Cutting (down): The Play Between Non-Suicidal Self-Injury and Disordered Eating

Editorial note: The article expertly explores the complex relationship between non-suicidal self-injury (NSSI) and disordered eating, shedding light on how these behaviours influence one another. Follow this link if you would benefit from more insight on non-suicidal self injury.

Did you know that many people who engage in non-suicidal self-injury also suffer from disordered eating? I know that, already in the first line, I introduced too many difficult words. So, let’s start from the beginning, by clarifying these technical terms in a not-so-technical and more understandable way.

Let’s define non-suicidal self-injury and disordered eating

1. Non-suicidal self-injury [or NSSI for short]: When talking about NSSI I refer to all those direct and deliberate behaviors aimed at damaging one’s own skin, and that do not have suicidal intents¹, like for example, scratching until bleeding, cutting, hitting the head against the wall, etc… More detailed information about this can be found on the previous blog about Understanding Non-Suicidal Self Injury.
2. Disordered eating: When talking about disordered eating I refer to those behaviors that fall under the category of anorexia nervosa [clear underweight due to the restriction of food intake, together with a distorted body image and fear of gaining weight²], bulimia nervosa [body weight within the healthy range or elevated with episodes of binge eating, followed by behaviors aimed at avoiding weight gain, such as vomiting²], and binge-eating [elevated body weight, with recurrent episodes of binge eating but without behaviors aimed at avoiding weight gain³]. 

Now that these terms are clearer, I would like to go back to my original question and give you more information about the link between NSSI and disordered eating. In fact, almost 30 people out of 100 who are diagnosed with disordered eating also use some form of NSSI. This seems to be particularly true for those who suffer from bulimia⁴.

The association between NSSI and disordered eating has, from the very beginning of its discovery, interested researchers, who have tried to understand what comes first: NSSI (which leads to disordered eating) or disordered eating (which in turn leads to NSSI)? 

Being able to answer this question would allow us to prevent the occurrence of both these behaviors. However, there is currently not much research that has been able to answer this question.

The reason is that to conduct such studies, researchers need to gather information from the same people over several years (you can imagine the cost and the effort to run such studies). The few scientific publications that exist at the moment seem to show that these two behaviors influence each other overtime. 

For example, adolescents who engage in NSSI repetitively at age 14 seem to be more likely to develop an eating disorder by age 17⁵. At the same time, people who show symptoms of eating disorders are more likely to engage in NSSI later on in their life⁶.

So, according to the current research, it seems like disordered eating and NSSI go in a vicious cycle, influencing each other.

But now I’m sure you are wondering: why is it that a person engages in both types of behaviors? Do these two behaviors have something in common? Let’s find out the answer to these questions below.

[1] Both behaviors come from a place of pain

It seems like people use both NSSI and disordered eating to cope with painful emotions. These emotions could range from, for example, concerns about the body appearance, to feeling lonely because rejected by friends, or to feeling stressed because of a conflict with a loved one. In all these cases, both behaviors give short-term relief from them, as they work as distractors.

[2] Both behaviors have commonalities that make them more likely to co-occur 

Often, it seems like people who engage in both NSSI and disordered eating have common underlying features. For example, the tendency to overthink and get lost in a spiral of negative thoughts without solutions, as well as a negative view of their own body.

Also, people who engage in both behaviors report a lower pain sensitivity. This means that they feel less pain compared to those who do not engage in these behaviors. This decreased sensitivity could partially explain why it is easier to engage in these two behaviors. Finally, people who engage in both behaviors have a higher risk for suicidal ideations or actions compared to those who engage in only one or neither⁷.

NSSI and disordered eating are two behaviors that can be challenging for everyone involved, namely clinicians, loved ones, and the person who suffers from them. This is even more true when NSSI and disordered eating co-occur. For this reason, it could be important to keep the following points in mind: 

Advice for clinicians

1. When treating a patient who shows one of the two behaviors, and given the high co-occurrence of both conducts, make sure to ask about the possible engagement in the other one.
2. When both behaviors co-occur, make sure to first treat the one that has the priority in term of threat to life (e.g., superficial scars vs heavy purging; deep scars with suicidal ideations vs binge eating only when extremely stressed). Given the commonalities in functions, treating the more life-threatening one might indirectly help treating the less threatening one.

Advice for the loved ones

1. Take a deep breath. Knowing about a loved one who engages in either (or both) behaviors is surely difficult. 
2. Put yourself in a place of listening without judgment. Don’t come up with solutions. Be there for the person who suffers from these issues. That really means a lot.
3. Remember to check-in with the person who suffers from these issues.

For the person who engages in NSSI and disordered eating

1. The fact that you don’t know how to deal with difficult situations in a different way from harming yourself (through NSSI or disordered eating) is not your fault. Don’t feel ashamed of asking a professional for help to learn new and more adaptive coping strategies. 
2. You are not alone. 

Sources:

¹ Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6, 1–9.

² Treasure, J., Duarte, T.A., & Schmidt, U. (2020). Eating disorders. Lancet, 395, 899–911.

³ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. ed. Washington, DC: American Psychiatric Press; 2013.

⁴ Cucchi, A., Ryan, D., Konstantakopoulos, G., Stroumpa, S., Kaçar, A. Ş., Renshaw, S., … & Kravariti, E. (2016). Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis. Psychological Medicine, 46, 1345-1358.

⁵ Wilkinson, P. O., Qiu, T., Neufeld, S., Jones, P. B., & Goodyer, I. M. (2018). Sporadic and recurrent non-suicidal self-injury before age 14 and incident onset of psychiatric disorders by 17 years: prospective cohort study. The British Journal of Psychiatry, 212, 222-226.

⁶ Riley, E. N., Davis, H. A., Combs, J. L., Jordan, C. E., & Smith, G. T. (2016). Nonsuicidal self‐injury as a risk factor for purging onset: Negatively reinforced behaviours that reduce emotional distress. European Eating Disorders Review, 24, 78-82.

⁷ Kiekens, G., & Claes, L. (2020). Non-suicidal self-injury and eating disordered behaviors: an update on what we do and do not know. Current Psychiatry Reports, 22, 1-11.

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