Restrictive eating and nonsuicidal self-injury in a nonclinical sample: Co-occurrence and associations with emotion dysregulation and interpersonal problems

Non-suicidal self-injury among women hospitalised for anorexia nervosa

INTRODUCTION

Non-suicidal self-injury (NSSI) is frequent in eating disorders (ED). The aim of this study was to describe NSSI among subjects hospitalised for anorexia nervosa (AN) who self-harm and factors associated with NSSI in this population.

METHODS

This study was part of a larger French longitudinal multi-centre study. Two hundred and two women with AN were recruited from inpatient treatment facilities for ED from 2009 to 2011. All participants fulfilled the DSM-5 diagnostic criteria of AN. Subjects with and without NSSI were compared for clinical characteristics and comorbidities in bivariate analyses. Logistic regression analysis was then used to identify factors associated with NSSI.

RESULTS

The mean age of the sample was 20.8 years (± 6.6). The mean BMI was 14.3 (± 1.5). Overall 36.1% had self-harmed in the past 6 months. The main factors that triggered NSSI were a feeling of physical or psychological unease (45.2%), feelings of anger (24.7%), an attempt to relieve discomfort (19.2%), and low self-esteem (16.4%). Lifetime major depressive disorder, suicide attempts and eating concerns were independently associated with NSSI.

DISCUSSION

ED symptoms were linked to NSSI, but psychiatric history also played a key role. This is consistent with hypotheses of common underlying transdiagnostic mechanisms linking emotional dysregulation to NSSI and ED.

LEVEL OF EVIDENCE

Level III, well-designed cohort or case-control analytic studies.

Anorexia Nervosa in Comorbidity With Borderline Personality Disorder in Adolescence: A Specific Clinical Endophenotype?

OBJECTIVE

Anorexia nervosa and borderline personality disorder are often associated and share some core elements, including emotional dysregulation and affective instability. Nevertheless, the association of these two conditions in adolescence is still little studied.

METHOD

The present study aims at investigating, through a multidimensional assessment, the psychopathological characteristics of adolescents affected by anorexia nervosa in comorbidity with borderline personality disorder on a sample of 127 female adolescents, through the comparison with adolescents with borderline personality disorders and adolescents with anorexia nervosa. All participants completed a validated psychometric battery assessing alexithymia (Toronto Alexithymia Scale-20), depression (Children's Depression Inventory), psychological symptoms (Symptom Checklist-90-Revised) and psychological symptoms relevant in eating disorders (Eating Disorders Inventory-3).

RESULTS

Adolescents with anorexia nervosa in comorbidity with borderline personality disorder show intermediate features between the two disorders individually in the general psychopathological profile, but a peculiar psychological profile regarding the eating symptomatology, with worse features compared to adolescents with the sole anorexia nervosa.

CONCLUSIONS

Results suggest a peculiar clinical and psychopatological endophenotype in adolescents with anorexia nervosa in comorbidity with borderline personality disorders, indicating the need to define specific and tailored treatment for this population.

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.

Non-Suicidal Self-Injury in Eating and Feeding Disorder Patients: Characteristics and Clinical Implications in a Group of Referred Female Adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) and Feeding or Eating Disorders (FEDs) often coexist during adolescence with reciprocal influences on their clinical picture. The present study aimed to identify differences and similarities in the clinical presentation of young patients with both conditions compared to those with the two non-comorbid disorders.

METHODS

We consecutively recruited forty-five female patients aged between 11 and 18 at our third-level hospital and subdivided them into three groups (NSSI: n = 15; FED: n = 15; NSSI + FED: n = 15). Patients underwent a full clinical assessment.

RESULTS

Based on our results, the NSSI + FED group was characterized by higher rates of binging/purging behaviors, greater prevalence of Cyclothymic Disorder, and a more severe clinical presentation compared to the non-comorbid groups. Moreover, higher levels of suicidal ideation were found in the NSSI + FED group. Pharmacological treatment patterns also differed, with SSRI being prescribed more frequently to NSSI + FED patients while mood stabilizers were prescribed more frequently to NSSI ones. A Principal Component Analysis identified four main dimensions: "Body Image" impairment was more pronounced in NSSI + FED patients, indicating negative attitudes towards their own body; "Metacognition" deficits were higher in NSSI than FED.

CONCLUSIONS

The present study underscores distinctive clinical features in patients with comorbid NSSI and FED, emphasizing the urgent need for tailored intervention strategies focusing on specific symptom domains.

Reward responsivity and habit formation in the co-occurrence of restrictive eating and nonsuicidal self-injury

Dysfunctions in reward and/or habit formation have been proposed as factors contributing individually to the maintenance of restrictive eating and nonsuicidal self-injury (NSSI). However, despite the high comorbidity between these behaviors, the associations between reward and habit formation in their co-occurrence remains unclear. This study examined self-reported reward responsivity and habit strength among individuals with co-occurring restrictive eating and NSSI (Comorbid group; n = 108) and those with one behavior only (One-behavior group; n = 113). Hierarchical logistic regression analyses assessed the association between reward and habit features and the co-occurrence of restrictive eating and NSSI, accounting for the effects of impulsivity (a characteristic commonly considered to underlie co-occurring disordered eating and NSSI). Partial correlations examined the relationships between these features and the severity of eating disorder and NSSI symptoms, also controlling for impulsivity. Lower reward responsivity was associated with the co-occurrence of restrictive eating and NSSI, even after accounting for impulsivity (p = 0.017). In exploratory analyses, this relationship was no longer significant after accounting for self-reported depression. No significant associations were found regarding habit formation and restrictive eating and NSSI co-occurrence. Lower reward responsivity was linked to increased NSSI frequency and versatility in both groups and associated with severity of eating pathology in the Comorbid group (ps < 0.05). Our findings suggest that blunted reward responsivity may relate to the co-occurrence of restrictive eating, NSSI, and depressive symptoms, as well as the severity of restrictive eating and NSSI. Reward disturbances may serve as a crucial target in the treatment of multiple self-destructive behaviors.

Prevalence of non-suicidal self-injury, suicidal ideation, suicide attempts, suicide mortality in eating disorders: a systematic review and meta-analysis

Eating disorders have a wide and profound impact on psychological and general health. The study aims to provide a comprehensive and up-to-date review of non-suicidal self-injury, suicidal ideation, suicide attempts, and suicide mortality in a variety of eating disorders. A systematic search was conducted using four databases from inception until April 2022, limiting the search to English-language. For each of the eligible studies, the prevalence of suicide-related issues in eating disorders was calculated. The prevalence of non-suicidal self-injury, suicide ideation, and suicide attempts was then calculated for each anorexia nervosa and bulimia nervosa. The random-effects method was used for the pool of studies. Fifty-two articles were used for this study and included in the meta-analysis. The prevalence of non-suicidal self-injury is 40% with a confidence interval between 33-46% (I2 97.36%). The prevalence of suicide ideation is 51% with a confidence interval between 41-62% (I2 97.69%). The prevalence of suicide attempts is 22% with a confidence interval between 18-25% (I2 98.48%). The heterogeneity in the studies included in this meta-analysis was high. There is a high prevalence of non-suicidal self-injury, suicidal ideation, and suicide attempts in eating disorders. Thus, comorbidity between eating disorders and suicide issues is an important topic that can provide insights into etiology. Future studies must consider eating disorders along with other types of mental health issues, such as depression, anxiety, sleep problems, and aggression.

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.

Latent profile analyses of disordered eating behaviors and nonsuicidal self-injury among Vietnamese adolescents

OBJECTIVE

Comorbidity of disordered eating (DE) behaviors and nonsuicidal self-injury (NSSI) is linked to increased functional impairment. The present study identified subtypes of DE and NSSI comorbidity in a non-Western, low- and middle-income country where there has been particularly little research in this area.

METHOD

Latent profile analyses (LPA) were conducted to identify patterns of subgroup comorbidity in self-reported DE behaviors and NSSI behaviors, in a sample of Vietnamese high-school students (N = 1451, 51% female). Parallel-process LPA was used to predict NSSI subgroup membership from DE subgroup membership.

RESULTS

A seven-class LPA model was identified for DE: (1) Low frequencies of all DE behaviors; (2) Frequent levels of all DE behaviors; (3) Frequent fasting and purging behaviors; (4) Frequent binge eating only; (5) Moderate binge eating; (6) Moderate fasting and purging behaviors; (7) Exercise and fasting. A two-class (high versus low) model was identified for NSSI. Odds of membership in the high-NSSI class were significantly increased for all DE classes except the class characterized by moderate binge eating. Odds of belonging to the high-NSSI class were highest for those in DE classes involving purging behaviors. Males predominated in classes characterized by high behavior dysregulation.

DISCUSSION

DE and NSSI represent important clinical concerns among Vietnamese youth in urban contexts, and males may show particular vulnerability for certain risk behaviors. The association of classes of DE behaviors to NSSI was particularly strong for classes that involved purging, highlighting the importance of this specific behavior for understanding comorbidity of DE and NSSI.

PUBLIC SIGNIFICANCE

Disordered eating and nonsuicidal self-injury (NSSI; hurting oneself without intending to die) commonly co-occur. There has been less research on disordered eating and NSSI among individuals from non-Western or low/middle-income countries. We examined patterns of these behaviors in a school-based sample of Vietnamese adolescents. We found that patterns of disordered eating distinguished by purging showed particular links to NSSI, which could have implications for screening and treatment.

Support for a Transdiagnostic Motivational Model of Self-Damaging Behaviors: Comparing the Salience of Motives for Binge Drinking, Disordered Eating, and Nonsuicidal Self-Injury

Integrating across motivational models suggests that different self-damaging behaviors (SDBs) are enacted for similar reasons. However, it remains unclear whether some motives are more relevant to certain SDBs than others. To answer this question, the present study compared the salience of 8 potentially shared motives across 3 exemplar SDBs, selected to represent different points along the internalizing and externalizing spectra: binge drinking, disordered eating (binge eating, purging, fasting), and nonsuicidal self-injury (NSSI). Seven hundred and four first-year university students (73% female, M_age = 17.97) completed monthly surveys assessing their engagement in and motives for SDBs. Motives were conceptualized as either interpersonal (bonding with others, conforming with others, communicating strength, communicating distress, reducing demands) or intrapersonal (reducing negative emotions, enhancing positive emotions, punishing oneself). Multilevel models compared endorsement of each motive across SDBs. Results revealed that SDBs were motivated by similar goals, albeit to different degrees. Although some exceptions emerged, interpersonal motives were most salient to binge drinking, followed by disordered eating, and then NSSI. In contrast, intrapersonal motives were most salient to NSSI, followed by disordered eating, and then binge drinking. Motivational differences were also found within disordered eating. For example, punishing oneself was more relevant to purging and fasting than binge eating, whereas relieving negative emotions was more relevant to binge eating and purging than fasting. Similar to dimensional models that position SDBs on internalizing or externalizing spectra, the salience of motives for binge drinking and NSSI may fall on distinct spectra (i.e., interpersonal and intrapersonal, respectively), with motives for disordered eating exhibiting elements consistent with both spectra. This study supports a common motivational framework for investigating and potentially treating a variety of topographically distinct SDBs.

Differential comorbidity profiles in avoidant/restrictive food intake disorder and anorexia nervosa: Does age play a role?

OBJECTIVE

Research comparing psychiatric comorbidities between individuals with avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) is limited. ARFID often develops in childhood, whereas AN typically develops in adolescence or young adulthood. Understanding how age may impact differential psychological comorbidity profiles is important to inform etiological conceptualization, differential diagnosis, and treatment planning. We aimed to compare the lifetime frequency of psychiatric comorbidities and suicidality between females with ARFID (n = 51) and AN (n = 40), investigating the role of age as a covariate.

METHOD

We used structured interviews to assess the comparative frequency of psychiatric comorbidities/suicidality.

RESULTS

When age was omitted from analyses, females with ARFID had a lower frequency of depressive disorders and suicidality compared to AN. Adjusting for age, only suicidality differed between groups.

DISCUSSION

This is the first study to compare comorbidities in a similar number of individuals with ARFID and AN, and a structured clinical interview to confer ARFID and comorbidities, covarying for age, and the first to compare suicidality. Although suicidality is at least three times less common in ARFID than AN, observed differences in other psychiatric comorbidities may reflect ARFID's relatively younger age of presentation compared to AN.

PUBLIC SIGNIFICANCE

Our results highlight that, with the exception of suicidality, which was three times less common in ARFID than AN irrespective of age, observed differences in psychiatric comorbidities in clinical practice may reflect ARFID's younger age at clinical presentation compared to AN.

Body dissatisfaction and non-suicidal self-injury among Chinese young adults: a moderated mediation analysis

OBJECTIVE

Extensive evidence from Western societies supports the role for body dissatisfaction in the etiological models of non-suicidal self-injury (NSSI). However, research of the underlying mechanisms of this relationship has been limited, especially in China. Therefore, the aim of this study was to examine the association between body dissatisfaction and NSSI among college students in China. Possible mediating roles for psychological distress and disordered eating, as well as a moderating role for self-compassion, were also examined.

METHODS

College students (n = 655, M_age = 20.32 years, SD = 1.02) were recruited from Henan province, China. Each participant completed questionnaires regarding body dissatisfaction, psychological distress, disordered eating, and self-compassion.

RESULTS

A close to medium positive relationship between body dissatisfaction and NSSI was revealed with r = 0.24 (p < .001). The relationship was found to be fully mediated by psychological distress and disordered eating. The mediation role for disordered eating was found to be further moderated by self-compassion, suggesting that self-compassion acted as a buffer against the relationship between disordered eating and NSSI.

CONCLUSION

These findings indicate that body dissatisfaction, psychological distress, disordered eating, and self-compassion may play important roles in Chinese young adults' NSSI. Researchers and practitioners need to pay closer attention to the underlying mechanisms of how body dissatisfaction links to NSSI to deepen the understanding of their linkage as well as to provide appropriate interventions.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

A nonhuman primate model of human non-suicidal self-injury: serotonin-transporter genotype-mediated typologies

While non-suicidal self-injury (NSSI) occurs in the general population at a surprisingly high rate, with higher rates among certain clinical  populations, its etiology is not well-understood. Consequently, the DSM-5 lists NSSI as requiring further research. This study utilizes a translational model of naturally-occurring NSSI to assess the role of early parental neglect and variation in the serotonin transporter genotype (5-HTT) in the etiology of NSSI. Subjects (N = 161) were rhesus macaques (Macaca mulatta) reared in one of three conditions (mother-reared (MR), peer-reared (PR), or surrogate peer-reared (SPR)), and classified as NSSI (n = 18) or non-NSSI (n = 143). Subjects were genotyped for 5-HTT and their behaviors were recorded during an ecologically-meaningful, stress-evoking, intruder paradigm. Two weeks prior to testing, blood samples were obtained and assayed for plasma cortisol and adrenocorticotropic hormone (ACTH) concentrations. NSSI subjects were more likely to be SPR, paralleling human studies showing that individuals that exhibit NSSI tend to have experienced abuse or neglect early in life. Results also indicated that variation in the 5-HTT genotype differentiated the NSSI subjects. NSSI subjects that were homozygous for the L allele exhibited high plasma ACTH and high rates of stress-induced stereotypies; whereas NSSI subjects with the s allele exhibited impulsive behaviors, including frequently approaching the potentially dangerous intruder, high rates of aggressive vocal threats, and more activity. These results suggest that there may be different 5-HTT genotype-mediated NSSI typologies and that both early experiences and variation in the 5-HTT genotype may be important factors in understanding the etiology of NSSI.

Biased and inflexible interpretations of ambiguous social situations: Associations with eating disorder symptoms and socioemotional functioning

BACKGROUND

Research indicates that difficulties across multiple socioemotional functioning domains (e.g., social emotion expression/regulation, response to social elicitors of emotion) and negatively biased interpretations of ambiguous social situations may affect eating disorder symptoms. The impact of inflexible interpretations of social situations on eating disorder symptoms is less clear. The present study therefore examined relations between inflexible and biased social interpretations, socioemotional functioning, and eating disorder symptoms.

METHOD

A total of 310 participants from the general population, recruited from an online crowdsourcing platform, completed measures of socioemotional functioning (e.g., rejection sensitivity, negative social exchange), eating disorder symptoms, and positive and negative interpretation bias and inflexibility on a single measurement occasion.

RESULTS

Socioemotional functioning impairments (Pillai's trace = 0.11, p < .001), but not negative (β = .07, p = .162) or positive (β = -.01, p = .804) interpretation bias or inflexible interpretations (β = .04, p = .446), were associated with eating disorder symptoms in multiple regression models. In network analyses controlling statistically for multiple markers of socioemotional functioning, eating disorder symptoms were directly associated with negative (but not positive) interpretation bias. Inflexible interpretations were indirectly linked to symptoms via co-dampening of positive emotions. Exploratory causal discovery analyses suggested that several socioemotional functioning variables (social anxiety, depression, negative social exchange) may cause eating disorder symptoms.

CONCLUSIONS

Consistent with cognitive-interpersonal models of disordered eating, our results suggest that less accurate (biased, inflexible) interpretations of social information contribute to patterns of cognition (anxious anticipation of rejection) and emotion regulation (down-regulation of positive social emotion) thought to encourage disordered eating.

PUBLIC SIGNIFICANCE

This study suggests that less accurate interpretations of ambiguous social information encourage anxious anticipation of rejection and downregulation of positive social emotions, both of which are thought to promote eating disorder symptoms. Knowledge provided by this study about the likely relations between interpretive processes, social/emotional functioning, and eating disorder symptoms may help inform treatments for eating disorders, particularly those that attempt to modify patterns of interpretation.

Functional assessment of restrictive eating: A three-study clinically heterogeneous and transdiagnostic investigation

Restrictive eating is common and associated with negative psychological outcomes across the life span and eating disorder (ED) severity levels. Little is known about functional processes that maintain restriction, especially outside of narrow diagnostic categories (e.g., anorexia nervosa). Here, we extend research on operant four-function models (identifying automatic negative, automatic positive, social negative, and social positive reinforcement functions) that have previously been applied to nonsuicidal self-injury (NSSI), binge eating, and purging to restricting. We assessed restrictive eating functions in three samples: clinically heterogeneous adolescents (Study 1: N = 457), transdiagnostic adults (Study 2: N = 145), and adults with acute or recently weight-restored anorexia nervosa (Study 3: N = 45). Study 1 indicated the four-function model was a good fit for restricting (root mean square error of approximation [RMSEA] = .06, Tucker-Lewis index [TLI] = .88). This factor structure replicated in Study 2 (comparative fit index [CFI] = .97, RMSEA = .07, TLI = .97, standardized root mean square residual [SRMR] = .09). Unlike NSSI, binge eating, and purging, which have been found to primarily serve automatic negative reinforcement functions, all three present studies found automatic positive reinforcement was most highly endorsed (by up to 85% of participants). In Studies 1 and 3, automatic functions were associated with poorer emotion regulation (ps < .05). In Study 1, social functions were associated with less social support (ps < .001). Across studies, automatic functions were associated with greater restriction ps < .05). Functions varied slightly by ED diagnosis. Across ED presentation, severity, and developmental stage, restrictive eating may be largely maintained by automatic positive reinforcement, with some variability across presentations. Continued examination of restrictive eating functions will establish processes that maintain restriction, allowing more precise treatment targeting for these problematic behaviors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Nonsuicidal self-injury and suicide attempts are uniquely associated with eating disorder pathology and behaviors over and above negative urgency

Nonsuicidal self-injury (NSSI) and suicidal behaviors are prevalent in individuals with eating disorders (EDs). Negative urgency (NU; the tendency to act rashly when distressed) is a common correlate of NSSI, suicide, and ED pathology. The aim of this study was to examine whether lifetime history of NSSI and suicide attempts (SA) contributed unique variance to current ED pathology after controlling for the variance accounted for by NU. Undergraduate students (N = 871; 25.4% male) self-reported lifetime SA and completed a modified Deliberate Self-Harm Inventory to assess lifetime NSSI, the Eating Disorder Examination-Questionnaire (EDE-Q), and the NU scale of the UPPS Impulsive Behavior Scale-Revised. Hierarchical regression analyses indicated that lifetime NSSI but not SA was associated with higher Global EDE-Q scores (NSSI: β = 0.11, p < .001; SA: β = 0.007, p > .05) and restrictive eating (NSSI: β = 0.10, p < .001; SA: β = 0.05, p > .05) after controlling for NU. In addition, lifetime NSSI (OR = 2.98, 95% CI = 1.54-5.76) and SA (OR = 5.68, 95% CI = 1.90-17.02) were significantly associated with past month purging but not binge eating after controlling for NU. Results suggest that NSSI is uniquely associated with increased likelihood of past month ED pathology in a nonclinical sample. Study limitations included low rates of behavioral problems in the sample and no measures of suicidal ideation. Clinicians who treat EDs should regularly assess NSSI and suicidal ideation.

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.

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.

Brief report: Differences in nonsuicidal self-injury according to binge eating and purging status in an adolescent sample seeking eating disorder treatment

Nonsuicidal self-injury (NSSI) is elevated in adults with eating disorders (EDs), with a particularly increased incidence among individuals who engage in binge eating and/or purging (B/P) behaviors. Despite substantially elevated prevalence of NSSI in adolescence in general, NSSI in child and adolescent ED samples is understudied. There is some evidence for elevated prevalence of NSSI between B/P and restriction-only groups; however, this finding is not consistently reported and research in this area has excluded certain diagnostic groups (e.g., other specified feeding or eating disorder). Our aim was to identify the rates at which a transdiagnostic sample of adolescent patients with EDs (n = 155) report lifetime or past-month NSSI, and whether these rates differ between individuals who engaged in recent B/P behaviors vs. restriction only. Lifetime NSSI was present in 40.6% of the sample, and 23.2% of participants reported engaging in NSSI in the month prior to treatment. Individuals who reported recent B/P behaviors were more likely to report past-month (p = .005, OR = 5.57) and lifetime (p = .004, OR = 4.39) NSSI compared to individuals who did not report B/P behaviors. These results suggest an increase in risk for NSSI in child and adolescent patients in ED treatment who endorse B/P behaviors compared to patients who endorse restriction only. Research is needed to clarify the etiologic factors that may explain this association and the longitudinal changes in NSSI throughout the course of EDs.

Restrictive eating, but not binge eating or purging, predicts suicidal ideation in adolescents and young adults with low-weight eating disorders

OBJECTIVE

This study examined the relationship between eating-disorder behaviors-including restrictive eating, binge eating, and purging-and suicidal ideation. We hypothesized that restrictive eating would significantly predict suicidal ideation, beyond the effects of binge eating/purging.

METHODS

Participants were 82 adolescents and young adults with low-weight eating disorders. We conducted a hierarchical logistic regression, with binge eating and purging in Step 1 and restrictive eating in Step 2, to predict suicidal ideation.

RESULTS

Step 1 was significant (p = .01) and explained 20% variance in suicidal ideation; neither binge eating nor purging significantly predicted suicidal ideation. Adding restrictive eating in Step 2 significantly improved the model (ΔR² = .07, p = .009). This final model explained 27% of the variance, and restrictive eating (but not binge eating/purging) significantly predicted suicidal ideation (p = .02).

DISCUSSION

Restrictive eating is associated with suicidal ideation in youth with low-weight eating disorders, beyond the effects of other eating-disorder behaviors. Although healthcare providers may be more likely to screen for suicidality in patients with binge eating and purging, our findings indicate clinicians should regularly assess suicide and self-injury in patients with restrictive eating. Future research examining how individuals progress from suicidal ideation to suicidal attempts can further enhance our understanding of suicide in eating disorders.

Non-Suicidal Self-Injury and Eating Disordered Behaviors: An Update on What We Do and Do Not Know

PURPOSE OF REVIEW

The current report aims to summarize recent advances about the relationship between non-suicidal self-injury (NSSI) and eating disordered (ED) behaviors and highlights meaningful directions for future research.

RECENT FINDINGS

While there is solid evidence indicating a robust cross-sectional association between NSSI and ED behaviors, emerging evidence suggests that the temporal relationship between these behaviors may be bidirectional. Shared functions and risk factors may explain why these behaviors often co-develop. At the same time, little is still known about the psychosocial consequences of comorbid NSSI and ED engagement, and there is a lack of intervention studies that target these behaviors simultaneously. It is well-established that NSSI and ED behaviors frequently co-occur. The field should now turn to longitudinal designs to advance our understanding of the longer-term developmental and the shorter-term momentary relationship of these behaviors in daily life. Providing insight into these areas will help guide the deployment of evidence-based interventions that match the needs of clients who report comorbid NSSI and ED behaviors.

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.