Eating disorders are about more than just food. Disordered eating behaviours develop as ways to cope with – or in response to – feelings, attitudes, and thoughts.
Usually, these causes include an overvaluation of shape and weight. But other factors may be involved. Someone may use disordered eating behaviours to regulate their emotions, cope with distress, or in response to interpersonal difficulties.
One motivation that experts have identified for disordered eating behaviours is self-harm. Self-harm and eating disorders often co-occur, with over ¼ of people with eating disorders engaging in NSSI (non-suicidal self-injury). Moreover, NSSI and eating disorders sometimes share the same motivation, and some young people with eating disorders describe an intent to harm themselves with their behaviours.
Understanding the feelings and thoughts that underpin a young person’s disordered eating behaviours is a fundamental part of treatment. This blog offers some information on eating disorders, as self-harming behaviour, co-occurring eating disorders and NSSI, and what it means for young people’s treatment and recovery.
When Do Eating Disorders Involve Self-Harming Motivations?
Typically, scientists and medics classify eating disorders as a form of indirect self-harm. This means that while eating disorders harm a young person’s mental and physical well-being, it’s not part of their motivation or intention for their behaviours.
But recent research suggests that eating disorders do involve self-harming motivations for some people in certain situations. Many young people with eating disorders experience high levels of self-criticism and low self-esteem. Sometimes, they express a desire to use eating disorders as a kind of self-punishment, and both eating disorders and non-suicidal self-injury (NSSI) have similarly strong associations with self-criticism.
Eating disorders and NSSI often co-occur, suggesting that there may be some shared motivations behind both eating disorders and NSSI. Some evidence also suggests that people spontaneously classify eating disorders as a type of self-harm.
A study from 2019 found that in different kinds of eating disorder behaviours and NSSI, people reported some intention both to hurt themselves in the moment and in the long run. This was true for restricting energy intake and compensating behaviours like vomiting, and binge eating.
In general, people reported a stronger intention to hurt themselves in the moment with NSSI than with eating disorder behaviours. However, they described a stronger intention to hurt themselves in the long run with restrictive eating than with any other behaviour. They also had a greater awareness of the long-term physical harm caused by restrictive eating than by NSSI or binge eating.
The study shows that while self-harming intentions may not be as common in eating disorders as NSSI, some people do use disordered eating behaviours as a type of self-harm.
This doesn’t mean that self-harm is the only – or the most important – factor driving disordered eating behaviours for these people. They may also use disordered eating behaviours as a form of emotional regulation or in response to body dissatisfaction or an over-evaluation of shape and weight. On the other hand, for some young people, self-harm may be the most important motivation for their behaviours.
Understanding that intentions of self-harm can underpin disordered eating behaviours is important. It helps psychologists and other mental health professionals to provide treatment that addresses the specific underlying causes of each individual’s eating disorder, facilitating lasting and meaningful recovery.
Self-injury and Eating Disorders as Co-Occurring Disorders
Many people with eating disorders also engage in non-suicidal self-injury (NSSI). Data shows that 27% of people diagnosed with anorexia or bulimia nervosa report non-suicidal self-injury, while between ½ and ¼ of people engaging in NSSI also report disordered eating.
There is a lot of evidence suggesting that NSSI is more common among binge/purge eating patterns than restrictive eating. Studies have found that rates of NSSI are higher among people with bulimia nervosa (32.7%) than anorexia nervosa (21.8%). That said, some research has found that among college students, restrictive eating is more associated with NSSI than any other disordered eating behaviour.
Despite this, awareness of the co-occurrence between NSSI and eating disorders remains low. Research has found that in some settings, less than 50% of people with eating disorders are also screened for NSSI. Unfortunately, this can lead to missed diagnoses that prevent young people from receiving the treatment they need.
Experts have several ideas about why people often experience NSSI alongside eating disorders. Firstly, NSSI and eating disorders may both involve similar motivations that can lead to engagement in both behaviours. For example, NSSI and eating disorders may both involve the intent to self-harm, as well as other intentions.
Researchers have identified several other shared motivations that are both individual and interpersonal. These include managing emotions and alleviating emotional pain, self-punishment, creating interpersonal boundaries, and marking emotional distress.
Researchers also think that there may be shared risk factors for both eating disorders and NSSI. For example, one study identified impulsivity, obsessive-compulsive characteristics, affect dysregulation, dissociation, a self-criticizing cognitive style, and a need for control as traits that may make both eating disorders and NSSI more likely.
Moreover, social and cultural factors – especially childhood experiences – may increase the risk of both eating disorders and NSSI. Social factors may include aspects of the family environment, such as low emotional support, high levels of control and criticism, and insecure attachment. Traumatic experiences, such as emotional abuse and peer bullying, may also make someone more vulnerable to both NSSI and eating disorders.
What Are the Consequences of Co-Morbid Self-Injury and Eating Disorders?
Young people who have eating disorders and engage in self-injury may experience specific consequences for their mental health and social lives.
Evidence suggests that people who engage in multiple self-damaging behaviours are more likely to die by suicide, compared to those who engage in only one behaviour. A study found that college students with a history of both NSSI and eating disorders were at a greater risk of suicide than those who had experienced only one of the disorders.
Both NSSI and eating disorders may also negatively impact the psychosocial development of young people. Self-injury and eating disorders are both linked to a future risk of mental health disorders, particularly depression. They also increase the likelihood of an unstable or insecure identity, difficulties regulating emotions, low self-esteem, and academic difficulties. More research is needed to understand how disordered eating and self-harm behaviours may interact and reinforce developmental pathways through adolescence and young adulthood.
What Treatment Is Available for Young People with Eating Disorders and Self-Harming Intentions or Behaviours?
There are several different evidence-based treatment options that are usually offered to young people with eating disorders.
These include enhanced cognitive behavioural therapy (CBT-e), a transdiagnostic treatment that supports young people to recover from anorexia nervosa, bulimia nervosa, and binge eating disorder. Adolescents with anorexia may also be offered family-based therapy, a treatment approach that teaches families to create structures and dynamics that lead to recovery.
For binge eating disorder and bulimia nervosa, interpersonal psychotherapy may also be recommended.
Unfortunately, most randomised controlled trials on eating disorder treatments don’t include data on self-injury or suicidal thoughts and behaviours. Some experts think that standard treatments for anorexia nervosa and other eating disorders may not be as effective when disordered eating behaviours are motivated by self-harm, without strong concerns about shape and weight.
For example, CBT-e is based on the assumption that anorexia, bulimia, and binge eating disorder all share a core pathology of over-evaluation of shape and weight. This means that it may not be effective for young people who don’t share this pathology, preventing recovery from the disorder.
Moreover, family-based therapy (FBT) may be counterproductive for young people who may use eating disorders as a form of self-harm to seek proximity from others. FBT involves empowering parents to support their child’s recovery from an eating disorder, through mealtime practices and other techniques that manage their eating behaviours. This can reinforce self-harming restrictive eating that may be motivated by a desire for proximity.
Young people who engage in disordered eating as a self-harming behaviour may benefit from therapies developed for young people who self-harm, combined with eating disorder treatment approaches. These include dialectical behavioural therapy (DBT), emotion regulation group therapy (ERGT), manual-assisted cognitive therapy (MACT), and dynamic deconstructive therapy. Standard eating disorder treatments may also be adapted to reflect the different attitudes and motivations that underly disordered eating behaviours.
The Wave Clinic: Transformative Recovery Programs for Young People
The Wave Clinic offers specialist mental health support for young people, making a difference in their lives and futures. Our programs combine a diverse selection of evidence-based modalities designed and delivered by experts in child and adolescent psychiatry. Alongside exceptional clinical care, our residential centre supports young people on a journey of personal growth and exploration as they take part in personal learning programs, vocational education qualifications, enriching experiences, and community projects.
Our outpatient centre in Kuala Lumpur provides weekly sessions, monthly check-ins or quarterly medication reviews, one-off assessments, school support, or longer-term care. Outpatient care offers invaluable extra support to those facing mental health challenges in their daily lives. It can also support the transition from residential care back to school, university, or independent living.
The Wave Clinic is a Global Centre of Excellence for the treatment of eating disorders. Within our team, we offer specialist skills in eating disorders, self-harm, suicidal behaviours, obsessive-compulsive disorders, oppositional defiant disorder, borderline personality disorder, and complex trauma.
If you’re interested in finding out more about our programs, get in touch today. We’re here for you.
