Self-Destructive Behavior & Eating Disorders: A Complex Intersection
By Randy A. Sansone, MD & John L. Levitt, PhD
Reprinted from Eating Disorders Recovery Today
2004 Volume 2, Number 5
©2004 Gürze Books
Research indicates that a variety of factors contribute to the development of eating disorders and that these causal factors vary widely from individual to individual. Therefore, professionals in the field consider eating disorders to be multidimensional, and consequently, there appear to be many different subgroups of individuals who suffer from these disorders. Self-destructive behavior represents one of these subgroups.
Types of Self-Destructive Behavior
Self-destructive behavior is a general label that refers to many types of actions that a person might demonstrate. Although at the most dangerous end of the spectrum are suicide attempts, the majority of these behaviors are not life-threatening. Examples include superficial self-mutilation (e.g., abrading, cutting, scratching, or burning one’s skin), hitting or biting oneself, pulling one’s hair, and head-banging.
Self-destructive behavior may also take more elusive or less obvious forms. These may include repeated "accidents" such as falling down stairs, bumping into tables and walls, or mishaps at work. As a result, mysterious and unexplainable bruises may appear. Less obvious examples might include remaining in relationships that are emotionally, sexually, or physically abusive, or even sabotaging one’s own successes (e.g., prolonging an eating disorder, functioning poorly on the job, or purposefully causing difficulties in relationships). Some individuals may intentionally sabotage their medical care by not taking medication as prescribed. This might include enhancing the effects of illness (e.g., skipping insulin doses), exposing oneself to situations that are likely to cause physical symptoms or an infection (e.g., to an allergen or to a person who is infected with HIV), and picking or scratching at scars.
According to our recent research, about one quarter of individuals with eating disorders report non-life-threatening self-destructive behaviors (e.g., hair pulling and self-mutilation such as cutting or scratching). The prevalence of these self-destructive behaviors among anorexic and bulimic individuals is fairly evenly distributed at around 25 percent.
Studies suggest that among individuals with either anorexia nervosa or bulimia nervosa, nearly one quarter have attempted suicide. When these statistics are examined by specific eating disorder diagnosis, the breakdowns of suicide attempts are as follows:
- 10 percent of those with anorexia nervosa
- 22 percent of outpatients with bulimia nervosa
- 39 percent of inpatients with bulimia nervosa
- 54 percent of bulimic individuals with alcohol abuse or addiction
Impulsive and Compulsive Behaviors
The precise relationship between self-destructive behavior and eating disorders is unclear. However, both demonstrate interesting relationships to impulsive and compulsive behaviors. Impulsive behaviors are fairly spontaneous, impetuous behaviors that gratify the individual and relieve negative feelings such as loneliness, anxiety, anger, and emptiness. Generally, persons who are impulsive appear to "act without thinking," but can still have some awareness of what they are doing.
Compulsive behaviors, on the other hand, tend to be somewhat habitual and automatic and appear to function without conscious intent. These behaviors seem to relieve mounting tension when acted upon. Both types of behaviors are potentially similar in that they provide relief from difficult or intolerable feelings. Research indicates that both impulsive and compulsive elements exist in individuals with eating disorders and self-destructive behavior. Further study may result in distinct treatment strategies.
Borderline Personality Disorder
Another possible explanation for the coexistence of eating disorders and self-destructive behavior is the presence of another, underlying psychiatric disorder such as a personality disorder. Borderline personality disorder is characterized by a socially intact façade (i.e., the individual may appear very normal in casual social interaction). However, beneath this transient veneer of normalcy often lies deep-seated difficulties with psychological, behavioral, relational, and emotional self-regulation.
Borderline personality disorder can affect the ability to maintain normal and healthy rhythms such as sleeping, eating, spending, and mood. This can result in difficulty with problem solving, maintaining stable long-term relationships, and so forth. When self-regulation difficulties begin to focus around the areas of food, eating, weight, and body image, the symptoms of eating disorders emerge. When self-regulation difficulties affect mood, then the symptoms of moodiness, or chronic depression or emptiness might be seen. Because self-regulation is so integral to a person’s well-being, disturbances in these areas tend to be long-standing or chronic.
The features of borderline personality seem to be a contradiction. On the one hand, these individuals may appear very normal, but on the other hand, they have deep-seated psychological difficulties. Because of this unusual combination of features, movie characters with borderline personality have fascinated Hollywood and filmgoers. Examples of female characters include: Leave Her to Heaven, Fatal Attraction, Single White Female, The Rose, Misery, The Crush, and Play Misty for Me. The male protagonist in Sleeping with the Enemy is another example.
The cause of borderline personality is not explicitly known, but research indicates that this disorder is also multidimensional and may be related due to a genetic predisposition, an early history of repetitive trauma, complex dynamics with caretakers, and other factors. Studies indicate that women with borderline personality frequently have eating disorders, while men often have substance abuse problems.
How does self-destructive behavior benefit an individual? Research suggests that self-destructive behavior in those with borderline personality may be an adaptive attempt to regulate negative feelings and moods. Literally, by stunning oneself with a damaging behavior, the individual may reset his or her own internal thermostat—in this case, the thermostat that regulates mood. Indeed, some investigators view eating disorder symptoms as self-injury equivalents (i.e., these are self-destructive behaviors, themselves, and promote the regulation of feelings or mood).
As for the treatment of individuals suffering from both eating disorders and self-destructive behavior, there is no current professional consensus. Many therapists use a variety of techniques both in individual and group treatment, such as cognitive-behavioral interventions, dynamic exploration, and contracting. There are also systematic approaches to intervention that have been developed for the treatment of self-destructive behaviors in borderline personality disorder. These include Dialectical Behavior Therapy (DBT), Integrative Cognitive Therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), and the Self-Regulatory Approach.
Studies are divided regarding the long-term treatment outcome. Some studies indicate that recovery from the eating disorder is less favorable among those with both problems. Other studies indicate that the eating disorder outcome is comparable to those individuals without other psychiatric symptoms. Though presently there is no clear research support, it would be reasonable to expect that clinicians with training and expertise in both eating disorders and self-destructive behaviors might be able to provide effective guidance for recovery. With further research, we are optimistic that our recognition, understanding, and treatment methods will improve.
About the Authors
Randy A. Sansone, MD, is a Professor in Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio.
John L. Levitt, PhD, is the Director of the Eating Disorder and Violence Abuse Programs for Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois.
Both authors are coeditors of the book, Self-Harm Behavior and Eating Disorders: Assessment, Dynamics, and Treatment (Brunner-Routledge, 2004), and on the Editorial Board of Eating Disorders: The Journal of Treatment and Prevention.