Self-injurious behavior and eating disorders: the extent and nature of the association

Non-suicidal self-injury and anorexia nervosa: A systematic scoping review

OBJECTIVES

Psychiatric comorbidities are frequent in anorexia nervosa, non-suicidal self-injury being one of the more frequent. The aim of this study was to review the literature exploring the links between these disorders and thus to improve our understanding of their causality, risks, and consequences.

METHOD

We used electronic searches in Pubmed, Cochrane, PsychInfo, and Web of Science to conduct a systematic scoping review of the publications dealing with the association between non-suicidal self-injury and anorexia nervosa published through November 2023.

RESULTS

The study finally included thirty-three studies, mainly of female adolescents and young women, and most frequently from an epidemiological perspective. The results confirmed a frequent association between non-suicidal self-injury and anorexia nervosa, and a significantly higher prevalence of such self-injury in the anorexia subtype involving binge-eating/purging than in the purely restrictive subtype. This result appears to confirm an earlier finding that only the diagnosis of anorexia nervosa with binge-eating/purging behaviours predicts the occurrence of non-suicidal self-injury during eating disorder. In addition, results reported that the risks of psychiatric comorbidities and of suicide were higher and that the treatment of anorexia was longer and the weight gain slower in those patients.

CONCLUSIONS

This study confirmed the association between these two disorders which makes their management more complex. More rapid identification of non-suicidal self-injury in anorexia nervosa and a better understanding of its underlying psychopathological processes are needed to propose appropriate multidisciplinary care. More systematic studies on the associations between these disorders are essential.

Suicidal and Self-Harming Behaviors in Patients With Borderline Personality Disorder With and Without Eating Disorders

Borderline personality disorder (BPD) and eating disorders (EDs) frequently co-occur. The present study investigated whether treatment-seeking patients with BPD and a comorbid ED experienced increased risk of self-harm or suicide behaviors. In a sample of 350 patients with BPD, 61 (17.4%) had a comorbid ED: 25 (7.1%) had bulimia nervosa (BN), 15 (4.2%) had an eating disorder not otherwise specified (EDNOS), 13 (3.7%) had bingeeating disorder (BED), and 8 (2.2%) had anorexia nervosa (AN). Comorbid BED and AN were individually significantly associated with recurrent suicide attempt over the past year, while comorbid AN was associated with greater lethality of recent self-harm. These results suggest that ED diagnosis may constitute a risk factor for self-harm and suicide behaviors in patients with BPD.

The role of body image dissatisfaction in the relationship between body size and disordered eating and self-harm: complimentary Mendelian randomization and mediation analyses

Disordered eating and self-harm commonly co-occur in young people suggesting potential for shared underlying causes. Body image dissatisfaction (BID) has been recognised as a psychological correlate of body size, associated with both disordered eating and self-harm. However, the investigation into etiological pathways early in the lifecourse to provide detail on how body size and BID may foster disordered eating and self-harm remains largely unexplored. Employing data from two large population-based cohorts, the UK Biobank and the Avon Longitudinal Study of Parents And Children (ALSPAC), we conducted bidirectional Mendelian randomization (MR) to determine the causal direction of effect between genetically predicted prepubertal body size and two measures of BID indicating (i) desire to be smaller, and (ii) desire to be larger. We then used multivariable regression followed by counterfactual mediation analyses. Bidirectional MR indicated robust evidence that increased genetically predicted prepubertal body size increased desire to be smaller and decreased desire to be larger. Evidence for the reverse causal direction was negligible. These findings remained very similar across sensitivity analyses. In females and males, multivariable regression analyses demonstrated that being overweight increased the risk of disordered eating (risk ratio (RR), 95% confidence interval (CI): 1.19, 1.01 to 1.40 and 1.98, 1.28 to 3.05, respectively) and self-harm (RR, 95% CI: 1.35, 1.04 to 1.77 and 1.55, 0.86 to 2.81, respectively), while being underweight was protective against disordered eating (RR, 95% CI: 0.57, 0.40 to 0.81 and 0.81, 0.38 to 1.73, respectively). There was weak evidence of an increase in the risk of self-harm among underweight individuals. Mediation analyses indicated that the relationship between being overweight and subsequent disordered eating was largely mediated by the desire to be smaller. Our research carries important public health implications, suggesting distinct risk profiles for self-harm and disordered eating in relation to weight and body image. In addition, a better understanding of genetically predicted prepubertal BID may be valuable in the prevention and treatment of disordered eating and self-harm in adolescence.

Core psychopathology underlying disordered eating behaviors and nonsuicidal self-injury in university students: a network analysis

OBJECTIVE

Disordered eating behaviors (DEBs) and nonsuicidal self-injury (NSSI) frequently co-occur in university students, yet what underlies this co-occurrence remains unknown. Network analysis was used to identify psychosocial correlates that may link DEBs and NSSI in university students and test whether networks were similar across gender.

PARTICIPANTS

Four hundred and seventy college women and 473 college men (aged 18-25 years).

METHODS

Participants completed online questionnaires. Networks were estimated for men, women, and a combined sample.

RESULTS

The networks for men and women were invariant. The most central nodes in the combined network were difficulties in emotion regulation and body dissatisfaction. Interoception and difficulties in emotion regulation were directly associated with past-month NSSI and strongly associated with body dissatisfaction, linking DEBs and NSSI in the network.

CONCLUSIONS

Difficulties in emotion regulation, interoception, and body dissatisfaction may play critical roles in the comorbidity of DEBs and NSSI in university students.

From early relational experiences to non-suicidal self-injury in anorexia and bulimia nervosa: a structural equation model unraveling the role of impairments in interoception

PURPOSE

Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) frequently exhibit Non-Suicidal Self-Injury (NSSI), yet their co-occurrence is still unclear. To address this issue, the aim of this study was to elucidate the role of impairments in interoception in explaining the NSSI phenomenon in AN and BN, providing an explanatory model that considers distal (insecure attachment/IA and traumatic childhood experiences/TCEs) and proximal (dissociation and emotional dysregulation) risk factors for NSSI.

METHOD

130 patients with AN and BN were enrolled and administered self-report questionnaires to assess the intensity of NSSI behaviors, interoceptive deficits, IA, TCEs, emotional dysregulation and dissociative symptoms.

RESULTS

Results from structural equation modeling revealed that impairments in interoception acted as crucial mediators between early negative relational experiences and factors that contribute to NSSI in AN and BN, particularly emotional dysregulation and dissociation. Precisely, both aspects of IA (anxiety and avoidance) and various forms of TCEs significantly exacerbated interoceptive deficits, which in turn are associated to the emergence of NSSI behaviors through the increase in levels of dissociation and emotional dysregulation.

CONCLUSIONS

The proposed model provided a novel explanation of the occurrence of NSSIs in patients with AN and BN by accounting for the significance of interoception.

LEVEL OF EVIDENCE

Level V-Cross-sectional observational study.

Gender differences in borderline personality disorder: a narrative review

Borderline personality disorder (BPD) is a severe and complex mental disorder that traditionally has been found to be more frequent in the female gender in clinical samples. More recently, epidemiological studies have provided conflicting data about the prevalence of borderline disorder in the two genders in community samples. In order to explain this heterogeneity, some authors hypothesized the presence of a bias in the diagnostic criteria thresholds (more prevalent in one gender than another), in the population sampling (community versus clinical), in the instruments of evaluation (clinician versus self-report measures), and in the diagnostic construct of BPD. Beyond the question of the different prevalence of the disorder between genders, the debate remains open as to how personality and clinical characteristics, and attitude toward treatments express themselves in the two genders. This narrative review is aimed to provide an updated overview of the differences among genders in BPD in terms of diagnosis, temperamental and clinical characteristics, comorbidities, findings of neuroimaging, and treatment attitudes. Studies that specifically investigated the gender differences in BPD patients are rather limited. Most of the investigations did not consider gender as a variable or were characterized by a significant imbalance between the two genders (more commonly in favor the female gender). The main results indicated that men were more likely to endorse the criteria "intense and inappropriate anger" and "impulsivity," whereas women endorsed the criteria "chronic feelings of emptiness," "affective instability," and "suicidality/self-harm behaviors." These findings reflect differences in temperament and symptoms of the two genders. Other relevant differences concern pattern of comorbidity, specific neurobiological mechanisms and attitude to treatments. Main limitations were that only one database was searched, time of publications was limited, non-English manuscripts were excluded, and the quality of each paper was not commented.

Risk of self-harm in patients with eating disorders: English population-based national record-linkage study, 1999-2021

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) are eating disorders associated with high rates of self-harm (SH). This is the first national study in England to quantify this association in a hospital population.

METHOD

A retrospective cohort study using a linked national dataset of Hospital Episode Statistics for 1999-2021. The exposure cohort included individuals aged <35 years admitted to hospital with a diagnosis of AN or BN. The reference cohort included hospital controls. We calculated the rate ratio (RR) of SH in each cohort. The individuals in the two cohorts were matched on multiple socio-demographic indicators. The main outcome was a subsequent hospitalization or death record with an SH diagnosis.

RESULTS

We identified 15,004 females and 1411 males with AN, and 6055 females and 741 males with BN. The RR with 95% confidence intervals (95%CI) for a subsequent admission with intentional self-harm after admission with AN was 4.9 (95%CI 4.7-5.1) in females and 4.8 (95%CI 3.9-5.8) in males. For BN it was 9.0 (95%CI 8.4-9.6) in females and 9.8 (95%CI 7.7-12.2) in males. There were strong associations between AN and BN and other SH.

DISCUSSION

Women and men admitted to English hospitals with AN or BN have a very high risk of a subsequent admission with SH. For some SH behaviors, such as alcohol intoxication, the RR was >10-fold elevated. The magnitude of risk was higher for BN than for AN. Clinicians should be aware of the scale of risk increase. Providing those at risk with appropriate support is required.

PUBLIC SIGNIFICANCE

This study is the first national study in an English hospital population that confirms and quantifies the association between eating disorders and self-harm. We have found that both women and men admitted to hospital with anorexia nervosa or bulimia nervosa are at an increased risk of subsequent admission with self-harm. It is important that clinicians are aware of this increased risk to support those at highest risk of self-harm.

A multisite comparison using electronic health records and natural language processing to identify the association between suicidality and hospital readmission amongst patients with eating disorders

OBJECTIVES

To describe and compare the association between suicidality and subsequent readmission for patients hospitalized for eating disorder treatment, within 2 years of discharge, at two large academic medical centers in two different countries.

METHODS

Over an 8-year study window from January 2009 to March 2017, we identified all inpatient eating disorder admissions at Weill Cornell Medicine, New York, USA (WCM) and South London and Maudsley Foundation NHS Trust, London, UK (SLaM). To establish each patient's-suicidality profile, we applied two natural language processing (NLP) algorithms, independently developed at the two institutions, and detected suicidality in clinical notes documented in the first week of admission. We calculated the odds ratios (OR) for any subsequent readmission within 2 years postdischarge and determined whether this was to another eating disorder unit, other psychiatric unit, a general medical hospital admission or emergency room attendance.

RESULTS

We identified 1126 and 420 eating disorder inpatient admissions at WCM and SLaM, respectively. In the WCM cohort, evidence of above average suicidality during the first week of admission was significantly associated with an increased risk of noneating disorder-related psychiatric readmission (OR 3.48 95% CI = 2.03-5.99, p-value < .001), but a similar pattern was not observed in the SLaM cohort (OR 1.34, 95% CI = 0.75-2.37, p = .32), there was no significant increase in risk of admission. In both cohorts, personality disorder increased the risk of any psychiatric readmission within 2 years.

DISCUSSION

Patterns of increased risk of psychiatric readmission from above average suicidality detected via NLP during inpatient eating disorder admissions differed in our two patient cohorts. However, comorbid diagnoses such as personality disorder increased the risk of any psychiatric readmission across both cohorts.

PUBLIC SIGNIFICANCE

Suicidality amongst is eating disorders is an extremely common presentation and it is important we further our understanding of identifying those most at risk. This research also provides a novel study design, comparing two NLP algorithms on electronic health record data based in the United States and United Kingdom on eating disorder inpatients. Studies researching both UK and US mental health patients are sparse therefore this study provides novel data.

Risk of non-fatal self-harm and premature mortality in the three years following hospitalization in adolescents and young adults with an eating disorder: A nationwide population-based study

INTRODUCTION

Eating disorders (ED) are associated with high rates of suicide attempts and premature mortality. However, data in large samples of adolescents and young adults are limited. This study aims to assess the risk of self-harm and premature mortality in young people hospitalized with an ED.

METHODS

Individuals aged 12 to 25 years old hospitalized in 2013-2014 in France with anorexia nervosa and/or bulimia nervosa as a primary or associated diagnosis were identified from French national health records. They were compared to two control groups with no mental disorders, and with any other mental disorder than ED. The main outcomes were any hospitalization for deliberate self-harm and mortality in the 3 years following hospitalization. Logistic regression models were used.

RESULTS

This study included 5, 452 patients hospitalized with an ED, 14,967 controls with no mental disorder, and 14,242 controls with a mental disorder other than an ED. During the three-year follow-up, 13.0% were hospitalized for deliberate self-harm (vs. 0.2 and 22.0%, respectively) and 0.8% died (vs. 0.03 and 0.4%). After adjustment, hospitalization with an ED was associated with more self-harm hospitalizations (hazard ratio [HR] = 46.0, 95% confidence interval [32.3-65.3]) and higher all-cause mortality (HR = 12.6 [4.3-37.3]) relative to youths without any mental disorder; less self-harm hospitalizations (HR = 0.5 [0.5-0.6]) but higher mortality (HR = 1.6 [1.0-2.4]) when compared to youths with any other mental disorder.

CONCLUSION

Young patients hospitalized with an ED are at high risk of self-harm and premature mortality. It is urgent to evaluate and implement the best strategies for post-discharge care and follow-up.

PUBLIC SIGNIFICANCE

We found that the risk of being hospitalized for a suicide attempt is 46 times higher and mortality 13 times higher than the general population in adolescents and young adults during the 3 years following hospitalization with an eating disorder. Eating disorders are also associated with a 1.5 higher risk of premature mortality relative to other mental disorders. This risk is particularly high in the 6 months following hospitalization. It is therefore crucial to implement careful post-discharge follow-up in patients hospitalized for eating disorders.

Temporal trends in eating disorder and self-harm incidence rates among adolescents and young adults in the UK in the 2 years since onset of the COVID-19 pandemic: a population-based study

BACKGROUND

Self-harm and eating disorders share multiple risk factors, with onset typically during adolescence or early adulthood. We aimed to examine the incidence rates of these psychopathologies among young people in the UK in the 2 years following onset of the COVID-19 pandemic.

METHODS

We conducted a population-based study using the primary care electronic health records of patients aged 10-24 years in the UK Clinical Practice Research Datalink (CPRD). The observation period was from Jan 1, 2010, to March 31, 2022. We calculated the monthly incidence rates of eating disorders and self-harm according to the first record of each outcome. On the basis of antecedent trends between January, 2010, and February, 2020, negative binomial regression models were fitted to predict monthly incidence rates after the pandemic began in March, 2020. Percentage differences between observed and expected incidence were calculated to indicate changes since the onset of the pandemic, with stratification by sex, age, and deprivation quintile.

FINDINGS

The primary care health records of 9 184 712 patients aged 10-24 years (4 836 226 [52·7%] female patients and 4 348 486 [47·3%] male patients; n=1881 general practices) were included for analysis. The incidence rates of eating disorders and self-harm among girls were higher than expected between March 1, 2020, and March 31, 2022. The observed incidence of eating disorders was 42·4% (95% CI 25·7-61·3) higher than expected for girls aged 13-16 years, and 32·0% (13·3-53·8) higher than expected for girls aged 17-19 years, whereas other age groups showed little difference between observed and expected incidence. Similarly, the increase in self-harm incidence was driven by girls aged 13-16 years, for whom the observed incidence was 38·4% (20·7-58·5) higher than expected. By contrast, among boys in all age groups, the incidence rates of eating disorders and self-harm were lower than, or close to, the expected rates. Among boys, the observed incidence of eating disorders was 22·8% (9·2-34·4) lower than expected, and the observed incidence of self-harm was 11·5% (3·6-18·7) lower than expected. The estimated increases in eating disorder and self-harm incidence among girls aged 13-16 years were largely attributable to increases within less deprived communities.

INTERPRETATION

Although causes are uncertain, increased incidence of eating disorder diagnoses and self-harm among teenage girls in the UK during the first 2 years of the COVID-19 pandemic highlight an urgent need for intervention. Early identification of mental health difficulties by primary care clinicians is necessary. Timely access to treatments and sufficient support from general practitioners and mental health services needs to be available to manage presenting problems and to prevent exacerbations of conditions.

FUNDING

National Institute for Health and Care Research.

Emotional dysregulation in childhood and disordered eating and self-harm in adolescence: prospective associations and mediating pathways

BACKGROUND

Emotional dysregulation may be a risk factor for disordered eating and self-harm in young people, but few prospective studies have assessed these associations long-term, or considered potential mediators. We examined prospective relationships between childhood emotional dysregulation and disordered eating and self-harm in adolescence; and social cognition, emotional recognition, and being bullied as mediators.

METHODS

We analysed Avon Longitudinal Study of Parents and Children data on 3,453 males and 3,481 females. We examined associations between emotional dysregulation at 7 years and any disordered eating and any self-harm at 16 years with probit regression models. We also assessed whether social cognition (7 years), emotional recognition (8 years) and bullying victimisation (11 years) mediated these relationships.

RESULTS

Emotional dysregulation at age 7 years was associated with disordered eating [fully adjusted probit B (95% CI) = 0.082 (0.029, 0.134)] and self-harm [fully adjusted probit B (95% CI) = 0.093 (0.036, 0.150)] at age 16 years. There was no evidence of sex interactions or difference in effects between self-harm and disordered eating. Mediation models found social cognition was a key pathway to disordered eating (females 51.2%; males 27.0% of total effect) and self-harm (females 15.7%; males 10.8% of total effect). Bullying victimisation was an important pathway to disordered eating (females 17.1%; males 10.0% of total effect), but only to self-harm in females (15.7% of total effect). Indirect effects were stronger for disordered eating than self-harm.

CONCLUSIONS

In males and females, emotional dysregulation in early childhood is associated with disordered eating and self-harm in adolescence and may be a useful target for prevention and treatment. Mediating pathways appeared to differ by sex and outcome, but social cognition was a key mediating pathway for both disordered eating and self-harm.

The functions of binge eating scale (FBES): Development and preliminary psychometric validation

OBJECTIVE

Binge eating within binge-eating disorder (BED) is a behaviour widely understood as a response to dietary restraint and emotion dysregulation. However, qualitative literature suggests that a wider range of functions of binge eating exist, with associations between functions of binge eating and adverse childhood experiences highlighted across this research. The present study sought to develop a scale to measure a wide range of functions of binge eating within BED. A secondary aim was to examine the relationship between these functions and adverse childhood experiences (ACEs).

METHOD

The researchers developed an initial item pool for the Functions of Binge Eating Scale (FBES) and invited experts within the eating disorder (ED) field (n = 22) to review the items. The refined item pool was administered online to adults with self-reported binge eating symptoms (N = 882), along with related measures to establish scale validity.

RESULTS

Exploratory and confirmatory factor analyses produced an eight-factor structure (emotion regulation, hedonic hunger, compensatory eating, numbness/dissociation, emotion expression, self-punishment, control, self-protection). The scale demonstrated good internal reliability and adequate construct and predictive validity. Results also showed that functions theoretically related to childhood maltreatment were predicted by ACEs.

DISCUSSION

Findings extend our understanding of the range of functions of binge eating experienced in BED. Additionally, findings indicate that type of adverse childhood experience predicts functions of binge eating. Initial validation of the FBES suggests that functions of binge eating are wider than previously understood. Accordingly, clinicians are encouraged to explore and target more complex processes which might perpetuate binge-eating behaviour.

Co-occurrence of nonsuicidal self-injury and eating disorder pathology in adolescents

OBJECTIVE

Little is known about the co-occurrence of nonsuicidal self-injurious (NSSI) behaviors and eating disorder (ED) pathology in community samples of adolescents.

METHODS

A total of 1558 Norwegian upper secondary school students (Grades 11, 12, and 13) completed the Deliberate Self-Harm Inventory and a measure of ED pathology.

RESULTS

Adolescents (53.1% F, 46.9% M) were a mean age of 17.1 years. A higher level of ED pathology was reported (12.1 vs. 5.3, p < .001) among adolescents who had a history of NSSI. Significantly higher levels of ED pathology were found among females who reported hitting themselves until bruised, head banging, severe scratching, and burning with a lighter, but not cutting, or the other forms of self-injury. Of adolescents with a history of NSSI, 60% of females and 15% of males scored above a cutoff for ED pathology. Of adolescents scoring above a cutoff for ED pathology, 42.5% of females and 37.1% of males had engaged in lifetime NSSI.

DISCUSSION

Adolescents-in particular, females- with a history of NSSI reported significantly greater ED pathology. Notably, a higher proportion of males with ED pathology reported lifetime self-injury than vice versa, underscoring the importance of carefully screening for the presence of self-harm among males with ED pathology.

PUBLIC SIGNIFICANCE STATEMENT

Over 1500 upper secondary school students with an average age of 17 years completed an online survey assessing current ED pathology and lifetime NSSI. Adolescents, particularly females, with a history of self-harm reported significantly more ED pathology. Findings also indicated the need to carefully screen for self-harm among males with ED pathology. Parents, schools, and health professionals should be aware that self-harm and ED pathology commonly co-occur and warrant assessment.

Risk and protective factors for new-onset binge eating, low weight, and self-harm symptoms in >35,000 individuals in the UK during the COVID-19 pandemic

OBJECTIVE

The disruption caused by the COVID-19 pandemic has been associated with poor mental health, including increases in eating disorders and self-harm symptoms. We investigated risk and protective factors for the new onset of these symptoms during the pandemic.

METHOD

Data were from the COVID-19 Psychiatry and Neurological Genetics study and the Repeated Assessment of Mental health in Pandemics Study (n = 36,715). Exposures were socio-demographic characteristics, lifetime psychiatric disorder, and COVID-related variables, including SARS-CoV-2 infection/illness with COVID-19. We identified four subsamples of participants without pre-pandemic experience of our outcomes: binge eating (n = 24,211), low weight (n = 24,364), suicidal and/or self-harm ideation (n = 18,040), and self-harm (n = 29,948). Participants reported on our outcomes at frequent intervals (fortnightly to monthly). We fitted multiple logistic regression models to identify factors associated with the new onset of our outcomes.

RESULTS

Within each subsample, new onset was reported by: 21% for binge eating, 10.8% for low weight, 23.5% for suicidal and/or self-harm ideation, and 3.5% for self-harm. Shared risk factors included having a lifetime psychiatric disorder, not being in paid employment, higher pandemic worry scores, and being racially minoritized. Conversely, infection with SARS-CoV-2/illness with COVID-19 was linked to lower odds of binge eating, low weight, and suicidal and/or self-harm ideation.

DISCUSSION

Overall, we detected shared risk factors that may drive the comorbidity between eating disorders and self-harm. Subgroups of individuals with these risk factors may require more frequent monitoring during future pandemics.

PUBLIC SIGNIFICANCE

In a sample of 35,000 UK residents, people who had a psychiatric disorder, identified as being part of a racially minoritized group, were not in paid employment, or were more worried about the pandemic were more likely to experience binge eating, low weight, suicidal and/or self-harm ideation, and self-harm for the first time during the pandemic. People with these risk factors may need particular attention during future pandemics to enable early identification of new psychiatric symptoms.

Self-mutilation in people with psychiatric diagnosis - literature review

Introduction: Self-mutilation is of an auto-aggressive nature. They take many forms. Usually they do not occur as an isolated phenomenon. Self-injuring persons often have a diagnosed mental disorder, and a psychiatric diagnosis is one of the risk factors for the occurrence of self-harm. Material and method: In this study, articles were analyzed that contained information on the occurrence of various mental disorders. These articles searched for information on the occurrence of self-mutilation, its type, origin and causes.  Discussion: Self-mutilation is common in patients with a psychiatric diagnosis. The frequency of such behaviors can range from 33% to 50% in people with autism, up to 22%, and even 49% in people diagnosed with psychotic disorders. Acts of selfharm may affect 50-78% of people diagnosed with border-line personality disorder. In adolescents with eating disorders, 41% of patients report self-harm. In the group of people diagnosed with bipolar disorder, it may be as high as 77.3%. People with depression are also a large self-injuring group. It is reported that it may be up to 71.2% of patients with unipolar disorder. Conclusions: Self-mutilation is a phenomenon that is more and more topical and common not only in the adolescent population. This is a multi-factorial issue. One of the risk factors are mental disorders. Self-mutineers choose various methods, and this choice depends, among others, on from recognition. The size of the phenomenon and its evolution make it necessary to study it in order to increase the level of knowledge, update information and, consequently, the ability to help people at risk of NSSI.  Keywords: self-mutilation, autism spectrum disorder, schizophrenia, bipolar disorder, personality disorders

Evaluating the use of lamotrigine to reduce mood lability and impulsive behaviors in adults with chronic and severe eating disorders

BACKGROUND

Gold-standard psychological and pharmacological treatments for bulimic-spectrum eating disorders only result in remission for around 50% of patients; patients with affective lability and impulsivity represent a subgroup with particularly poor outcomes. Both dialectical behavior therapy (DBT), a treatment for emotion dysregulation, and lamotrigine, a mood stabilizer, have demonstrated promise for targeting affective lability and impulsivity; however, data exploring the combination of these interventions remain limited.

OBJECTIVE

We followed a group of women with recurrent dysregulated eating behaviors (N = 62) throughout intensive DBT treatment and compared the symptom trajectory of those prescribed lamotrigine (n = 28) and those who were not (n = 34).

METHOD

Participants completed surveys every 2 weeks throughout treatment.

RESULTS

Group analyses suggested that all participants self-reported decreases in emotional reactivity, negative urgency, and symptoms of borderline personality disorder (BPD). The lamotrigine group reported greater elevations in BPD symptoms at baseline, but demonstrated steeper decreases in emotion and behavioral dysregulation than the non-matched comparison group. Within-subject analyses suggested that within the lamotrigine group, subjects reported greater decreases in symptoms following prescription of lamotrigine.

CONCLUSIONS

Findings provide initial data suggesting that lamotrigine could be useful as an adjunctive treatment for patients with affective lability and impulsivity.

LEVEL OF EVIDENCE

IV, time series without randomization.

Adolescents with anorexia nervosa with or without non-suicidal self-injury: clinical and psychopathological features

PURPOSE

Anorexia nervosa (AN) and non-suicidal self-injury (NSSI) share typical onset in adolescence, greater prevalence in females and similar risk factors. Nevertheless, clinical features of eating disorders (ED) in this population are still under-investigated, especially associated to psychological features.

METHODS

The present study aims at comparing clinical and ED characteristics and psychopathological traits in a sample of 253 female adolescents with AN with or without NSSI and to determine possible clinical and psychological predictors on the presence of NSSI. The two groups were compared through multivariate analyses, while correlation and regression analyses were conducted to determine possible associations and predictors.

RESULTS

AN + NSSI group showed higher prevalence of binging-purging-type AN (p < .001), and mean higher age (p = .008) and Body Mass Index (BMI) (p = .002) than AN without NSSI group. Concerning psychological scales, AN + NSSI group showed higher scores in mostly of the sub-scale of the test Eating Disorders Inventory-3, higher scores at the scale for depression (p < 0.001) and higher scores at the three indexes of Symptom Checklist 90-Revised test, Global Severity Index (p < 0.001), Positive Symptoms total (p = .003) and Positive Symptom Distress Index (p < 0.001). No differences emerged at Children's Global Assessment Scale and at scale for evaluation of alexithymia. Regression analyses showed that a diagnosis of binging-purging-type AN (p = .001) predicts NSSI.

CONCLUSION

Results suggest that adolescents with AN and NSSI show peculiar clinical features with higher prevalence of binging-purging-type AN and more severe psychopathological traits than adolescents with AN without NSSI.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Increase in urgent care for patients with an eating disorder during the COVID-19 pandemic in a Spanish province

INTRODUCTION

The COVID-19 pandemic has had a great impact on people's mental health. Patients with eating disorders (ED) are also highly sensitive to the pandemic situation due to their physical and mental health. The objective of this study is to evaluate the impact that the COVID-19 pandemic may have had on the reasons for the urgent care of patients with an eating disorder, comparing the reasons for care with those from a previous period.

METHOD

We compared the visits to the emergency room and their characteristics before and after the pandemic of patients with an eating disorder in the province of Lleida. Information regarding sociodemographic status, reason for consultation, diagnosis, characteristics of suicidal behaviour, and other data were obtained from the electronic medical records.

RESULTS

Within the total emergency attendances, eating disorders increased from 1.7% in the pre-pandemic period to 3.1% during the pandemic (p=0.030). Regarding the reason for consultation, a change in the pattern is observed, decreasing consultations for anxious decompensation (p<0.001) and increasing suicidal behaviour (p=0.016) and behavioural disorder (p=0.022).

CONCLUSIONS

In our study we ascertained an increase in urgent care given to patients with an eating disorder during the two states of alarm, while consultations for anxiety symptoms decreased notably. However, care for suicidal behaviour increased, especially in women with comorbidity of personality disorders and who were unemployed.

Increase in urgent care for patients with an eating disorder during the COVID-19 pandemic in a Spanish province

Introduction

The COVID-19 pandemic has had a great impact on people's mental health. Patients with eating disorders (ED) are also highly sensitive to the pandemic situation due to their physical and mental health. The objective of this study is to evaluate the impact that the COVID-19 pandemic may have had on the reasons for the urgent care of patients with an eating disorder, comparing the reasons for care with those from a previous period.

Method

We compared the visits to the emergency room and their characteristics before and after the pandemic of patients with an eating disorder in the province of Lleida. Information regarding sociodemographic status, reason for consultation, diagnosis, characteristics of suicidal behaviour, and other data were obtained from the electronic medical records.

Results

Within the total emergency attendances, eating disorders increased from 1.7% in the pre-pandemic period to 3.1% during the pandemic (p = 0.030). Regarding the reason for consultation, a change in the pattern is observed, decreasing consultations for anxious decompensation (p < 0.001) and increasing suicidal behaviour (p = 0.016) and behavioural disorder (p = 0.022).

Conclusions

In our study we ascertained an increase in urgent care given to patients with an eating disorder during the two states of alarm, while consultations for anxiety symptoms decreased notably. However, care for suicidal behaviour increased, especially in women with comorbidity of personality disorders and who were unemployed.

Eating Disorders and Posttraumatic Stress Disorder: A Network Analysis of the Comorbidity

Eating disorders (EDs) and posttraumatic stress disorder (PTSD) commonly co-occur, but the mechanisms driving this co-occurrence are not well understood. The current study explored the relationships between symptoms of ED and PTSD in a sample of male and female undergraduate students in order to identify pathways that may maintain the comorbidity. Network analysis was conducted in a sample of 344 first-year undergraduates to visualize partial correlations between each symptom in the comorbidity. Core symptoms, bridge symptoms, and direct pathways between ED and PTSD symptoms were identified. The PTSD symptoms negative emotions (strength = 1.13) and negative beliefs (strength = 1.11) were the strongest symptoms in the network. The strongest bridge nodes were the ED symptoms restriction (bridge strength = 3.32) and binge eating (bridge strength = 2.63). The strongest edges between ED and PTSD nodes were between binge eating and concentration (part r = .16), restriction and sleep (part r = .14), and binge eating and positive emotions (part r = .11). Findings suggest that PTSD symptoms related to negative alterations in cognitions and mood may be highly influential in the ED-PTSD network due to their relatedness to all other symptoms. The pathway between binge eating and inability to experience positive emotions suggest that the comorbidity may be partially maintained through an affect regulation function of binge eating.

Lifetime prevalence and clinical correlates of nonsuicidal self-injury in youth inpatients with eating disorders: a retrospective chart review

BACKGROUND

Youths with eating disorders (EDs) engaging in nonsuicidal self-injury (NSSI) are at higher suicide risk because EDs and NSSI are associated with suicidality. However, epidemiologic data on NSSI lacks in the vulnerable group of youth ED inpatients.

METHODS

This retrospective chart review included patients up to 18 years of age with an ICD-10 diagnosis of anorexia nervosa, restricting type (AN-R), anorexia nervosa, binge-purge type (AN-BP), and bulimia nervosa (BN), treated at the child and adolescent inpatient department of the University Hospital in Berlin, Germany, between 1990 and 2015. Across and within ED subgroups, lifetime NSSI prevalence, methods of self-harm, and clinical correlates were evaluated. Independent correlations of demographic and clinical factors with NSSI were identified via multivariable regression models.

RESULTS

Of 382 inpatients (median = 15.6 (range = 9-18) years, females = 97.1%), 21.5% reported lifetime NSSI, consisting of cutting = 86.6%, scratching = 12.2%, and hitting = 8.5%. NSSI was more frequent in BN (47.6%) and AN-BP (39.3%) than AN-R (8.3%) (Φ = 0.43). Across ED subgroups, NSSI was associated with a higher prevalence of psychiatric comorbidities (AN-R: Φ = 0.55; AN-BP: Φ = 0.69; BN: Φ = 0.78), suicidal ideation (AN-R: Φ = 0.30; AN-BP: Φ = 0.38; BN: Φ = 0.29), and psychiatric medication use (AN-R: Φ = 0.23; AN-BP: Φ = 0.64; BN: Φ = 0.60). In multivariable regression analyses, NSSI was independently associated with a higher prevalence of psychiatric comorbidities (AN-R: OR = 2.93 [1.42, 6.04]; AN-BP: OR = 2.67 [1.13, 6.31]; BN: OR = 3.75 [1.71, 8.23]). Additionally, independent correlates with NSSI in AN-R included a higher prevalence of suicidal ideation (OR = 0.21 [0.72, 0.64]) and less weekly weight gain (OR = 0.03 [0.02, 0.43]), while in BN, NSSI was correlated with longer inpatient treatment duration (OR = 1.01 [1.00, 1.02]).

CONCLUSIONS

There is a high lifetime prevalence of NSSI among youth with AN and BN requiring inpatient treatment, especially those with binge-purge behaviors. Treatment programs must be tailored to address psychiatric comorbidities and suicidality to improve patient care and suicide prevention.

TRIAL REGISTRATION

This study was not considered a clinical trial but a retrospective chart review based on routinely assessed clinical parameters. The study includes data from human participants, however: (1) no intervention and no prospective assignment to interventions were performed, and (2) no evaluation of an intervention on participants was accomplished.

Psychopathological and Neurobiological Overlap Between Anorexia Nervosa and Self-Injurious Behavior: A Narrative Review and Conceptual Hypotheses

Empirical evidence and clinical observations suggest a strong -yet under acknowledged-link between anorexia nervosa (AN) and non-suicidal self-injurious behavior (NSSI). By reviewing the literature on the psychopathology and neurobiology of AN and NSSI, we shed light on their relationship. Both AN and NSSI are characterized by disturbances in affect regulation, dysregulation of the reward circuitry and the opioid system. By formulating a reward-centered hypothesis, we explain the overlap between AN and NSSI. We propose three approaches understanding the relationship between AN and NSSI, which integrate psychopathology and neurobiology from the perspective of self-destructiveness: (1) a nosographical approach, (2) a research domain (RDoC) approach and (3) a network analysis approach. These approaches will enhance our knowledge of the underlying neurobiological substrates and may provide groundwork for the development of new treatment options for disorders of self-destructiveness, like AN and NSSI. In conclusion, we hypothesize that self-destructiveness is a new, DSM-5-transcending concept or psychopathological entity that is reward-driven, and that both AN and NSSI could be conceptualized as disorders of self-destructiveness.

Using natural language processing to extract self-harm and suicidality data from a clinical sample of patients with eating disorders: a retrospective cohort study

OBJECTIVES

The objective of this study was to determine risk factors for those diagnosed with eating disorders who report self-harm and suicidality.

DESIGN AND SETTING

This study was a retrospective cohort study within a secondary mental health service, South London and Maudsley National Health Service Trust.

PARTICIPANTS

All diagnosed with an F50 diagnosis of eating disorder from January 2009 to September 2019 were included.

INTERVENTION AND MEASURES

Electronic health records (EHRs) for these patients were extracted and two natural language processing tools were used to determine documentation of self-harm and suicidality in their clinical notes. These tools were validated manually for attribute agreement scores within this study.

RESULTS

The attribute agreements for precision of positive mentions of self-harm were 0.96 and for suicidality were 0.80; this demonstrates a 'near perfect' and 'strong' agreement and highlights the reliability of the tools in identifying the EHRs reporting self-harm or suicidality. There were 7434 patients with EHRs available and diagnosed with eating disorders included in the study from the dates January 2007 to September 2019. Of these, 4591 (61.8%) had a mention of self-harm within their records and 4764 (64.0%) had a mention of suicidality; 3899 (52.4%) had mentions of both. Patients reporting either self-harm or suicidality were more likely to have a diagnosis of anorexia nervosa (AN) (self-harm, AN OR=3.44, 95% CI 1.05 to 11.3, p=0.04; suicidality, AN OR=8.20, 95% CI 2.17 to 30.1; p=0.002). They were also more likely to have a diagnosis of borderline personality disorder (p≤0.001), bipolar disorder (p<0.001) or substance misuse disorder (p<0.001).

CONCLUSION

A high percentage of patients (>60%) diagnosed with eating disorders report either self-harm or suicidal thoughts. Relative to other eating disorders, those diagnosed with AN were more likely to report either self-harm or suicidal thoughts. Psychiatric comorbidity, in particular borderline personality disorder and substance misuse, was also associated with an increase risk in self-harm and suicidality. Therefore, risk assessment among patients diagnosed with eating disorders is crucial.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: a UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals. The aim of this project was to explore the mental health of young adults with disordered eating behaviours (such as fasting, vomiting/taking laxatives, binge-eating and excessive exercise) and self-harm during the COVID-19 pandemic. We analysed data from an established study that has followed children from birth (in 1991 and 1992) up to present day, including during the pandemic when participants were 28 years old. We looked at the relationship between disordered eating and/or self-harm behaviours from before the pandemic and mental health problems (symptoms of depression and anxiety) and mental wellbeing during the pandemic. We also explored whether there were any lifestyle changes (such as changes in sleep, exercise, visiting green space) that might be linked to better mental health and wellbeing in young adults with disordered eating and self-harm. We found that young adults with prior disordered eating and/or self-harm had more symptoms of depression and anxiety, and worse mental wellbeing than individuals without prior disordered eating or self-harm. However, lifestyle changes did not appear to affect mental health and wellbeing in these young adults. Our findings suggest that people with a history of disordered eating and/or self-harm were at high risk for developing mental health problems during the pandemic, and they will need help from mental health services.

A new integrative model for the co-occurrence of non-suicidal self-injury behaviours and eating disorder symptoms

OBJECTIVE

The high co-occurrence of non-suicidal self-injury (NSSI) behaviours and eating disorder (ED) symptoms suggests these conditions share common aetiological processes. We assessed a new integrative model of shared factors for NSSI and ED symptoms, where affect dysregulation, impulsivity, self-esteem, and body dissatisfaction mediated the relationship between insecure attachment and maladaptive schemas and NSSI and ED symptoms. A further aim of the study was to assess whether the model behaved similarly across a clinical eating disorder (ED) and a community sample.

METHOD

123 females with a lifetime ED diagnosis and 531 female individuals from the community completed an online survey, which included measures assessing the variables of interest. A cross-sectional single time point analysis was used.

RESULTS

Invariance testing indicated that the model was structurally non-invariant (different across groups). The proposed integrative model was a good fit for the ED group, but for the community sample only a revised model reached an acceptable fit. Both attachment and maladaptive schemas, included early in the model, were implicated in the pathways leading to ED and NSSI symptoms in the ED and community groups. In the community group, impulsivity, a mediator, was a shared predictor for NSSI and bulimic symptoms. No other mediating variables were shared by NSSI and ED symptoms in the two groups. Overall, the proposed model explained slightly more variance for the ED group relative to the community group in drive for thinness (R² = .57 vs .51) and NSSI (R² = .29 vs .24) but less variance in bulimic symptoms (R² = .33 vs .39).

CONCLUSION

We conclude that the current model provides only limited support for explaining the comorbidity between NSSI and ED symptoms. It is vital to consider both common (e.g., attachment and maladaptive schemas) and specific factors (e.g., impulsivity) to better understand the pathways that lead to the co-occurrence of NSSI and ED symptoms. A new integrative model assessed whether emotion dysregulation, impulsivity, self-esteem, and body dissatisfaction were mediators in the relationship between insecure attachment and maladaptive beliefs about the world and the self and subsequent eating disorder and self-harm symptoms. A further aim was to assess whether the proposed model differed between a clinical eating disorder and a community sample. All participants were female and included 123 patients with a lifetime eating disorder and 531 individuals from the community. Participating individuals completed an online survey at one timepoint, which included measures assessing the variables of interest. The findings of the current study indicated that the proposed model was a good match for the clinical eating disorder sample, but for the community sample only a revised model yielded acceptable statistical fit. Both insecure attachment and maladaptive beliefs about the world and the self, included early in the model, were indirectly related to eating disorder and self-harm symptoms for both the eating disorder and the community groups. Impulsivity, a mediator, was the only shared predictor for self-harm, and bulimic symptoms in the community group. We conclude that the current model provides only limited support for explaining the comorbidity between self-harming behaviours and disordered eating symptoms.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: A UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2,657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals.

Big Five Personality Clusters in Relation to Nonsuicidal Self-Injury

Nonsuicidal self-injury (NSSI) is a complex behavior that serves many functions and may be motivated by several factors. Although previously limited to the context of personality disorders, consideration of how general personality traits might be related to NSSI warrants examination. Our aims were to investigate whether clusters based upon the Big Five personality traits exist among people who have engaged in NSSI, and explore systematic differences with regard to gender, age, key indicators of NSSI severity, functions of NSSI, emotional avoidance, alexithymia, psychological distress, and emotion regulation strategies. A sample of 236 university students (83% female, M age = 21.59, SD = 5.43) who had engaged in NSSI completed an anonymous online questionnaire. Cluster analysis yielded three subgroups who were characterized by tendencies for resilience, dysregulation, and disagreeableness. Resilient and dyregulated profiles fell within opposite ends of a continuum with regard to severity of NSSI, psychological distress and alexithymia, and adaptive vs less adaptive emotion regulation strategies. Dysregulated characteristics were also associated with affect regulation and self-punishment functions of NSSI. Disagreeable characteristics were associated with high alexithymia and psychological distress. Implications of these findings for theory and tailored treatment approaches to NSSI are discussed.

Comorbidity of self-harm and disordered eating in young people: Evidence from a UK population-based cohort

BACKGROUND

Self-harm and eating disorders are often comorbid in clinical samples but their co-occurrence in the general population is unclear. Given that only a small proportion of individuals who self-harm or have disordered eating present to clinical services, and that both self-harm and eating disorders are associated with substantial morbidity and mortality, it is important to study these behaviours at a population level.

METHODS

We assessed the co-occurrence of self-harm and disordered eating behaviours in 3384 females and 2326 males from a UK population-based cohort: the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants reported on their self-harm and disordered eating behaviours (fasting, purging, binge-eating and excessive exercise) in the last year via questionnaire at 16 and 24 years. At each age we assessed how many individuals who self-harm also reported disordered eating, and how many individuals with disordered eating also reported self-harm.

RESULTS

We found high comorbidity of self-harm and disordered eating. Almost two-thirds of 16-year-old females, and two-in-five 24-year old males who self-harmed also reported some form of disordered eating. Young people with disordered eating reported higher levels of self-harm at both ages compared to those without disordered eating.

LIMITATIONS

We were not able to measure whether participants identified their disordered eating as a method of self-harm.

CONCLUSIONS

Self-harm and disordered eating commonly co-occur in young people in the general population. It is important to screen for both sets of difficulties to provide appropriate treatment.

Non-suicidal self-injury in patients with eating disorders: nuclear aspects

Background:

Through the culture of thinness, increasingly promoted in our society as a beauty canon, it is not surprising that the number of people affected by eating disorders is increasing.

Objective:

This research aims to study the relationship between non-suicidal self-injuries and nuclear aspects of eating disorders specified along with this article.

Methods:

The sample consisted of 60 women diagnosed with anorexia and bulimia. Questionnaires assessing impulsivity, body satisfaction, alexithymia, body attitude and self-esteem were administered. Participants with non-suicidal self-harm were compared with those without it, and participants with anorexia with and without self-harm and participants with bulimia with and without self-harm were compared.

Results:

Differences were found in body dissatisfaction= 5.71; p ≤0.01), body attitudes= 4.80; p ≤0.02), self-esteem= 14.09; p ≤0.00) and impulsivity (t= 3.39; p ≤0.01) between participants with and without non-suicidal self-harm.

Conclusions:

These are key factors for the clinical area in the treatment of eating disorders to prevent the presence of self-harm, as it allows focusing the treatment target on those aspects such as dissatisfaction and impulsivity, which are key in the development of self-harm.

Identifying Predictors of Non-Suicidal Self-Injuries in Individuals with Eating Disorders

PURPOSE

Nearly one third of all patients with an eating disorder (ED) present with non-suicidal self-injury (NSSI). Although it is necessary to pay attention clinically to NSSI in ED patients due to an increased suicidal risk, there are limited data on potential predictors of NSSI in ED. We conducted this study to uncover predictors of NSSI in ED.

MATERIALS AND METHODS

A total of 1355 ED patients who visited an ED clinic was evaluated through structured interviews by psychiatrists. The demographic and clinical characteristics of ED patients with NSSI (NSSI group) and ED patients without NSSI (non-NSSI group) were analyzed to identify potential predictors of NSSI in ED.

RESULTS

Among all ED individuals, 242 (17.9%) reported a history of NSSI. Compared to the non-NSSI group, the NSSI group reported more severe eating symptomatology, more comorbid psychiatric disease, and more suicidal risk. Comorbid alcohol use disorder, depressive disorder, purging behavior, history of suicide attempt, and rumination symptoms were uncovered as predictors of NSSI in ED.

CONCLUSION

The findings of the study are meaningful in that they highlight predictors of NSSI in ED in a large clinical sample. Understanding risk factors of NSSI and offering appropriate interventions are important to preventing suicidality in ED.

The Interpersonal-Psychological Theory of Suicide to Explain Suicidal Risk in Eating Disorders: A Mini-Review

Suicide is a major cause of death in Eating Disorders (EDs) and particularly in anorexia nervosa (AN). The aim of the present mini-review was to summarize the literature focusing on the interpersonal-psychological theory of suicide (IPTS) by Thomas E. Joiner, as applied to explain suicidal risk in EDs. PubMed database was used to search articles focused on IPTS in EDs; 10 studies were eventually included. The majority of the included studies reported data from the same sample, even though the hypotheses and analyses for each study were unique. The investigated suicidal outcomes were suicidal ideation (SI) (40%), non-suicidal self-injury (10%), suicide attempt (40%) and suicide (10%). In ED patients Perceived Burdensomeness (PB) may play an important role, especially regarding SI risk. ED patients may feel like a burden to their close ones, and actually some of the ED symptoms may be an expression of anger and hate against the self. Overall, currently available research has supported some IPTS derived predictions (i.e., ED symptoms may increase PB and thereby SI), but not others (i.e., the elevated suicide rate in AN may be due to higher acquired capability for suicide). Further research on IPTS tenets as well as on other theoretical perspectives and constructs (e.g., interoceptive awareness), hopefully with a longitudinal design and adequate follow-up duration, might allow a more thorough understanding of the complex topic of suicidal behavior in ED patients.

Predictors and correlates of lifetime and persistent non-suicidal self-injury and suicide attempts among adult survivors of childhood sexual abuse

Background: Childhood sexual abuse (CSA) is a well-established risk factor for non-suicidal self-injury (NSSI) and suicide attempts (SA); still few studies have examined predictors of individual differences in NSSI/SA amongst CSA survivors. Objective: To examine predictors of NSSI and SA among adult CSA-survivors. Methods: In a sample of 516, primarily female adult CSA-survivors recruited from support centres for sexual abuse survivors in Norway, we examined the role of abuse/perpetrator characteristics, and the degree/severity of exposure to other types of childhood maltreatment (cumulative childhood maltreatment; CCM), as predictors of lifetime NSSI and SA. In a subsample of 138 individuals responding to follow-up waves two- and four years later, these same distal factors, as well as previous NSSI and proximal factors in the form of symptoms of mental health disorders (posttraumatic stress, anxiety, depression, sleep disturbances, and eating disorders), relational problems, and perceived social support, were examined as predictors of persistent NSSI. Finally, those attempting new SA during the follow-up period were compared to those who did not on these variables. Results: Higher CCM scores and having had an unknown perpetrator positively predicted lifetime NSSI scores. Higher CCM scores, violent abuse, and having had an unknown perpetrator predicted lifetime SA. Higher CCM scores, previous NSSI, having had a known perpetrator, as well as higher depression-, anxiety- and eating disorder scores, positively predicted persistent NSSI during the four-year follow-up period. Compared to those with no new SA, those reporting new SA during the follow-up period had higher CCM, lifetime NSSI, mental health symptoms and relational problem scores, lower perceived social support scores, and were more likely to have done a past SA and to have experienced abuse involving physical violence. Conclusions: A broad range of both distal and proximal factors should be assessed as potential predictors of NSSI and SA among adult CSA-survivors.

The inter-relationship between diet, selflessness, and disordered eating in Australian women

Personality traits and diet can be used to predict if a person is predisposed to disordered eating. Results of this study demonstrate a strong significant relationship between the personality trait of selflessness, diet group, and disordered eating. Vegans were most likely to display selflessness tendencies associated with disordered eating; however when selflessness was controlled for, vegans displayed substantially less disordered eating pathology than non-vegetarians.

OBJECTIVE

To explore the relationship between diet group (non-vegetarian, semi-vegetarian, true-vegetarian, and vegan) and disordered eating while investigating to what extent personality trait of selflessness mediates the relationship between diet group and disordered eating.

METHOD

Cross-sectional data from 634 Australian nonclinical women who completed a series of online questionnaires including measures of diet group, disordered eating, and selflessness were used to examine associations between diet, personality (selflessness), and disordered eating.

RESULTS

Selflessness was found to be a significant positive predictor of disordered eating. Results confirm that selflessness played a suppressing role in the relationship between the vegan diet group and disordered eating, when compared to non-vegetarians. Surprisingly, vegans displayed significantly less disordered eating than non-vegetarians and semi-vegetarians.

DISCUSSION

Results of the current study imply that the role of selflessness on disordered eating, when broken down across diet group, may be more complex than first thought. If replicated, these results suggest that targeted treatment of selflessness in different diet groups may improve treatment outcomes for disordered eating. Further research should explore why diet groups differ in terms of selflessness and how this impacts disordered eating.

Nonsuicidal self-injury, difficulties in emotion regulation, negative urgency, and childhood invalidation: A study with outpatients with eating disorders

OBJECTIVES

Among outpatients with eating disorders (ED), we compared participants without nonsuicidal self-injury (non-NSSI group), with NSSI over a year ago (past NSSI group) and with NSSI in the previous year (current NSSI group) regarding different variables, and examined whether difficulties in emotion regulation and negative urgency moderated the relationship between maternal/paternal invalidation and NSSI.

METHOD

The sample included 171 outpatients (94.2% female; M_age  = 28.78, SD_age  = 11.19).

RESULTS

Fifty-four participants (31.6%) had NSSI in the previous year. This group showed higher eating pathology, difficulties in emotion regulation, negative urgency, and maternal/paternal invalidation than the non-NSSI group. Analyses revealed an adequate fit to the data for the model that included moderating effects of emotional awareness and negative urgency in the relationship between maternal/paternal invalidation and increased likelihood of NSSI in the previous year.

CONCLUSIONS

Interventions for NSSI and ED should include emotion regulation, impulse control, and validation strategies.

Longitudinal relations of self-criticism with disordered eating behaviors and nonsuicidal self-injury

OBJECTIVE

Self-criticism has been proposed as a transdiagnostic predictor of disordered eating and nonsuicidal self-injury (NSSI). First, this study explored cross-sectional associations of multiple disordered eating behaviors, NSSI, and self-criticism. Second, it tested longitudinal relations of self-criticism with disordered eating and NSSI, adjusting for baseline levels of both behaviors.

METHODS

In Sub-study 1, undergraduates (N = 251, 79.5% female, Mage = 19.1 years) completed self-report measures of disordered eating, NSSI, and self-criticism at baseline and after 8 weeks. In Sub-study 2, community-based young adults with histories of disordered eating, NSSI, or both (N = 517, 88.8% female, Mage = 24.7 years) completed measures of disordered eating, NSSI, and self-criticism at baseline and after 4 weeks. All measures were completed online.

RESULTS

In Sub-study 1, both disordered eating and NSSI showed significant cross-sectional associations with self-criticism, and self-criticism was significantly related to binge eating, fasting, and NSSI at follow-up. In Sub-study 2, both behaviors again showed significant cross-sectional associations with self-criticism. Self-criticism showed significant longitudinal relations with fasting, purging, and excessive exercise. Longitudinal relations of self-criticism with NSSI varied across disordered eating behaviors.

DISCUSSION

NSSI showed cross-sectional associations with a range of disordered eating behaviors. Self-criticism reflects a common correlate of both disordered eating and NSSI. Evidence supported transdiagnostic longitudinal impact of self-criticism across multiple forms of disordered eating but provided more limited support for impacts on NSSI.

Non-suicidal self-injury in patients with eating disorders: nuclear aspects

Background: Through the culture of thinness, increasingly promoted in our society as a beauty canon, it is not surprising that the number of people affected by eating disorders is increasing. Objective: This research aims to study the relationship between non-suicidal self-injuries and nuclear aspects of eating disorders specified along with this article. Methods: The sample consisted of 60 women diagnosed with anorexia and bulimia. Questionnaires assessing impulsivity, body satisfaction, alexithymia, body attitude and self-esteem were administered. Participants with non-suicidal self-harm were compared with those without, and participants with anorexia with and without self-harm and participants with bulimia with and without self-harm were compared. Results: Differences were found in body dissatisfaction = 5,71; p ≤ ,01), body attitudes = 4,80; p ≤ ,02), self-esteem = 14,09; p ≤ .00) and impulsivity (t = 3,39; p ≤ ,01) between participants with and without non-suicidal self-harm. Conclusions: These are key factors for the clinic in the treatment of eating disorders to prevent the presence of self-harm, as it allows focusing the treatment target on those aspects such as dissatisfaction and impulsivity, which are key in the development of self-harm.

Suicide attempts requiring hospitalization in patients with eating disorders: A retrospective cohort study

OBJECTIVE

Suicide attempts requiring hospitalization are known to be common in patients who are diagnosed with eating disorders. Attempting suicide is a major indicator for those at risk of completed suicide. Both the specific eating disorder diagnosis and the influence of psychiatric comorbidities on suicide attempts requiring hospitalization were investigated, with demographic and socioeconomic variables as confounders, over a 10-year observation period from January 2007 to March 2017.

METHODS

Anonymized health-record data from the South London and Maudsley NHS Foundation Trust (SLaM) were retrieved through the Clinical Record Interactive Search (CRIS) data resource; this is linked to national Hospital Episode Statistics (HES) data. These data include all diagnoses for inpatient admissions. Hazard ratios, with 95% confidence intervals (CIs), were calculated from cox regression analyses and the effects of a number of confounders were estimated by performing multivariable analyses.

RESULTS

In total, 4,895 patients were diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder otherwise not specified (EDNOS). Of these, 331 (6.7%) had attempted suicide requiring hospitalization and 21 (0.04%) completed suicide. The eating disorder category associated with the highest risk of a suicide attempt was AN (HR: 1.43, 95%CI: 1.08-1.89, p = .01). The risk was significantly increased further if the patient had a comorbid diagnosis of personality disorder, depression, bipolar affective disorder, and substance misuse.

DISCUSSION

Suicide attempts requiring hospitalization have a high incidence rate among patients with eating disorders, and the risk is significantly increased in AN. Comorbid psychiatric illness and suicidal ideation should be carefully assessed in all eating disorder patients.

Temperament and Character Traits of Female Eating Disorder Patients with(out) Non-Suicidal Self-Injury

Eating disorder (ED) patients show alarmingly high prevalence rates of Non-Suicidal Self-Injury (NSSI). Adolescents seem to be particularly at risk, as EDs and NSSI both have their onset in mid-adolescence. It has been suggested that personality could be a transdiagnostic mechanism underlying both EDs and NSSI. However, little attention has been given to adolescent clinical samples compared to adult and/or community samples. Therefore, the current study investigated the role of personality in a sample of 189 female inpatients with an ED (M = 15.93, SD = 0.98). Our results confirmed the high prevalence of NSSI in EDs, specifically in patients with bingeing/purging behaviours (ED-BP). Temperamental differences were found between ED-BP and the restrictive ED subtype (ED-R). Namely, ED-BP patients showed more harm avoidance and less self-directedness compared to ED-R. Temperamental differences were found in NSSI as well, regardless of ED subtype: ED patients who had engaged in NSSI during their lifetime reported less self-directedness and more harm avoidance. Interestingly, only ED patients who recently engaged in NSSI showed less novelty seeking. These temperamental profiles should be recognised as key mechanisms in the treatment of adolescent ED patients with and without NSSI.

Physical Disorders are Associated with Health Risk Behaviors in Chinese Adolescents: A Latent Class Analysis

It is known that health risk behaviors (HRBs) can lead to a variety of physical and mental health problems among adolescents, but few studies have paid attention to the relationship between latent classes of HRBs and adolescent diseases. The purpose of this study was to use latent class analysis (LCA) to clarify the potential subgroups of HRBs (smoking, drinking, screen time, non-suicidal self-injuries, suicidal behaviors, and unintentional injuries) and examine the association between the subgroups of HRBs and physical disorders (diarrhea, fever, cough, and vomiting) with multiple logistic regression analysis, in Chinese adolescents. Self-reported HRBs and physical disorders were used to evaluate 22,628 middle school students in six cities of China, from November 2015 to January 2016, based on a multistage stratified cluster sampling approach. The prevalence of diarrhea, fever, cough, and vomiting was 23.5%, 15.9%, 50.6%, and 10.7%, respectively. We identified four latent classes of HRBs by LCA, including low-risk class, moderate-risk class 1 (smoking, drinking, and screen time), moderate-risk class 2 (non-suicidal self-injuries and suicidal behaviors, unintentional injuries), and high-risk class (smoking, drinking, screen time, non-suicidal self-injuries, suicidal behaviors, and unintentional injuries), which were 64.0%, 4.5%, 28.8% and 2.7% of participants, respectively. Compared to the low-risk class, all other classes showed higher risk for these physical disorders (P < 0.01 for each). In particular, the high-risk class had the highest risk (diarrhea (odds ratio (OR) = 2.628, 95% confidence interval (CI) 2.219 to 3.113), fever (OR = 3.103, 95% CI 2.591 to 3.717), cough (OR = 2.142, 95% CI 1.805 to 2.541), and vomiting (OR = 3.738, 95% CI 3.081 to 4.536). In conclusion, these results indicated that heterogeneity exists in HRBs, and subgroups of HRBs were correlated to the occurrence of common physical disorders in Chinese adolescents. Therefore, multiple HRBs rather than single factors should be considered for the prevention of common physical disorders in schools.

Is post-traumatic embitterment disorder a yet unknown comorbidity of anorexia nervosa?

Patients with anorexia nervosa (AN) present more frequently a personal history of traumatizing life events than they manifest a comorbid, clinically characterized, post-traumatic stress disorder (PTSD). The psychological impact of traumatic events on patients with AN may also manifest through a post-traumatic embitterment disorder (PTED). In PTED, the traumatic event is perceived as unjust and the patient's response involves feelings of embitterment, rage, and helplessness along with repeated intrusive memories and a persistent negative change in mental well-being. Patients with AN share several psychopathological features with the clinical disturbed dimensions described in PTED. Accordingly, the comorbidity between PTED and AN needs further characterization. Moreover, specific therapeutic intervention known to improve symptoms of PTED such as cognitive-behavioral therapy based on wisdom psychology should be tested in selected patients with AN.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Emotional Response Inhibition: A Shared Neurocognitive Deficit in Eating Disorder Symptoms and Nonsuicidal Self-Injury

Eating disorder (ED) symptoms often co-occur with non-suicidal self-injury (NSSI). This comorbidity is consistent with evidence that trait negative urgency increases risk for both of these phenomena. We previously found that impaired late-stage negative emotional response inhibition (i.e., negative emotional action termination or NEAT) might represent a neurocognitive mechanism for heightened negative urgency among people with NSSI history. The current study evaluated whether relations between negative urgency and ED symptoms similarly reflect deficits in this neurocognitive process. A total of 105 community adults completed an assessment of ED symptoms, negative urgency, and an emotional response inhibition task. Results indicated that, contrary to predictions, negative urgency and NEAT contributed independent variance to the prediction of ED symptoms, while controlling for demographic covariates and NSSI history. Worse NEAT was also uniquely associated with restrictive eating, after accounting for negative urgency. Our findings suggest that difficulty inhibiting ongoing motor responses triggered by negative emotional reactions (i.e., NEAT) may be a shared neurocognitive characteristic of ED symptoms and NSSI. However, negative urgency and NEAT dysfunction capture separate variance in the prediction of ED-related cognitions and behaviors, distinct from the pattern of results we previously observed in NSSI.

Clinical and personality characteristics of adolescents with anorexia nervosa with or without non-suicidal self-injurious behavior

PURPOSE

About one-fifth of patients with anorexia nervosa (AN) engage in non-suicidal self-injury (NSSI). This study examined clinical and temperament profile of female adolescents with both disorders (AN+NSSI) as compared with peers with AN only.

METHODS

A consecutive sample of 73 female adolescents with AN (mean age: 13.77 years), who had been admitted to inpatient or day-hospital services, received clinical, cognitive, and temperament/character evaluations. Of them, 32 met DSM-5 criteria also for NSSI. Assessments included demographics, standard nutrition parameters, Youth Self-Report (YSR), Wechsler Intelligence Scale for Children IV (WISC-IV), Temperament and Character Inventory (TCI), and Global Assessment of Functioning (GAF).

RESULTS

No differences were detected between AN+NSSI and AN in demographics, body mass index, or age at onset of AN. AN+NSSI had higher rate of binging and purging, higher YSR scores for both internalizing and externalizing psychopathology, lower total IQ, and lower Self-directedness and Cooperativeness scores.

CONCLUSIONS

These data suggest that adolescents with AN+NSSI have psychopathological, cognitive and overall character features that differ from patients with AN only. These characteristics may have implications for treatment and outcome.

Comparing self-harming intentions underlying eating disordered behaviors and NSSI: Evidence that distinctions are less clear than assumed

OBJECTIVE

Eating disordered (ED) behaviors (i.e., binge eating, compensatory behaviors, restrictive eating) and nonsuicidal self-injury (NSSI; intentional and nonsuicidal self-harm) are highly comorbid and share several similarities, including consequent pain and physical damage. However, whereas NSSI is considered direct self-harm, ED behaviors are considered indirect self-harm. These distinctions stem from theoretical understanding that NSSI is enacted to cause physical harm in the moment, whereas ED behaviors are enacted for other reasons, with consequent physical harm occurring downstream of the behaviors. We sought to build on these theoretically informed classifications by assessing a range of self-harming intentions across NSSI and ED behaviors.

METHOD

Study recruitment was conducted via online forums. After screening for inclusion criteria, 151 adults reported on their intent to and knowledge of causing physical harm in the short- and long-term and suicide and death related cognitions and intentions when engaging in NSSI and specific ED behaviors.

RESULTS

Participants reported engaging in ED and NSSI behaviors with intent to hurt themselves physically in the moment and long-term, alongside thoughts of suicide, and with some hope and knowledge of dying sooner due to these behaviors. Distinctions across behaviors also emerged. Participants reported greater intent to cause physical harm in the moment via NSSI and in the long-run via restrictive eating. NSSI and restrictive eating were associated with stronger endorsement of most suicide and death-related intentions than binge eating or compensatory behaviors.

CONCLUSIONS

Findings shed light on classification of self-harming behaviors, casting doubt that firm boundaries differentiate direct and indirectly self-harming behaviors.

Prevalence of Self-Injurious Thoughts and Behaviors in Transgender Individuals With Eating Disorders: A National Study

PURPOSE

This study examined prevalence of self-injurious thoughts and behaviors (SITBs) in transgender individuals with eating disorders, as compared to cisgender individuals with eating disorders and transgender individuals without eating disorders.

METHODS

Data were analyzed from 365,749 individuals (median age 21 years, 71.8% White/Caucasian, 34.9% male, 64.9% female, and 0.2% transgender) who participated in American College Health Association-National College Health Assessment, an annual national assessment of college student health, from 2008 to 2011.

RESULTS

Rates of past-year nonsuicidal self-injury, suicidal ideation, and suicide attempts were elevated in transgender participants with eating disorders (74.8%, 75.2%, and 74.8%, respectively), as compared to cisgender participants with eating disorders and transgender participants without eating disorders. Follow-up logistic regression analyses indicated these differences were statistically significant above and beyond the effects of demographic variables and depression.

CONCLUSIONS

Results found extremely high rates of SITBs in transgender individuals with eating disorders. This combination of identities, each associated with SITBs, may have a compounding effect.