for the means and the difference between proportions noid ideation, and psychoticism), and three global indices was estimated with the standardized Cohen’s-d coefficient [global severity index (GSI), positive symptom total (PST), and (effect size was considered low-poor |d| > 0.20, moderate- positive symptom distress index (PSDI)]. Participants are medium for |d| > 0.5, and large-high for |d| > 0.8) (Kelley & requested to answer each item by considering their symptoms Preacher, 2012). during the last few weeks including the day of the assessment. A Logistic regression selected the significant predictors of Spanish adaptation of this tool is available and obtained the suicidal behavior in the study. The set of independent adequate properties (the mean Cronbach’s alpha was α 5 0.75) variables of these models included the sociodemographic (Derogatis, 1997). In the present study, the internal consistency variables (gender, marital status, education, socioeconomic was also in the adequate to good range (α 5 0.790, for the index, employment and age), age of onset and duration of paranoid ideation scale, to α 5 0.981 for the global indices). the disorder, severity of the disorder, global psychopatho- Temperament and Character Inventory-Revised (TCI-R) logical distress (SCL-90-R GSI) and personality profile (TCI- (Cloninger, 1999). This questionnaire is based on Cloninger R scales). The predictive models in the study were per- model of personality and therefore assesses the four di- formed combining different estimate-procedures: a) a first mensions of temperament (harm avoidance, novelty seeking, model entered simultaneously and fixed all the predictors; reward dependence, and persistence) and the three di- b) a second model used stepwise method to automatically mensions of character (self-directedness, cooperativeness, select the significant predictors (this selection was used due and self-transcendence). Participants are requested to the large set of potential predictors and the exploratory nature answer each item considering how they usually act and feel, of the analysis) (Kleinbaum, Kupper, Nizam, & Rosenberg, not just how they feel or act at the moment of the assess- 2014); c) the final model was generated selecting all the sig- ment. A validated Spanish version of the questionnaire is nificant predictors obtained in the previous two steps, and it available and obtained adequate properties (the mean was only considered the most optimal if the final regression Cronbach’s alpha was α 5 0.87) (Gutiérrez-Zotes et al., allowed reliable clinical interpretation. A predictive model 2004). The internal consistency in the sample of the study was adjusted within the total sample, and two additional was in the adequate to good range (α 5 0.707, for reward models were also obtained stratified by the diagnostic subtype dependence, to α 5 0.861 for persistence). (GD and BSED) based on the potential moderator effect of Other relevant sociodemographic and clinical variables: this feature. For the predictive analysis, the whole dataset was socio-demographic characteristics including gender (female/ randomly split into two groups (regardless of diagnosis) for a male), age (years-old), employment status (unemployed or cross-validation procedure. The first group (which selected student and employed), socio-economic position index 50% of the participants) was used to obtain the predictive -according to Hollingshead’s scale (based on the partici- models; next, the resulting regressions were applied to the pants’ level of education, the profession and the employment cross-validation group (the other 50% of the participants), status) (Hollingshead, 2011)- marital status (single, married and a prediction was made summarized with the Nagelkerke’s or stable partner and divorced or separated), education level pseudo-R2 coefficient and the area under the curve (AUC) of (primary or less than primary, secondary and university), a receiver operating characteristic (ROC) curve. It was verified were collected. Clinical information was also collected con- that both groups were similar in the diagnostic distribution cerning age of onset and duration of the disorder (measured and the other variables used for obtaining the predictive in years). models. It was verified that both groups were similar in the In this study, the severity of the disorder was calculated diagnostic distribution and the other variables used for as the standardized T-score in the EDI-2 total score (for obtaining the predictive models. patients with BSED) and in the number of DSM-5 criteria To control the increase in the Type-I error due to the (for patients with GD). The standardized T-scores have been multiple statistical tests, Finner’s method was used, a fam- calculated from the normative data published in the Spanish ilywise error rate procedure which is more powerful than the validation studies of each tool. The converted T-scores classical Bonferroni correction (Finner, 1993). Familywise provide the position of the raw scores relative to the refer- error rate (FWER) is defined as the probability that statis- ence-normative groups, and they were used in the study for tical systems make at least k false rejections. When using comparing the symptom severity level between BSED versus these methods, a fixed number of k-1 of erroneous rejections GD patients (raw scores were not adequate because the is tolerated, and under the assumption that all the null hy- different ranges of the original scales). potheses are equal, controlling the FWER at α-level is equivalent to combine the set of P-values to obtain a single testing for H0 which is at level α. The use of Finner’s method Statistical analysis consists in adjusting the rejection criteria for each of the Statistical analysis was carried out with Stata16 for Windows individual hypothesis fixing the familywise error rate no (Stata-Corp, 2019). The comparisons between the groups for higher than a certain prespecified significance alpha-level the proportions registered in the categorical variables were (like α 5 0.05). Then, all the p(unadjusted)-values p1, …, pk based on chi-square tests (χ2), while analysis of variance obtained in k-independent null-hypothesis tests are ordered (ANOVA) was conducted to compare the means registered lowest-to-highest. The final step of the method consists in among the groups in the quantitative measures. The effect applying the next algorithm: p (adjusted) 5 (1 – (1-p (non- Journal of Behavioral Addictions 11 (2022) 4, 963–978 967 adjusted))^(total null-hypothesis tests/position of the test sports-betting or the stock market); c) mixed gambling is within the ordered tests)). considered for gamblers who select both gambling types, non-strategic and strategic. The likelihood of both suicide Ethics attempts and suicidal ideation was higher for BSED patients compared to GD (suicide attempts: χ 2 5 427.5, df 5 1, The present study was developed in accordance with the P < 0.001; |d| 5 0.54; suicidal ideation: χ 2 5 743.3, df 5 1, Declaration of Helsinki and approved by The Clinical P < 0.001; |d| 5 0.72). Additional information on the Research Ethics Committee (CEIC) of Bellvitge University prevalence of suicidal behavior according to the diagnostic Hospital (reference number: 307/06). Signed informed subtypes can be found in the Appendix and in Figure A1. consent was provided by all the patients participating in this study. Comparison between patients with and without suicide attempts RESULTS Table 1 contains the comparison of the phenotypes (socio- demographic and clinical variables of the study) between the Characteristics of the participants four groups defined by the diagnostic subtype and the sui- cide attempts (Fig. 2 also includes the graph-lines with the Table A1 includes the descriptive statistics of the sample of prevalence of patients outside the normative ranges in the GD and BSED patients. Differences between the diagnostic SCL-90-R and the TCI-R). The first column with the pair- subtypes were obtained for participants’ gender, marital wise comparisons of this table showed that among patients status, education, social index and employment status. with GD, the presence of suicidal behavior was related to Among the BSED subsample (compared to GD), the pro- female gender, individuals separated or divorced, lower so- portion was higher for female gender, single status, higher cial position indexes, unemployment, older age, longer education levels, lower social positions, and unemployed duration of the gambling problems, worse psychopatholog- or student states. Additionally, BSED patients reported ical state, higher scores in harm avoidance and self-tran- lower ages, earlier age of onset and longer duration of the scendence traits and lower scores in self-directedness. disorder. Among the BSED groups, the presence of suicide at- tempts was related to (see the second column with the Prevalence of suicidal behavior in the study pairwise comparisons in Table 1) lower education levels, Figure 1 includes the bar-chart with the prevalence of pa- lower social position indexes, earlier onset and longer tients with suicide attempts and suicidal ideation in the duration of the eating problems, higher severity of the eating study stratified by the diagnostic subtypes. The classification symptoms, worse psychopathological state, and personality of the gambling preference in this work was based on the traits characterized by higher scores in harm avoidance and individuals’ capacity-skills for impacting on the outcomes: self-transcendence, and lower scores in reward dependence, a) non-strategic gambling includes games with little delib- self-directedness and cooperativeness. eration or skill to predict the results (these games are also Finally, considering patients with GD and suicidal called total chance-based games, and include slot-machines, behavior versus BSED patients also with suicidal behavior, it bingo and lotteries); b) strategic gambling includes games was observed that BSED registered higher proportion of which allow gamblers to attempt to use some knowledge to women, single individuals, higher education levels, lower predict potential results (these games are also called skill- social indexes, unemployed/student status, younger age, based games, and includes games such as dice, poker, earlier onset and longer duration of the disorder, higher severity level of the disorder, worse psychopathological state and a personality phenotype characterized by lower scores in novelty seeking and self-directedness, and higher scores in harm avoidance. Predictive models for the presence of suicide attempts Table 2 contains the results of the predictive analysis in the study (the models obtained among the predictive-test group and the results within the cross-validation group). Among patients with GD (first model of the Table), the features with the significant contribution increasing the risk of sui- cidal behavior were: female gender, older age, earlier onset of the gambling problems, and higher levels in harm avoidance and self-transcendence. Among patients with BSED, the higher likelihood of suicidal behavior were: lower education levels, unemployment status, older age, earlier Fig. 1. Presence of suicidal behavior in the study (total sample) age of onset of the eating problems, higher severity of the 968 Journal of Behavioral Addictions 11 (2022) 4, 963–978 Table 1. Comparison between the groups with and without suicide attempts Descriptives Pairwise comparisons GD-SA GDþSA BSED-SA BSEDþSA GD-SA BSED-SA GDþSA (n 5 3,426) (n 5 260) (n 5 1,764) (n 5 627) GDþ SA BSEDþSA BSEDþSA n % n % n % n % p |d| p |d| p |d| Gender Women 278 8.1% 53 20.4% 1,655 93.8% 596 95.1% 0.001 p 0.36 0.258 0.05 0.001 p 1.76† Men 3,148 91.9% 207 79.6% 109 6.2% 31 4.9% Marital Single 1,433 41.8% 103 39.6% 1,269 71.9% 445 71.0% 0.015p 0.05 0.112 0.02 0.001p 0.64† Married/Partner 1,548 45.2% 101 38.8% 373 21.1% 123 19.6% 0.13 0.04 0.43 Divorced/Separated 445 13.0% 56 21.5% 122 6.9% 59 9.4% 0.23 0.09 0.34 Education Primary 1970 57.5% 158 60.8% 737 41.8% 331 52.8% 0.094 0.07 0.001p 0.22 0.001p 0.16 Secondary 1,232 36.0% 93 35.8% 754 42.7% 230 36.7% 0.00 0.12 0.02 University 224 6.5% 9 3.5% 273 15.5% 66 10.5% 0.14 0.15 0.29 Social index High 52 1.5% 1 0.4% 10 0.6% 4 0.6% 0.026p 0.12 0.001p 0.01 0.001p 0.04 Mean-high 162 4.7% 8 3.1% 64 3.6% 11 1.8% 0.09 0.12 0.09 Mean 375 10.9% 26 10.0% 110 6.2% 18 2.9% 0.03 0.16 0.30 Mean-low 1,093 31.9% 78 30.0% 732 41.5% 246 39.2% 0.04 0.05 0.19 Low 1744 50.9% 147 56.5% 848 48.1% 348 55.5% 0.11 0.15 0.02 Laboral Unem./student 1,428 41.7% 143 55.0% 1,247 70.7% 522 83.3% 0.001p 0.27 0.001p 0.30 0.001p 0.63† Employed 1998 58.3% 117 45.0% 517 29.3% 105 16.7% Mean SD Mean SD Mean SD Mean SD P |d| P |d| P |d| Age (yrs) 41.50 13.32 44.67 11.71 28.60 9.48 28.17 9.28 0.001 p 0.25 0.443 0.05 0.001 p 1.56† Onset disorder (yrs) 29.75 11.71 29.95 10.82 20.51 8.26 18.63 8.18 0.758 0.02 0.001p 0.23 0.001p 1.18† Duration disorder (yrs) 6.06 5.87 7.48 6.59 8.14 7.12 9.62 6.95 0.001p 0.23 0.001p 0.21 0.001p 0.32 Severity of disorder 86.28 10.33 87.24 9.92 84.13 12.21 90.78 8.37 0.163 0.09 0.001p 0.64† 0.001p 0.39 SCL-90R Somatic 1.00 0.80 1.32 0.94 1.80 0.68 2.25 0.60 0.001p 0.37 0.001p 0.70† 0.001p 1.17† SCL-90R Obss-com 1.21 0.81 1.47 0.85 1.90 0.66 2.26 0.56 0.001p 0.32 0.001p 0.59† 0.001p 1.09† SCL-90R Int.sens. 1.09 0.82 1.36 0.92 2.06 0.71 2.31 0.59 0.001p 0.30 0.001p 0.38 0.001p 1.23† SCL-90R Depress. 1.58 0.88 2.06 0.95 2.22 0.69 2.69 0.55 0.001p 0.53† 0.001p 0.76† 0.001p 0.81† SCL-90R Anx 1.07 0.79 1.44 0.91 1.66 0.68 2.13 0.61 0.001p 0.43 0.001p 0.73† 0.001p 0.89† SCL-90R Hostility 0.99 0.83 1.17 0.95 1.38 0.77 1.78 0.73 0.001p 0.20 0.001p 0.54† 0.001p 0.72† SCL-90R Pho.Anx 0.51 0.67 0.80 0.85 1.01 0.69 1.46 0.66 0.001p 0.38 0.001p 0.66† 0.001p 0.86† SCL-90R Paranoia 0.99 0.78 1.17 0.90 1.47 0.67 1.74 0.56 0.001p 0.22 0.001p 0.44 0.001p 0.76† SCL-90R Psychotic 0.97 0.75 1.26 0.84 1.33 0.57 1.63 0.55 0.001p 0.36 0.001p 0.53† 0.001p 0.52† SCL-90R GSI 1.12 0.69 1.44 0.77 1.75 0.55 2.13 0.48 0.001p 0.44 0.001p 0.74† 0.001p 1.07† SCL-90R PST 48.3 20.8 53.4 21.0 44.8 27.9 39.7 30.7 0.001p 0.24 0.001p 0.17 0.001p 0.52† SCL-90R PSDI 1.93 0.58 2.24 0.66 2.37 0.43 2.62 0.36 0.001p 0.50† 0.001p 0.63† 0.001p 0.72† TCI-R Novelty seeking 110.6 12.7 111.2 13.7 103.0 12.9 103.9 11.0 0.475 0.04 0.121 0.08 0.001p 0.59† TCI-R Harm avoidance 101.3 16.1 107.1 16.5 117.1 15.6 122.9 13.1 0.001p 0.36 0.001p 0.40 0.001p 1.06† TCI-R Reward depend. 97.9 13.9 97.2 13.7 102.8 12.6 98.9 10.3 0.371 0.06 0.001p 0.34 0.079 0.14 TCI-R Persistence 108.2 18.8 107.3 19.3 107.2 16.5 106.8 15.0 0.439 0.05 0.702 0.02 0.715 0.03 TCI-R Self-directedness 125.7 19.4 118.3 17.4 115.0 15.9 108.0 13.0 0.001p 0.40 0.001p 0.51† 0.001p 0.67† TCI-R Cooperativeness 129.3 15.4 128.3 15.2 133.1 12.5 128.9 11.3 0.304 0.06 0.001p 0.35 0.566 0.04 TCI-R Self-transcend. 63.7 14.1 67.8 15.1 64.3 11.8 68.2 10.5 0.001p 0.28 0.001p 0.35 0.699 0.03 Note. GD-SA: gambling disorder without suicide attempts. GDþSA: gambling disorder with suicide attempts. BSED-SA: bulimic spectrum eating disorder without suicide attempts. BSEDþSA: bulimic spectrum eating disorder with suicide attempts. SD: standard deviation. p Bold: significant comparison (0.05). † Bold: effect size into the ranges mild-moderate (|d| > 0.50) to the high-large (|d| > 0.80). eating problems, worse psychopathological distress, and earlier onset, higher severity of the disorder, higher psy- higher level in self-transcendence. According to the model chopathological distress, higher harm avoidance and self- obtained for the whole sample, the diagnostic subtype transcendence. The similar results (parameter estimates and contributed to the risk of suicidal behavior (patients with the global predictive indexes) obtained in both groups (the BSED achieved higher likelihood). Once the diagnostic type predictive-estimation and the cross-validation groups) is considered, other contributors to the presence of suicidal provided empirical validity to the results of the predictive behavior were female gender, unemployed status, older age, analyses. Journal of Behavioral Addictions 11 (2022) 4, 963–978 969 Fig. 2. Percentage of participants within the non-normative range To sum up the results obtained in the study, Fig. 3 in- Risk factors for suicide attempts that GD and BSED cludes the main features related to the presence of suicidal have in common behavior for each condition (in the center of the figure, the factors in common). The predictive model carried out in the present study indi- cated that the four factors that are more associated with suicide attempts in both types of disorders were unem- ployment, early onset of the disorder, high psychological DISCUSSION distress and high scores in self-transcendence. Consistent with previous studies and following the first hypothesis of The present study aimed to identify which risk factors of the present study, unemployment has been described as a suicide attempts a sample of patients with GD and a sample predictor of suicide attempts in the case of GD (Guillou- of patients with BSED have in common and which risk Landreat et al., 2016; Komoto, 2014; Newman & Thompson, factors are different. To the best of the authors’ knowledge, 2007; Thon et al., 2014), in BN (Forcano et al., 2009; this is the first study to examine risk factors in these two Goldstein & Gvion, 2019; Nickel et al., 2006) and in the related disorders following a transdiagnostic approach. In general population irrespectively of the presence of a mental accordance with previous literature, both suicidal ideation disorder (Blakely et al., 2003; Haw, Hawton, Gunnell, & and suicide attempts were more prevalent in BSED Platt, 2015; Nordt, Warnke, Seifritz, & Kawohl, 2015). The (particularly in those subtypes with purging episodes) relevance of unemployment may be interpreted by the fact compared to GD (Bodell et al., 2013; Fernández-Aranda that it is often associated with previous social maladjustment et al., 2021; Foulon et al., 2007; Mandelli et al., 2019; Thon (Sciulli, 2016) as well as great difficulties to overcome et al., 2014). Patients with binge/purge disorders might financial problems due to a lack of a regular income and low become less sensitive to pain due to the constant self-harm levels of subjective well-being (Paul, Vastamäki, & Moser, that purging-related behavior may cause through actions 2016). Another interesting finding was that an early onset of such as vomiting and excessive use of laxatives (Mandelli the disorder was associated with a greater likelihood of a et al., 2019). This fact has led to the hypothesis that purging suicide attempt later in life. Bischof et al. (2015) explained behavior might be a critical risk factor for committing a that individuals with gambling problems and suicidal idea- suicidal act but the underlying mechanisms that accounts for tion were more likely to report an early onset of maladaptive this phenomenon remains uncertain (Franko et al., 2004). It gambling behavior. In a study carried out in a sample of is worth noting that prevalence estimates of lifetime suicide patients with ED, the authors identified that an early onset attempts both in BSED and GD in the present sample are of the disorder was related to a higher risk of suicide only in significantly higher compared to previous epidemiological the case of BN and BED (Udo et al., 2019). studies that estimated this behavior to range between Additionally, the results from the present study indicated 1% and 4.6% in the general population (Kessler, Borges, & that greater psychological distress is a key factor that might Walters, 1999; Lee et al., 2007). predict a future suicide attempt. Patients with BSED who 970 Table 2. Predictive models for the presence of suicidal behavior: stepwise logistic regression Group for the obtaining the prediction model Group for the cross-validation 2 B SE p OR 95% CI OR NR AUC B SE p OR 95% CI OR NR2 AUC 1 GD; n 5 1,841 and 1,845 0.060 0.674 0.074 0.679 Gender (1 5 men vs 0 5 women) 0.987 0.239 <0.001 0.373 0.233 0.596 0.770 0.261 0.003 0.463 0.278 0.772 Chronological age (yrs-old) 0.030 0.010 0.003 1.030 1.010 1.051 0.038 0.011 <0.001 1.039 1.017 1.061 Age of onset (yrs-old) 0.035 0.012 0.003 0.966 0.944 0.988 0.041 0.012 0.001 0.960 0.937 0.983 TCI-R: Harm-avoidance 0.017 0.006 0.002 1.018 1.006 1.029 0.022 0.006 <0.001 1.022 1.011 1.034 TCI-R: Self-transcendence 0.016 0.006 0.013 1.016 1.003 1.029 0.021 0.006 0.001 1.022 1.009 1.034 1 BSED; n 5 1,214 and 1,177 0.196 0.641 0.216 0.656 Education (higher levels) 0.098 0.105 0.349 0.907 0.739 1.113 0.404 0.110 <0.001 0.668 0.538 0.829 Employment (employed) 0.993 0.194 <0.001 0.371 0.253 0.542 0.613 0.188 0.001 0.542 0.374 0.784 Age (yrs-old) 0.039 0.010 <0.001 1.040 1.020 1.061 0.026 0.011 0.015 1.026 1.005 1.048 Age of onset (yrs-old) 0.051 0.012 <0.001 0.950 0.928 0.973 0.045 0.013 <0.001 0.956 0.932 0.980 Severity of the BSED 0.033 0.010 0.002 1.033 1.012 1.055 0.040 0.010 <0.001 1.040 1.019 1.062 Journal of Behavioral Addictions 11 (2022) 4, 963–978 SCL-90R: GSI 0.944 0.205 <0.001 2.570 1.721 3.839 0.848 0.187 <0.001 2.335 1.618 3.370 TCI-R: Self-transcendence 0.014 0.007 0.039 1.014 1.001 1.028 0.028 0.007 <0.001 1.029 1.015 1.043 1 Total; n 5 3,055 and 3,022 0.216 0.666 0.228 0.685 Disorder (1 5 BSED vs 0 5 GD) 0.388 0.227 0.087 1.474 0.945 2.300 0.812 0.241 0.001 2.251 1.404 3.609 Gender (1 5 men vs 0 5 women) 0.658 0.205 0.001 0.518 0.346 0.775 0.345 0.215 0.049 0.708 0.465 0.998 Employment (employed) 0.575 0.127 <0.001 0.563 0.439 0.722 0.592 0.129 <0.001 0.553 0.430 0.712 Age (yrs-old) 0.030 0.007 <0.001 1.031 1.017 1.045 0.028 0.007 <0.001 1.028 1.013 1.043 Age of onset (yrs-old) 0.038 0.008 <0.001 0.963 0.947 0.978 0.036 0.009 <0.001 0.964 0.948 0.981 Severity of the disorder 0.022 0.007 0.001 1.022 1.009 1.035 0.024 0.007 <0.001 1.024 1.011 1.038 SCL-90R: GSI 0.543 0.112 <0.001 1.720 1.383 2.141 0.450 0.116 <0.001 1.568 1.248 1.969 TCI-R: Harm avoidance 0.010 0.004 0.026 1.010 1.001 1.018 0.011 0.004 0.018 1.011 1.002 1.020 TCI-R: Self-transcendence 0.014 0.005 0.004 1.014 1.004 1.024 0.022 0.005 <0.001 1.022 1.013 1.032 Note. SE: standard error. OR: odds ratio. NR2: Nagelekerke’s pseudo-R2. AUC: Area under the receiver operator curve (ROC) Journal of Behavioral Addictions 11 (2022) 4, 963–978 971 did find that younger age was associated with a higher risk for suicidal behavior (Tae & Chae, 2021; Wardle & McManus, 2021), our findings are in line with other studies which have found that older age is a risk factor in addictive behaviors (Guillou-Landreat et al., 2016; Mallorquí-Bagué et al., 2018; Yuodelis-Flores & Ries, 2015). The association Fig. 3. Main features related to the presence of suicidal behavior in between a great suicidal risk and older age may be due to a the study cumulative effect of several years of financial and familial damages. While younger individuals with gambling prob- lems may foresee possibilities to start a new life free of gambling, this may be seen as more complicated in the case reported higher scores in the SCL-90-R GSI increased the of older individuals who have accumulated several negative likelihood of suicide attempts. Specifically, depressive consequences and may find more difficulties to find a way symptomatology is especially predominant in patients with out of their current situation. Following this idea, a recent suicide attempts, as we found in the present study, as well as it was described in previous studies (Bischof et al., 2016; study described that older patients with GD were more likely to present comorbid health problems and greater emotional Corcos et al., 2002; Guillou-Landreat et al., 2016). distress (Granero et al., 2014). The results from the present Interestingly, in the present study, higher scores in self- study led to partially support the hypothesis given that only transcendence personality trait appeared to be a trans- the association between older age and risk of a suicide diagnostic risk factor for suicide attempts in GD and BSED. attempt was applicable in GD, but the contrary was not Self-transcendence refers to the experience of spiritual ideas applicable in BSED, as it was hypothesized. Therefore, more and considering oneself an integral part of the universe and studies are required to elucidate the role of age in terms of it has been described earlier as a risk factor for suicidal events in BSED (Anderson, Carter, McIntosh, Joyce, & suicide risk. Finally, the present study indicated that greater levels of Bulik, 2002; Bulik et al., 1999). Despite the fact that it is the harm avoidance are observed in patients with GD with sui- most scientifically controversial character dimension of cide attempts compared to those without suicidal risk. This Cloninger’s theory of personality (MacDonald & Holland, difference was not detected in patients with BSED. This is in 2002), it has been described as a risk factor for suicidal line with a previous study which described that high levels of behavior in mood disorders and psychotic disorders (Jakšic harm avoidance and novelty seeking were observed in in- & Margetic, 2017; Woo et al., 2014). In that sense, self- dividuals with GD (Guillou-Landreat et al., 2016). Harm transcendence may constitute an important variable to consider when assessing patients with GD and BSED to avoidance is related to negative emotionality in conjunction with the tendency to inhibit responses to signals of aversive detect individuals at higher risk for suicidal behavior. stimuli. It has been described as a personality trait in suicidal Nevertheless, self-transcendence on its own is not enough to individuals (Calati et al., 2008; Perroud, Baud, Mouthon, predict future suicide attempts as it is the combination of Courtet, & Malafosse, 2011) and it is common in female certain temperament and character dimensions which in- patients with GD (Jiménez-Murcia et al., 2020). creases the likelihood of suicidal behavior. In a study carried Concerning the specific risk factors that appeared to be out in a sample of patients with ED, high scores in persis- associated with a greater likelihood of presenting a history of tence and self-transcendence and low score in self-direct- edness were associated with a history of suicide attempts suicide attempt in BSED, the present study’s findings indi- cated that lower education constituted a relevant factor. Low (Bulik et al., 1999). In another study, only self-transcendence education has previously been identified as a risk factor for and low self-directedness were associated with suicide at- suicidal behavior in BN (Forcano et al., 2009) and in other tempts in individuals with BN (Favaro et al., 2008). mental disorders (Christiansen, Agerbo, Larsen, Bilenberg, Differential risk factors for suicide attempts in GD and & Stenager, 2015), as well as in the general population (Abel & Kruger, 2005). BSED Our results also suggested that longer duration of the Regarding specific risk factors for suicide attempts in GD, BSED is more frequent in patients reporting a lifetime his- and consistent with previous research, we found that women tory of suicide attempts. Based on the abovementioned constitute a vulnerable group in terms of suicidal behavior finding from our study which indicates that older age con- (Bischof et al., 2015; Carr et al., 2018; Husky et al., 2015). stitutes a risk factor in GD, chronicity in BSED may Gender differences in suicide rate may be explained by aggravate the individual’s perception that nothing can be differences in emotional and behavioral problems (Kaess done to resolve the situation and suicide appears to be a et al., 2011). drastic solution to end the suffering. As described in previ- Another relevant finding from the current study was that ous studies (Forcano et al., 2009; Fennig & Hadas, 2010; patients with GD with a history of suicide attempts are older Stein, Lilenfeld, Wildman, & Marcus, 2004), patients with compared to patients with GD but without suicide attempts. longer duration of the ED are at higher risk to report a This significant difference could not be found in our sample history of suicide attempts. Contrary to this association, in a regarding patients with BSED. Even though several studies recent study, longer duration and suicide attempts were only 972 Journal of Behavioral Addictions 11 (2022) 4, 963–978 detected in AN while in the case of BN shorter duration was and other behavioral addictions, anorexia nervosa, obsessive- associated with suicide (Udo et al., 2019). compulsive disorder or body dysmorphic disorder. Lastly, our results pointed out the fact that patients with This study had the objective to identify common and BSED and lower reward dependence scores are at greater differential risk factors behind suicidal behavior, taking into risk to commit a suicide act. This feature has also been account that both disorders (GD and BSED) share two suggested by previous studies, adding that lower scores self- crucial risk factors such as high levels of impulsivity and directedness and cooperation and higher scores in harm emotional dysregulation, among others. Therefore, this avoidance have been described as a profile of personality study is contextualized in this translational perspective. especially at risk for committing suicide acts (Forcano et al., However, it will be essential to expand the samples in the 2009; Gómez-Expósito et al., 2016). Therefore, both future, in order to obtain groups of men and women that are temperament and character seemed to play an important more similar in number, reducing the potential effect of this role in determining the risk of suicidal events. Following this variable. Finally, despite the fact that psychopathological idea, lower reward dependence and cooperativeness seem to symptoms were assessed through SCL-90-R, comorbid be associated with a greater suicidal risk which could indi- mental disorders were not assessed -particularly depression cate that a strong social sphere may be a crucial protective followed by substance use disorders, psychotic disorders and factor for suicidal events (Coppersmith, Kleiman, Glenn, personality disorders which have been described as Millner, & Nock, 2019; Amitai & Apter, 2012). frequently present in individuals with lifetime suicide at- A dimensional conceptualization of mental disorders tempts (Bachmann, 2018; Probert-Lindström, Berge, West- reveals that transdiagnostic clinical features such as impul- rin, Öjehagen, & Skogman Pavulans, 2020)- and hence the sivity allow grouping seemingly unrelated disorders from a present findings may show some degree of bias. categorical perspective such as GD and BSED. Grouping Nevertheless, this study also presents relevant strengths. disorders under the prism of impulsivity makes it clear that Firstly, the large sample size of patients who sought treat- these disorders share clinical features, risk factors and be- ment with either GD or BSED provides robustness to the haviors, and opens the door to transdiagnostic treatments findings. Secondly, to the authors’ knowledge, this is the first that attempt to address the core elements of these disorders study considering transdiagnostic risk factors for suicide such as difficulties in emotional regulation and inhibitory attempts in two related disorders. control as well as repetitive desires to perform an act despite having negative consequences (Hamilton et al., 2015; Kim Conclusions et al., 2018). GD and BSED share risk factors for suicide attempts which constitute more evidence supporting that both disorders Limitations and strengths share a common impulsivity-related substratum. Some of The present findings should be interpreted cautiously due to the risk factors for suicide attempts may be considered as several limitations. First, this study was based on a cross- transdiagnostic risk factors of impulsivity-related disorders, sectional study design which did not allow to assess a po- and therefore clinicians may consider them when assessing tential causal link between the abovementioned risk factors the suicidal risk in this profile of patients. However, specific and suicide attempts. Second, given that suicidal ideation risk factors in each disorder have been identified and they and suicide attempts were assessed during a semi-structured led us to conclude that, after considering transdiagnostic risk interview and no specific assessment tool for measuring factors, clinicians would need to pay attention to particular suicidal behavior was used, complementary information risk factors of each disorder to reduce the risk of suicide. The such as suicide severity was not contemplated. Third, the use present study may have clear clinical and research implica- of a clinical sample of individuals who sought treatment may tions given that it provides a greater insight into the factors create a bias as many individuals with BSED and GD do not associated with suicidal risk in patients with a particular seek treatment. Following this idea, most of the participants vulnerability to such a dramatic behavior. with GD were men while most of the subjects with BSED were women. This gender unbalance in clinical samples -which has been widely described in previous studies- is very Funding sources: Financial support was received through the frequent (Masheb et al., 2021; Wong, Zane, Saw, & Chan, Ministerio de Ciencia, Innovación y Universidades through 2013) and, for this reason, more studies are needed aiming at the grant RTI2018-101837-B-100 (co-funded by European reducing this gender imbalance in the samples. Beyond the Regional Development Fund. ERDF, a way to build Europe). specific disorders with their sociodemographic and clinical FIS PI20/132, FIS PI17/01167 received aid from the Minis- manifestations and their differential risk profiles, the perspec- terio de Sanidad, Servicios Sociales e Igualdad. The research tive of dimensional classification of diseases, from a trans- was also funded by the Delegación del Gobierno para el Plan diagnostic point of view, tries to identify shared risk factors in Nacional sobre Drogas (2019I47 and 2021I031), CIBER pathologies as apparently different as those under study in this Fisiología Obesidad y Nutrición (CIBERobn) is an initiative research (BSED and GD), but also others. All these conditions of ISCIII. We thank CERCA Programme/Generalitat de could be included in the impulsive-compulsive spectrum dis- Catalunya for institutional support. E.V.-M. received orders, such as substance use disorders, compulsive shopping financial support through the 2021 grant to conclude the Journal of Behavioral Addictions 11 (2022) 4, 963–978 973 doctoral thesis from the Research Commission of Bellvitge and their first-degree relatives. Journal of Gambling Studies, 31, Campus, School of Medicine and Health Sciences, Univer- 1201–1214. https://doi.org/10.1007/s10899-014-9505-y. sity of Barcelona. Blakely, T. A., Collings, S. C. D., & Atkinson, J. (2003). Unem- ployment and suicide. Evidence for a causal association? Jour- Authors’ contribution: Study concept and design: E.V.-M., nal of Epidemiology and Community Health, 57(8), 594–600. S.J.-M., F.F.-A. and R.G. Project Administration: E.V.-M., https://doi.org/10.1136/jech.57.8.594. C.V.-A., B.M.-M., S.V.-S., I.S., J.J.-D., M.G.-P. and L.M. Bodell, L. P., Joiner, T. E., & Keel, P. K. (2013). Comorbidity-in- Analysis and interpretation of data: R.G., E.V.-M., F.F.-A. dependent risk for suicidality increases with bulimia nervosa and S.J.-M. Statistical analysis: R.G. Obtained funding: F.F.-A. but not with anorexia nervosa. Journal of Psychiatric Research, and S.J.-M. Study supervision: S.J.-M., F.F.-A. 47(5), 617–621. https://doi.org/10.1016/j.jpsychires.2013.01. 005. Conflict of interest: F.F.-A. received consultancy honoraria Bulik, C. M., Sullivan, P. F., & Joyce, P. R. (1999). Temperament, from Novo Nordisk and editorial honoraria as EIC from character and suicide attempts in anorexia nervosa, bulimia Wiley. The rest of the authors declare no conflict of interest. nervosa and major depression. Acta Psychiatrica Scandinavica, 100(1), 27–32. https://doi.org/10.1111/j.1600-0447.1999. tb10910.x. Calado, F., & Griffiths, M. D. (2016). Problem gambling worldwide: REFERENCES An update and systematic review of empirical research (2000– 2015). Journal of Behavioral Addictions, 5(4), 592–613. https:// Abel, E. L., & Kruger, M. L. (2005). Educational attainment and doi.org/10.1556/2006.5.2016.073. suicide rates in the United States. Psychological Reports, 97(1), Calati, R., Giegling, I., Rujescu, D., Hartmann, A. M., Möller, H. J., 25–28. https://doi.org/10.2466/pr0.97.1.25-28. De Ronchi, D., & Serretti, A. (2008). Temperament and character American Psychiatric Association. (2000). Diagnostic and statistical of suicide attempters. Journal of Psychiatric Research, 42(11), manual of mental disorders: DSM-IV-TR (text revision). 938–945. https://doi.org/10.1016/j.jpsychires.2007.10.006. American Psychiatric Association. Cano-Montalbán, I., & Quevedo-Blasco, R. (2018). Sociodemo- American Psychiatric Association (2013). Diagnostic and statistical graphic variables most associated with suicidal behaviour and manual of mental disorders: DSM-5 (5th ed.). American Psy- suicide methods in Europe and America. A systematic review. chiatric Association. European Journal of Psychology Applied to Legal Context, 10(1), Amitai, M., & Apter, A. (2012). Social aspects of suicidal behavior 15–25. https://doi.org/10.5093/ejpalc2018a2. and prevention in early life: A review. International Journal of Carr, M. M., Ellis, J. D., & Ledgerwood, D. M. (2018). Suicidality Environmental Research and Public Health, 9(3), 985–994. among gambling helpline callers: A consideration of the role of https://doi.org/10.3390/ijerph9030985. financial stress and conflict. American Journal on Addictions, Anderson, C. B., Carter, F. A., McIntosh, V. V., Joyce, P. R., & 27(6), 531–537. https://doi.org/10.1111/ajad.12787. Bulik, C. M. (2002). Self-harm and suicide attempts in in- Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause dividuals with bulimia nervosa. Eating Disorders, 10(3), 227–243. and suicide mortality in mental disorders: A meta-review. https://doi.org/10.1002/erv.472. World Psychiatry, 13(2), 153–160. https://doi.org/10.1002/wps. Bachmann, S. (2018). Epidemiology of suicide and the psychiatric 20128. perspective. International Journal of Environmental Research Christiansen, E., Agerbo, E., Larsen, K. J., Bilenberg, N., & and Public Health, 15(7), 1–23. https://doi.org/10.3390/ Stenager, E. (2015). Youth, suicide attempts and low level of ijerph15071425. education: A Danish historical register-based cohort study of Billieux, J., Lagrange, G., Van der Linden, M., Lançon, C., Adida, M., the outcome of suicide attempt. International Journal of & Jeanningros, R. (2012). Investigation of impulsivity in a sample Social Psychiatry, 61(8), 802–810. https://doi.org/10.1177/ of treatment-seeking pathological gamblers: A multidimensional 0020764015597460. perspective. Psychiatry Research, 198(2), 291–296. https://doi.org/ Claes, L., Vandereycken, W., & Vertommen, H. (2005). Impul- 10.1016/j.psychres.2012.01.001. sivity-related traits in eating disorder patients. Personality and Bischof, A., Meyer, C., Bischof, G., John, U., Wurst, F. M., Thon, N., Individual Differences, 39(4), 739–749. https://doi.org/10.1016/ … Rumpf, H. J. (2015). Suicidal events among pathological j.paid.2005.02.022. gamblers: The role of comorbidity of axis I and axis II disorders. Cloninger, C. (1999). The Temperament and Character Inventory- Psychiatry Research, 225(3), 413–419. https://doi.org/10.1016/j. Revised. St.Louis, MO, USA: Center for Psychobiology of Per- psychres.2014.11.074. sonality, Washington University. Bischof, A., Meyer, C., Bischof, G., John, U., Wurst, F. M., Thon, N., Coppersmith, D. D. L., Kleiman, E. M., Glenn, C. R., Millner, A. J., … Thomas, L. (2016). Type of gambling as an independent risk & Nock, M. K. (2019). The dynamics of social support among factor for suicidal events in pathological gamblers. Psychology of suicide attempters: A smartphone-based daily diary study. Addictive Behaviors, 30(2), 263–269. https://doi.org/10.1037/ Behaviour Research and Therapy, 120. https://doi.org/10.1016/j. adb0000152. brat.2018.11.016. Black, D. W., Coryell, W. H., Crowe, R. R., Shaw, M., McCormick, B., Corcos, M., Taïeb, O., Benoit-Lamy, S., Paterniti, S., Jeammet, P., & & Allen, J. (2014). Personality disorders, impulsiveness, and Flament, M. F. (2002). Suicide attempts in women with bulimia novelty seeking in persons with DSM-IV pathological gambling nervosa: Frequency and characteristics. Acta Psychiatrica 974 Journal of Behavioral Addictions 11 (2022) 4, 963–978 Scandinavica, 106(5), 381–386. https://doi.org/10.1034/j.1600- Foulon, C., Guelfi, J. D., Kipman, A., Adès, J., Romo, L., Houdeyer, K., 0447.2002.02318.x. … Gorwood, P. (2007). Switching to the bingeing/purging sub- Costanza, A., Rothen, S., Achab, S., Thorens, G., Baertschi, M., type of anorexia nervosa is frequently associated with suicidal Weber, K., … Zullino, D. (2020). Impulsivity and impulsivity- attempts. European Psychiatry, 22(8), 513–519. https://doi.org/10. related endophenotypes in suicidal patients with substance use 1016/j.eurpsy.2007.03.004. disorders: An exploratory study. International Journal of Franko, D. L., Keel, P. K., Dorer, D. J., Blais, M. A., Delinsky, S. S., Mental Health and Addiction, 19, 1729–1744. https://doi.org/ Eddy, K. T., … Herzog, D. B. (2004). What predicts suicide 10.1007/s11469-020-00259-3. attempts in women with eating disorders? Psychological Dalgleish, T., Black, M., Johnston, D., & Bevan, A. (2020). Trans- Medicine, 34(5), 843–853. https://doi.org/10.1017/S00332917 diagnostic approaches to mental health problems: Current 03001545. status and future directions. Journal of Consulting and Clinical Garner, D. (1991). Eating disorder inventory-2. Psychological Psychology, 88(3), 179– 195. https://doi.org/10.1037/ccp Assessment Resources. 0000482. Garner, D. (1998). Inventario de Trastornos de la Conducta ali- Davis, C., Mackew, L., Levitan, R. D., Kaplan, A. S., Carter, J. C., & mentaria (EDI-2). TEA ediciones. Kennedy, J. L. (2017). Binge Eating Disorder (BED) in Relation Giovanni, M., Fabiola, S., Federica, F., Mariangela, C., Nicola, P., to addictive behaviors and personality risk factors. Frontiers in Ilaria, T., … Massimo, D. G. (2017). Gambling disorder and Psychology, 8. https://doi.org/10.3389/fpsyg.2017.00579. suicide: An overview of the associated co-morbidity and clinical Del Pino-Gutiérrez, A., Jiménez-Murcia, S., Fernández-Aranda, F., characteristics. International Journal of High Risk Behaviors and Agüera, Z., Granero, R., Hakansson, A., … Menchón, J. M. Addiction, 6(3). https://doi.org/10.5812/ijhrba.30827. (2017). The relevance of personality traits in impulsivity-related Goldstein, A., & Gvion, Y. (2019). Socio-demographic and psy- disorders: From substance use disorders and gambling disorder chological risk factors for suicidal behavior among individuals to bulimia nervosa. Journal of Behavioral Addictions, 6(3), 396– with anorexia and bulimia nervosa: A systematic review. Jour- 405. https://doi.org/10.1556/2006.6.2017.051. nal of Affective Disorders, 245, 1149–1167. https://doi.org/10. Derogatis, L. R. (1994). Symptom checklist-90-revised: Adminis- 1016/j.jad.2018.12.015. tration, scoring and procedures manual. Symptom checklist-90- Gómez-Expósito, A., Wolz, I., Fagundo, A. B., Granero, R., Steward, T., R(SCL-90-R) administration, scoring, and procedures manual Jiménez-Murcia, S., … Fernández-Aranda, F. (2016). Correlates of (3rd ed.). non-suicidal self-injury and suicide attempts in bulimic spectrum Derogatis, L.R. (1997). SCL-90-R. Cuestionario de 90 Síntomas. disorders. Frontiers in Psychology, 7. https://doi.org/10.3389/fpsyg. Madrid, Spain: TEA Ediciones. 2016.01244. Favaro, A., Santonastaso, P., Monteleone, P., Bellodi, L., Mauri, M., Granero, R., Penelo, E., Stinchfield, R., Fernandez-Aranda, F., Rotondo, A., … Maj, M. (2008). Self-injurious behavior and Savvidou, L. G., Fröberg, F., … Jiménez-Murcia, S. (2014). attempted suicide in purging bulimia nervosa: Associations Is pathological gambling moderated by age? Journal of with psychiatric comorbidity. Journal of Affective Disorders, Gambling Studies, 30, 475–492. https://doi.org/10.1007/s10899- 105(1–3), 285–289. https://doi.org/10.1016/j.jad.2007.05.010. 013-9369-6. Fennig, S., & Hadas, A. (2010). Suicidal behavior and depression in Guillou-Landreat, M., Guilleux, A., Sauvaget, A., Brisson, L., Leb- adolescents with eating disorders. Nordic Journal of Psychiatry, oucher, J., Remaud, M., … Grall-Bronnec, M. (2016). Factors 64(1), 32–39. https://doi.org/10.3109/08039480903265751. associated with suicidal risk among a French cohort of problem Fernández-Aranda, F., Treasure, J., Paslakis, G., Agüera, Z., gamblers seeking treatment. Psychiatry Research, 240, 11–18. Giménez, M., Granero, R., Sánchez, I., Serrano-Troncoso, E., https://doi.org/10.1016/j.psychres.2016.04.008. Gorwood, P., Herpertz-Dahlmann, B., Bonin, E. M., Mon- Gutiérrez-Zotes, J. A., Bayón, C., Montserrat, C., Valero, J., Labad, A., teleone, P., & Jiménez-Murcia, S. (2021). The impact of dura- & Cloninger, C. R. (2004). Temperament and Character In- tion of illness on treatment nonresponse and drop-out: ventory-Revised (TCI-R). Standardization and normative data in Exploring the relevance of enduring eating disorder concept. a general population sample. Actas Españolas de Psiquiatria, European Eating Disorders Review, 29(3), 499–513. https://doi. 32(1), 8–15. org/10.1002/erv.2822. Gvion, Y., Levi-Belz, Y., Hadlaczky, G., & Apter, A. (2015). On the Finner, H. (1993). On a monotonicity problem in step-down multiple role of impulsivity and decision-making in suicidal behavior. test procedures. Journal of the American Statistical Association, 88, World Journal of Psychiatry, 5(3), 255–259. https://doi.org/10. 920–923. https://doi.org/10.1080/01621459.1993.10476358. 5498/wjp.v5.i3.255. Forcano, L., Álvarez, E., Santamaría, J. J., Jimenez-Murcia, S., Hamilton, K. R., Mitchell, M. R., Wing, V. C., Balodis, I. M., Bickel, Granero, R., Penelo, E., … Fernández-Aranda, F. (2011). Sui- W. K., Fillmore, M., …, … Moeller, F. G. (2015). Choice cide attempts in anorexia nervosa subtypes. Comprehensive impulsivity: Definitions, measurement issues, and clinical im- Psychiatry, 52(4), 352– 358. https://doi.org/10.1016/j. plications. Personality Disorders: Theory, Research, and Treat- comppsych.2010.09.003. ment, 6(2), 182–198. https://doi.org/10.1037/per0000099. Forcano, L., Fernández-Aranda, F., Álvarez-Moya, E., Bulik, C., Haw, C., Hawton, K., Gunnell, D., & Platt, S. (2015). Economic Granero, R., Gratacòs, M., … Estivill, X. (2009). Suicide at- recession and suicidal behaviour: Possible mechanisms and tempts in bulimia nervosa: Personality and psychopathological ameliorating factors. International Journal of Social Psychi- correlates. European Psychiatry, 24(2), 91–97. https://doi.org/ atry, 61(1), 73– 81. https://doi.org/10.1177/0020764014 10.1016/j.eurpsy.2008.10.002. 536545. Journal of Behavioral Addictions 11 (2022) 4, 963–978 975 van Heeringen, C., Bijttebier, S., & Godfrin, K. (2011). Suicidal comorbidity survey. Archives of General Psychiatry, 56(7), 617. brains: A review of functional and structural brain studies in https://doi.org/10.1001/archpsyc.56.7.617. association with suicidal behaviour. Neuroscience and Biobe- Kim, H. S., von Ranson, K. M., Hodgins, D. C., McGrath, D. S., & havioral Reviews, 35(3), 688–698. https://doi.org/10.1016/j. Tavares, H. (2018). Demographic, psychiatric, and personality neubiorev.2010.08.007. correlates of adults seeking treatment for disordered gambling Hodgins, D., & Holub, A. (2015). Components of impulsivity in with a comorbid binge/purge type eating disorder. European gambling disorder. International Journal of Mental Health and Eating Disorders Review, 26(5), 508–518. https://doi.org/10. Addiction, 13(6), 699–711. https://doi.org/10.1007/s11469-015- 1002/erv.2606. 9572-z. Kleinbaum, D. G., Kupper, L. L., Nizam, A., & Rosenberg, E. S. Hollingshead, A. B. (2011). Four factor index of social status. Yale (2014). Applied regression analysis and other multivariable Journal of Sociology, 8, 21–51. methods. Cengage Learning. Husky, M. M., Michel, G., Richard, J. B., Guignard, R., & Beck, F. Komoto, Y. (2014). Factors associated with suicide and bankruptcy (2015). Gender differences in the associations of gambling ac- in Japanese pathological gamblers. International Journal of tivities and suicidal behaviors with problem gambling in a na- Mental Health and Addiction, 12(5), 600–606. https://doi.org/ tionally representative French sample. Addictive Behaviors, 45, 10.1007/s11469-014-9492-3. 45–50. https://doi.org/10.1016/j.addbeh.2015.01.011. Krug, I., Binh Dang, A., Granero, R., Agüera, Z., Sánchez, I., Ioannidis, K., Hook, R., Wickham, K., Grant, J. E., & Chamberlain, Riesco, N., … Fernandez-Aranda, F. (2021). Drive for thinness S. R. (2019). Impulsivity in gambling disorder and problem provides an alternative, more meaningful, severity indicator gambling: A meta-analysis. Neuropsychopharmacology, 44, than the DSM-5 severity indices for eating disorders. European 1354–1361. https://doi.org/10.1038/s41386-019-0393-9. Eating Disorders Review, 29(3), 482–498. https://doi.org/10. Jakšic, N., & Margetic, B. A. (2017). Comments on the role of the 1002/erv.2776. character dimension self-transcendence in suicidal phenomena. Lavender, J. M., & Mitchell, J. E. (2015). Eating disorders and their Journal of Clinical Psychiatry, 78(2). https://doi.org/10.4088/ relationship to impulsivity. Current Treatment Options in Psy- JCP.16lr11229. chiatry, 2, 394–401. https://doi.org/10.1007/s40501-015-0061-6. Jiménez-Murcia, S., Granero, R., Giménez, M., del Pino-Gutiérrez, A., Lee, S., Fung, S. C., Tsang, A., Liu, Z. R., Huang, Y. Q., He, Y. L., … Mestre-Bach, G., Mena-Moreno, T., and Fernández-Aranda, F. Kessler, R. C. (2007). Lifetime prevalence of suicide ideation, (2020). Contribution of sex on the underlying mechanism of the plan, and attempt in metropolitan China. Acta Psychiatrica gambling disorder severity. Scientific Reports, 10, 18722. https:// Scandinavica, 116(6), 429–437. https://doi.org/10.1111/j.1600- doi.org/10.1038/s41598-020-73806-6. 0447.2007.01064.x. Jiménez-Murcia, S., Granero, R., Moragas, L., Steiger, H., Israel, M., MacDonald, D. A., & Holland, D. (2002). Examination of the Aymamí, N., … Fernández-Aranda, F. (2015). Differences and psychometric properties of the temperament and character similarities between bulimia nervosa, compulsive buying and inventory self-transcendence dimension. Personality and Indi- gambling disorder. European Eating Disorders Review, 23(2), vidual Differences, 32(6), 1013–1027. https://doi.org/10.1016/ 111–118. https://doi.org/10.1002/erv.2340. S0191-8869(01)00107-6. Jiménez-Murcia, S., Stinchfield, R., Álvarez-Moya, E., Jaurrieta, N., Mallorquí-Bagué, N., Mena-Moreno, T., Granero, R., Vintró- Bueno, B., Granero, R., and Vallejo, J. (2009). Reliability, Alcaraz, C., Sánchez-González, J., Fernández-Aranda, F., … validity, and classification accuracy of a Spanish translation of a Jiménez-Murcia, S. (2018). Suicidal ideation and history of measure of DSM-IV diagnostic criteria for pathological suicide attempts in treatment-seeking patients with gambling gambling. Journal of Gambling Studies, 25, 93–104. https://doi. disorder: The role of emotion dysregulation and high trait org/10.1007/s10899-008-9104-x. impulsivity. Journal of Behavioral Addictions, 7(4), 1112–1121. Jiménez-Murcia, Susana, Steiger, H., Isräel, M., Granero, R., Prat, R., https://doi.org/10.1556/2006.7.2018.132. … Fernández-Aranda, F. (2013). Pathological gambling in eating Mallorquí-Bagué, N., Testa, G., Lozano-Madrid, M., Vintró- disorders: Prevalence and clinical implications. Comprehensive Alcaraz, C., Sánchez, I., Riesco, N., … Fernández-Aranda, F. Psychiatry, 54(7), 1053–1060. https://doi.org/10.1016/j.comppsych. (2020). Emotional and non-emotional facets of impulsivity in 2013.04.014. eating disorders: From anorexia nervosa to bulimic spectrum Kaess, M., Parzer, P., Haffner, J., Steen, R., Roos, J., Klett, M., … disorders. European Eating Disorders Review, 28(4), 410–422. Resch, F. (2011). Explaining gender differences in non-fatal https://doi.org/10.1002/erv.2734. suicidal behaviour among adolescents: A population-based Mandelli, L., Arminio, A., Atti, A. R., & De Ronchi, D. (2019). study. BMC Public Health, 11, 597. https://doi.org/10.1186/ Suicide attempts in eating disorder subtypes: A meta-analysis of 1471-2458-11-597. the literature employing DSM-IV, DSM-5, or ICD-10 diag- Karlsson, A., & Håkansson, A. (2018). Gambling disorder, increased nostic criteria. Psychological Medicine, 49(8), 1237–1249. mortality, suicidality, and associated comorbidity: A longitudi- https://doi.org/10.1017/S0033291718003549. nal nationwide register study. Journal of Behavioral Addictions, Manning, V., Koh, P. K., Yang, Y., Ng, A., Guo, S., Kandasami, G., 7(4), 1091–1099. https://doi.org/10.1556/2006.7.2018.112. & Wong, K. E. (2015). Suicidal ideation and lifetime attempts in Kelley, K., & Preacher, K. J. (2012). On effect size. Psychological substance and gambling disorders. Psychiatry Research, 225(3), Methods, 17(2), 137–152. https://doi.org/10.1037/a0028086. 706–709. https://doi.org/10.1016/j.psychres.2014.11.011. Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and Masheb, R. M., Ramsey, C. M., Marsh, A. G., Decker, S. E., Maguen, S., risk factors for lifetime suicide attempts in the national Brandt, C. A., & Haskell, S. G. (2021). DSM-5 eating disorder 976 Journal of Behavioral Addictions 11 (2022) 4, 963–978 prevalence, gender differences, and mental health associations in Paul, K. I., Vastamäki, J., & Moser, K. (2016). Frustration of life United States military veterans. International Journal of Eating goals mediates the negative effect of unemployment on sub- Disorders, 54(7), 1171–1180. https://doi.org/10.1002/eat.23501. jective well-being. Journal of Happiness Studies, 17(2), 447–462. Mestre-Bach, G., Fernández-Aranda, F., Jiménez-Murcia, S., & https://doi.org/10.1007/s10902-014-9603-7. Potenza, M. N. (2020). Decision-Making in gambling disorder, Perroud, N., Baud, P., Mouthon, D., Courtet, P., & Malafosse, A. problematic pornography use, and binge-eating disorder: Simi- (2011). Impulsivity, aggression and suicidal behavior in uni- larities and differences. Current Behavioral Neuroscience Reports, polar and bipolar disorders. Journal of Affective Disorders, 7(3), 97–108. https://doi.org/10.1007/s40473-020-00212-7. 134(1–3), 112–118. https://doi.org/10.1016/j.jad.2011.05.048. Mestre-Bach, G., Steward, T., Granero, R., Fernández-Aranda, F., Probert-Lindström, S., Berge, J., Westrin, Å., Öjehagen, A., & Mena-Moreno, T., Vintró-Alcaraz, C., … Jiménez-Murcia, S. Skogman Pavulans, K. (2020). Long-term risk factors for suicide (2020). Dimensions of impulsivity in gambling disorder. Sci- in suicide attempters examined at a medical emergency in patient entific Reports, 10(1). https://doi.org/10.1038/s41598-019- unit: Results from a 32-year follow-up study. BMJ Open, 10(10), 57117-z. e038794. https://doi.org/10.1136/bmjopen-2020-038794. Micali, N., Martini, M. G., Thomas, J. J., Eddy, K. T., Kothari, R., Rømer Thomsen, K., Buhl Callesen, M., Hesse, M., Lehmann Russell, E., … Treasure, J. (2017). Lifetime and 12-month Kvamme, T., Mulbjerg Pedersen, M., Uffe Pedersen, M., & prevalence of eating disorders amongst women in mid-life: A Voon, V. (2018). Impulsivity traits and addiction-related be- population-based study of diagnoses and risk factors. BMC haviors in youth. Journal of Behavioral Addictions, 7(2), 317– Medicine, 15(1), 12. https://doi.org/10.1186/s12916-016-0766-4. 330. https://doi.org/10.1556/2006.7.2018.22. Michalczuk, R., Bowden-Jones, H., Verdejo-Garcia, A., & Clark, Ronzitti, S., Soldini, E., Smith, N., Potenza, M. N., Clerici, M., & L. (2011). Impulsivity and cognitive distortions in patho- Bowden-Jones, H. (2017). Current suicidal ideation in treat- logical gamblers attending the UK national problem ment-seeking individuals in the United Kingdom with gambling clinic: A preliminary report. Psychological Medi- gambling problems. Addictive Behaviors, 74, 33–40. https://doi. cine, 41(12), 2625–2635. https://doi.org/10.1017/S0033291 org/10.1016/j.addbeh.2017.05.032. 71100095X. Sciulli, D. (2016). Adult employment probabilities of socially mal- Milos, G., Spindler, A., Hepp, U., & Schnyder, U. (2004). Suicide adjusted children. Journal of Behavioral and Experimental Eco- attempts and suicidal ideation: Links with psychiatric comor- nomics, 60, 9–22. https://doi.org/10.1016/j.socec.2015.11.001. bidity in eating disorder subjects. General Hospital Psychiatry, Sperry, S. H., Lynam, D. R., Walsh, M. A., Horton, L. E., & Kwapil, 26(2), 129–135. https://doi.org/10.1016/j.genhosppsych.2003. T. R. (2016). Examining the multidimensional structure of 10.005. impulsivity in daily life. Personality and Individual Differences, Moeller, F. G., Barratt, E. S., Dougherty, D. M., Schmitz, J. M., & 94, 153–158. https://doi.org/10.1016/j.paid.2016.01.018. Swann, A. C. (2001). Psychiatric aspects of impulsivity. Amer- Stata-Corp (2019). Stata statistical software: Release 16. StataCorp ican Journal of Psychiatry, 158(11), 1783–1793. https://doi.org/ LLC. 10.1176/appi.ajp.158.11.1783. Stein, D., Lilenfeld, L. R. R., Wildman, P. C., & Marcus, M. D. Munguía, L., Jiménez-Murcia, S., Granero, R., Baenas, I., Agüera, Z., (2004). Attempted suicide and self-injury in patients diagnosed Sánchez, I., … Fernández-Aranda, F. (2021). Emotional regula- with eating disorders. Comprehensive Psychiatry, 45(6), 447– tion in eating disorders and gambling disorder: A transdiagnostic 451. https://doi.org/10.1016/j.comppsych.2004.07.011. approach. Journal of Behavioral Addictions, 10(3), 508–523. Stinchfield, R. (2003). Reliability, validity, and classification accu- https://doi.org/10.1556/2006.2021.00017. racy of a measure of DSM-IV diagnostic criteria for patholog- Newman, S. C., & Thompson, A. H. (2007). The association be- ical gambling. American Journal of Psychiatry, 160(1), 180–182. tween pathological gambling and attempted suicide: Findings https://doi.org/10.1176/appi.ajp.160.1.180. from a national survey in Canada. Canadian Journal of Psy- Tabri, N., Werner, K. M., Milyavskaya, M., & Wohl, M. J. A. (2021). chiatry, 52(9), 605–612. https://doi.org/10.1016/j.psychres.2014. Perfectionism predicts disordered eating and gambling via 11.011. focused self-concept among those high in erroneous beliefs Nickel, C., Simek, M., Moleda, A., Muehlbacher, M., Buschmann, W., about their disordered behavior. Journal of Behavioral Addic- Fartacek, R., … Nickel, M. K. (2006). Suicide attempts versus tions, 10(3), 524–533. https://doi.org/10.1556/2006.2021.00068. suicidal ideation in bulimic female adolescents. Pediatrics Inter- Tae, H., & Chae, J.-H. (2021). Factors related to suicide attempts: national, 48(4), 374–381. https://doi.org/10.1111/j.1442-200X. The roles of childhood abuse and spirituality. Frontiers in 2006.02224.x. Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.565358. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Thon, N., Preuss, U. W., Pölzleitner, A., Quantschnig, B., Scholz, H., Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Kühberger, A., …, … Zimmerl, H. (2014). Prevalence of suicide reviews. https://doi.org/10.1093/epirev/mxn002. attempts in pathological gamblers in a nationwide Austrian Nordt, C., Warnke, I., Seifritz, E., & Kawohl, W. (2015). Modelling treatment sample. General Hospital Psychiatry, 36(3), 342–346. suicide and unemployment: A longitudinal analysis covering 63 https://doi.org/10.1016/j.genhosppsych.2014.01.012. countries, 2000–11. The Lancet Psychiatry, 2(3), 239–245. Too, L. S., Spittal, M. J., Bugeja, L., Reifels, L., Butterworth, P., & https://doi.org/10.1016/S2215-0366(14)00118-7. Pirkis, J. (2019). The association between mental disorders and O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal suicide: A systematic review and meta-analysis of record link- behaviour. The Lancet Psychiatry, 1(1), 73–85. https://doi.org/ age studies. Journal of Affective Disorders, 259, 302–313. https:// 10.1016/S2215-0366(14)70222-6. doi.org/10.1016/j.jad.2019.08.054. Journal of Behavioral Addictions 11 (2022) 4, 963–978 977 Udo, T., Bitley, S., & Grilo, C. M. (2019). Suicide attempts in US Whiteside, S. P., Lynam, D. R., Miller, J. D., & Reynolds, S. K. adults with lifetime DSM-5 eating disorders. BMC Medicine, 17, (2005). Validation of the UPPS impulsive behaviour scale: A 120. https://doi.org/10.1186/s12916-019-1352-3. four‐factor model of impulsivity. European Journal of Person- Vintró‐Alcaraz, C., Munguía, L., Granero, R., Gaspar-Pérez, A., Solé- ality, 19(7), 559–574. https://doi.org/10.1002/per.556. Morata, N., Sánchez, I., Sánchez-González, J., Menchón, J. M., Wong, G., Zane, N., Saw, A., & Chan, A. K. K. (2013). Examining Jiménez-Murcia, S., & Fernández-Aranda, F. (2022). Emotion gender differences for gambling engagement and gambling regulation as a transdiagnostic factor in eating disorders and problems among emerging adults. Journal of Gambling Studies, gambling disorder: Treatment outcome implications. J Behav 29(2), 171–189. https://doi.org/10.1007/s10899-012-9305-1. Addict, 11(1), 140–146. https://doi.org/10.1556/2006.2022.00004. Woo, Y. S., Jun, T. Y., Jeon, Y. H., Song, H. R., Kim, T. S., Kim, J. B., Wardle, H., & McManus, S. (2021). Suicidality and gambling … Jo, S. J. (2014). Relationship of temperament and character among young adults in great britain: Results from a cross- in remitted depressed patients with suicidal ideation and sui- sectional online survey. The Lancet Public Health, 6(1), e39– cide attempts - results from the CRESCEND study. Plos One, e49. https://doi.org/10.1016/S2468-2667(20)30232-2. 9(10), e105860. https://doi.org/10.1371/journal.pone.0105860. Waxman, S. E. (2009). A systematic review of impulsivity in eating World Health Organization (2014). Preventing suicide: A global disorders. European Eating Disorders Review, 17(6), 408–425. imperative. In World Health Organization. https://doi.org/10.1002/erv.952. World Health Organization (2019). Suicide in the world: Global Whiteside, S. P., & Lynam, D. R. (2001). The five factor model and health estimates. impulsivity: Using a structural model of personality to under- Yuodelis-Flores, C., & Ries, R. K. (2015). Addiction and suicide: A stand impulsivity. Personality and Individual Differences, 30(4), review. American Journal on Addictions, 24(2), 98–104. https:// 669–689. https://doi.org/10.1016/S0191-8869(00)00064-7. doi.org/10.1111/ajad.12185. Appendix Table A1. Descriptive of the subsamples of GD and BSED patients GD (n 5 3,686) BSED (n 5 2,391) n % n % p |d| Gender Women 331 9.0% 2,251 94.1% <0.001 p 2.04† Men 3,355 91.0% 140 5.9% Marital status Single 1,536 41.7% 1714 71.7% <0.001p 0.62† Married/Partner 1,649 44.7% 496 20.7% 0.52† Divorced/Separated 501 13.6% 181 7.6% 0.20 Education Primary or less 2,128 57.7% 1,068 44.7% <0.001p 0.26 Secondary 1,325 35.9% 984 41.2% 0.11 University 233 6.3% 339 14.2% 0.26 Social index High 53 1.4% 14 0.6% <0.001p 0.09 Mean-high 170 4.6% 75 3.1% 0.08 Mean 401 10.9% 128 5.4% 0.21 Mean-low 1,171 31.8% 978 40.9% 0.19 Low 1891 51.3% 1,196 50.0% 0.03 Employment Unemployed./student 1,571 42.6% 1769 74.0% <0.001p 0.65† Employed 2,115 57.4% 622 26.0% Mean SD Mean SD P |d| Chronological age (years-old) 41.72 13.23 28.48 9.42 <0.001 p 1.15† Age of onset of disorder (years-old) 29.76 11.65 20.02 8.28 <0.001p 0.96† Duration of disorder (years) 6.16 5.93 8.53 7.10 <0.001p 0.36 Note. SD: standard deviation. p Bold: significant comparison (0.05). † Bold: effect size into the mild-moderate (|d| > 0.50) to the high-large range (|d| > 0.80). 978 Journal of Behavioral Addictions 11 (2022) 4, 963–978 Description of the results regarding the prevalence of (17.9% for non-strategic, 19.5% for strategic and 21.9% for suicidal behavioral according to the diagnostic mixed) (χ 2 5 4.45, df 5 2, P 5 0.065). Within the BSED subsample (second panel of subtypes Figure A1), the prevalence of suicide attempts was lower for Within the GD subsample (first panel of Figure A1), the BED (13.9%) compared to the other diagnostic subtypes prevalence of suicide attempts was higher for non-strategic (24.2% for OSFED, 28.8% for AN-BP and 29.1% for BN) gambling (7.6%), followed by mixed (6.1%) and strategic (χ 2 5 36.40, df 5 3, P < 0.001). In a similar way, the gambling (4.6%) (χ 2 5 6.47, df 5 2, P 5 0.039). No dif- prevalence of suicidal ideation was the lowest for BED ferences were found between the groups defined by the (44.3%), followed by AN-BP (46.6%), OSFED (54.2%) and gambling preferences for the prevalence of suicidal ideation BN (54.9%) (χ 2 5 17.52, df 5 3, P 5 0.001). Fig. A1. Presence of suicidal behavior in the study (within the diagnostic subtypes) Open Access. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited, a link to the CC License is provided, and changes – if any – are indicated.