NONSUICIDAL SELF-INJURY, EATING DISORDERS, AND SUICIDE
WRITTEN BY KIKI KLINE, M.S.W.
Fox, K. R., Wang, S. B., Boccagno, C., Haynos, A. F., Kleiman, E., & Hooley, J. M. (2019). Comparing self‐harming intentions underlying eating disordered behaviors and NSSI: Evidence that distinctions are less clear than assumed. International journal of eating disorders, 52(5), 564-575.
Relevance in Today’s World
In the United States and other Westernized cultures, physically hurting oneself is called self-harm. A common type of self-harm is nonsuicidal self-injury, where someone purposely hurts themselves without wanting to die (like by self-cutting). These forms of self-harm are considered separate from other behaviors that may cause physical harm but that are understood to serve different purposes. Eating disordered behaviors, like restriction, binge eating, or purging, fall into this category. When talked about in the self-harm context, eating disordered behaviors are described as ‘indirectly’ harmful, because they are not perceived to not cause immediate harm and because self-harm is not their perceived ‘primary’ function, even if they do cause physical harm over longer-term periods (for example, purging behavior by vomiting can cause intestinal damage, tooth decay, and electrolyte imbalance; binge eating may lead to altered blood sugar levels or insulin resistance; restrictive eating can lead to extreme stomach pains, heart problems, and other physical health consequences).
Eating disordered behaviors and nonsuicidal self-injury often co-occur and share many biological, psychological, and social characteristics. However, because of the common belief that nonsuicidal self-injury is ‘directly’ harmful and eating disorder behaviors are only ‘indirectly’ harmful, research considers these as distinct sets of mental health issues.
People who engage in eating disorder behaviors and/or nonsuicidal self-injury are also more likely to have suicidal thoughts and attempt suicide. Even though eating disorder behaviors are not typically linked with suicidal thoughts and behaviors, and nonsuicidal self-injury is “nonsuicidal” by definition, there may be reason to believe that thoughts of suicide may be present when engaging in these behaviors.
Given that eating disorder behaviors and nonsuicidal self-injury share many similarities and that both are linked to suicidal thoughts and suicide attempts, we wanted to understand if there were overlaps in the intentions to self-harm, as well as suicidal thoughts when engaging in these behaviors. Specifically, we wanted to test whether typical assumptions about potential self-harming functions (both suicidal and nonsuicidal) underlying these behaviors matched people's self-reported reasons for engaging in these behaviors.
Characteristics of those who participated:
The average age of participants was 24, most identified as female, and almost all reported lifetime eating disordered behaviors and/or nonsuicidal self-injury. The most common form of nonsuicidal self-injury was self-cutting. On average, participants reported engaging in about 5 episodes of nonsuicidal self-injury in the past month, and engaging in eating disordered behaviors on 20 or more days within that past month.
As expected, participants reported the highest intent to cause physical harm in the moment via nonsuicidal self-injury. Contrary to traditional classification systems, however, we also found that participants reported intent to cause physical harm via each eating disordered behavior, both in the short- and long-term.
We also found that participants reported suicidal thoughts and even intent to die sooner as a result of each behavior, with the highest levels observed for nonsuicidal self-injury and restrictive eating.
Conclusions & Future Directions
Self-harming intentions may occur alongside both nonsuicidal self-injury and many eating disordered behaviors.
Results tell us that assumptions that guide classification of eating disordered behavior as ‘indirect’ self-harm may not actually reflect some people’s intentions when engaging in these behaviors. Although in general intention to self-harm were lower across eating behaviors compared to nonsuicidal self-injury, they were present in all behaviors,
Both nonsuicidal and suicidal thoughts and intentions may be present when engaging in nonsuicidal self-injury and eating disordered behaviors.
Although nonsuicidal self-injury and eating disordered behaviors are considered nonsuicidal, on average, participants reported thoughts of suicide when engaging in each behavior, as well as knowledge and a hope of a shorter life because of them, and even using the behaviors to kill oneself (though these levels were very low). People may engage in nonsuicidal self-injury and eating disordered behaviors knowing they could be lethal and with some explicitly wanting to die sooner as a result.
Understanding that direct self-harming intentions may underlie a range of behaviors, both traditionally seen as self-harm and those behaviors typically viewed as distinct (like eating disordered behaviors) could help in the understanding of these behaviors and treatment approaches. Future research might explore more specific shared functions across eating disordered behaviors, nonsuicidal self-injury, and suicidal behaviors. Screenings assessing for eating disordered behaviors or nonsuicidal self-injury may consider assessing for both with presenting symptoms and assessing suicidal thoughts and behaviors (or a more comprehensive suicide assessment) may be useful.
How Can We Apply these Findings?
When treating people engaging in eating disordered behaviors, and particularly restrictive eating, consider also assessing for nonsuicidal self-injury, suicidal thoughts, and suicidal behaviors.
If clients report restrictive eating, binge eating, and purging, consider assessment of a range of reasons for these behaviors, including intention to cause physical self-harm and intention to die from these behaviors.
When treating nonsuicidal self-injury, consider assessment of a range of reasons for these behaviors, as well as thoughts of suicide and intent to die when engaging in these behaviors.
For you or someone you know is engaging in nonsuicidal self-injury or eating disordered behaviors:
Reach out to a friend, family member, or another person you trust for support.
Try these guided meditations for self-compassion and self-soothing.
Practice new ways of accepting and approaching your mental health through these FREE online Acceptance and Commitment Therapy self-guided videos.
Talk to your doctor, mental health provider, or this 24/7 National Helpline through SAMHSA (1-800-662-HELP ) for support resources.
National Institute of Mental Health. (2016). Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders/
Fox, K. R., Wang, S. B., Boccagno, C., Haynos, A. F., Kleiman, E., & Hooley, J. M. (2019). Comparing self‐harming intentions
underlying eating disordered behaviors and NSSI: Evidence that distinctions are less clear than assumed. International Journal of Eating Disorders, 52(5), 564–575. https://doi.org/10.1002/eat.23041
Kline, K. M., Jorgensen, S., Lawson, W., Bridges Ohashi, Y. G., Wang, S., & Fox, K. M. (2021, May). Comparing self-harming
intentions underlying eating disordered behaviors and nonsuicidal self-injury: Replication and extension in adolescents. Paper presented at the Association for Psychological Science 2021 Annual Conference, Virtual.
Zelkowitz, R., Ortiz, S., Fox, K. M., Wang, S., & Smith, A. (2019, November). Eating disorders, self-injury, and suicide: Common
pathways, mechanisms, and functions. Presentation at the 53rd Annual Association for Behavioral and Cognitive Therapies Convention, Atlanta, GA.