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

Examining Associations of Borderline Personality Disorder Symptoms and Eating Disorder Diagnoses: Results From a US Representative Sample

OBJECTIVES

Borderline personality disorder (BPD) and eating disorders (EDs) are common comorbid diagnoses. Given the various combinations of borderline personality disorder symptoms (BPDS) that can comprise a diagnosis, understanding whether specific BPDS are more likely to be associated with an ED (anorexia nervosa [AN], bulimia nervosa [BN], and binge eating disorder [BED]) is important for the conceptualization and treatment of BPD-ED comorbidity.

METHODS

This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study, a nationally representative dataset of US adults (N = 36,309). The association of BPDS with EDs, compared with psychiatric and healthy control groups, was examined in two binomial and two multinomial (i.e., with all ED diagnoses) models.

RESULTS

Compared with the healthy control group, affect instability, emptiness, impulsivity, self-injurious behaviors, and unstable relationships were positively associated with any ED diagnosis (AN, BN, or BED). Compared with the psychiatric control group, impulsivity was positively associated with any ED diagnosis. In the multinomial model with the healthy control group, impulsivity and self-injurious behaviors were positively associated with AN, BN, and BED, emptiness was positively associated with AN and BED, and unstable relationships and affect instability were positively associated with BED. In the multinomial model with the psychiatric control group, self-injurious behaviors were positively associated with AN, and impulsivity and affect instability were positively associated with BED.

DISCUSSION

Results suggest certain BPDS may be more common with certain EDs (AN, BN, and BED), even when controlling for other EDs and a psychiatric control group.

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.

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.

Analysis of Suicidal Behavior in Adult Inpatients with Anorexia Nervosa: Prevalence of Suicide Attempts and Non-Suicidal Self-Injury and Associated Factors-Data Before and After the COVID-19 Pandemic

Background/Objectives: Anorexia nervosa (AN) has a high mortality rate frequently related to suicidality; however, there are few studies on suicide attempts (SAs) and non-suicidal self-injuries (NSSIs) in adult inpatients with AN. This study aims to describe SA and NSSI prevalence and related clinical and sociodemographic factors in adult inpatients with AN. Methods: We retrospectively analyzed data on 298 inpatients hospitalized between 2014 and 2023. Suicidality and clinical and sociodemographic data were collected by experienced psychiatrists; then, the patients completed a battery of self-report questionnaires investigating eating-related and general psychopathology. Results: A total of 9.7% of the inpatients reported an SA in their lifetime, and 13.4% reported NSSI. The percentages were lower among patients with restricter-type AN (5.6% SA and 6.6% NSSI) and higher among patients with binge-purging AN (18% SA and 27% NSSI). SAs were associated with unemployment, binge-purging AN, personality disorders, and lifetime sexual abuse; NSSIs were correlated with family psychiatric disorders, binge-purging AN, personality disorders, body dissatisfaction, restriction, and eating-related concerns. No differences emerged in the frequency of reported suicidality between patients tested before and after the COVID-19 pandemic. Conclusions: Suicidality is a relevant issue in AN. Many factors in the history of the patients and their eating-related pathologies should be considered as potentially associated with SA and NSSI and carefully assessed.

Dietary intake and gastrointestinal symptoms are altered in children with Autism Spectrum Disorder: the relative contribution of autism-linked traits

BACKGROUND

Dietary and gastrointestinal (GI) problems have been frequently reported in autism spectrum disorder (ASD). However, the relative contributions of autism-linked traits to dietary and GI problems in children with ASD are poorly understood. This study firstly compared the dietary intake and GI symptoms between children with ASD and typically developing children (TDC), and then quantified the relative contributions of autism-linked traits to dietary intake, and relative contributions of autism-linked traits and dietary intake to GI symptoms within the ASD group.

METHODS

A sample of 121 children with ASD and 121 age-matched TDC were eligible for this study. The dietary intake indicators included food groups intakes, food variety, and diet quality. The autism-linked traits included ASD symptom severity, restricted repetitive behaviors (RRBs), sensory profiles, mealtime behaviors, and their subtypes. Linear mixed-effects models and mixed-effects logistic regression models were used to estimate the relative contributions.

RESULTS

Children with ASD had poorer diets with fewer vegetables/fruits, less variety of food, a higher degree of inadequate/unbalanced dietary intake, and more severe constipation/total GI symptoms than age-matched TDC. Within the ASD group, compulsive behavior (a subtype of RRBs) and taste/smell sensitivity were the only traits associated with lower vegetables and fruit consumption, respectively. Self-injurious behavior (a subtype of RRBs) was the only contributing trait to less variety of food. Limited variety (a subtype of mealtime behavior problems) and ASD symptom severity were the primary and secondary contributors to inadequate dietary intake, respectively. ASD symptom severity and limited variety were the primary and secondary contributors to unbalanced dietary intake, respectively. Notably, unbalanced dietary intake was a significant independent factor associated with constipation/total GI symptoms, and autism-linked traits manifested no contributions.

CONCLUSIONS

ASD symptom severity and unbalanced diets were the most important contributors to unbalanced dietary intake and GI symptoms, respectively. Our findings highlight that ASD symptom severity and unbalanced diets could provide the largest benefits for the dietary and GI problems of ASD if they were targeted for early detection and optimal treatment.

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.

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.

Increased Incidence of Upper Extremity Soft Tissue Injuries and Orthopaedic Surgeries in Patients with Eating Disorders

Background

Despite an established increased fracture risk in eating disorder patients, no studies, to our knowledge, have investigated the association between eating disorders and upper extremity soft tissue injury or surgery incidence. Given the association of eating disorders with nutritional deficiency and musculoskeletal sequelae, we hypothesized that patients with eating disorders would have an increased risk of soft tissue injury and surgery. The aim of this study was to elucidate this link and investigate if these incidences are increased in patients with eating disorders.

Methods

Cohorts of patients with anorexia ner-vosa or bulimia nervosa, identified using International Classification of Diseases (ICD) -9 and -10 codes, were identified in a large national claims database over 2010-2021. Control groups without these respective diagnoses were constructed, matched by age, sex, Charlson Comorbidity Index, record date, and geographical region. Upper extremity soft tissue injuries were identified using ICD-9 and -10 codes and surgeries using Current Procedural Terminology codes. Differences in incidence were analyzed using chi-square tests.

Results

Patients with anorexia and bulimia were significantly more likely to sustain a shoulder sprain (RR=1.77; RR=2.01, respectively), rotator cuff tear (RR=1.39; RR=1.62), elbow sprain (RR=1.85; RR=1.95), hand/wrist sprain (RR=1.73; RR=16.0), hand/wrist ligament rupture (RR=3.33; RR=1.85), any upper extremity sprain (RR=1.72; RR=1.85), or any upper extremity tendon rupture (RR=1.41; RR=1.65). Patients with bulimia were also more likely to sustain any upper extremity ligament rupture (RR=2.88). Patients with anorexia and bulimia were significantly more likely to undergo SLAP repair (RR=2.37; RR=2.03, respectively), rotator cuff repair (RR=1.77; RR=2.10), biceps tenodesis (RR=2.73; RR=2.58), any shoulder surgery (RR=2.02; RR=2.25), hand tendon repair (RR=2.09; RR=2.12), any hand surgery (RR=2.14; RR=2.22), or any hand/wrist surgery (RR=1.87; RR=2.06).

Conclusion

Eating disorders are associated with an increased incidence of numerous upper extremity soft tissue injuries and orthopaedic surgeries. Further work should be undertaken to elucidate the drivers of this increased risk. Level of Evidence: III.