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Published in final edited form as: Eat Behav. 2020 Apr 18;37:101389. doi: 10.1016/j.eatbeh.2020.101389

Brief report: Differences in nonsuicidal self-injury according to binge eating and purging status in an adolescent sample seeking eating disorder treatment

Jesse WP Dzombak a,b, Ann F Haynos a, Renee D Rienecke b,c,d, Jessica L Van Huysse b,*
PMCID: PMC9340432  NIHMSID: NIHMS1826260  PMID: 32388487

Abstract

Nonsuicidal self-injury (NSSI) is elevated in adults with eating disorders (EDs), with a particularly increased incidence among individuals who engage in binge eating and/or purging (B/P) behaviors. Despite substantially elevated prevalence of NSSI in adolescence in general, NSSI in child and adolescent ED samples is under-studied. There is some evidence for elevated prevalence of NSSI between B/P and restriction-only groups; however, this finding is not consistently reported and research in this area has excluded certain diagnostic groups (e.g., other specified feeding or eating disorder). Our aim was to identify the rates at which a trans-diagnostic sample of adolescent patients with EDs (n = 155) report lifetime or past-month NSSI, and whether these rates differ between individuals who engaged in recent B/P behaviors vs. restriction only. Lifetime NSSI was present in 40.6% of the sample, and 23.2% of participants reported engaging in NSSI in the month prior to treatment. Individuals who reported recent B/P behaviors were more likely to report past-month (p = .005, OR = 5.57) and lifetime (p = .004, OR = 4.39) NSSI compared to individuals who did not report B/P behaviors. These results suggest an increase in risk for NSSI in child and adolescent patients in ED treatment who endorse B/P behaviors compared to patients who endorse restriction only. Research is needed to clarify the etiologic factors that may explain this association and the longitudinal changes in NSSI throughout the course of EDs.

Nonsuicidal self-injury (NSSI) is the direct, deliberate destruction of one’s own body tissue without intent to die, and comprises a variety of behaviors such as cutting, scratching, or burning oneself (Nock & Favazza, 2009; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). NSSI is associated with physiological and psychological consequences including emotional and interpersonal difficulties, as well as damage to tissue beyond what was originally intended, and is a strong predictor of future suicide attempts (Klonsky, 2007; Wilkinson & Goodyer, 2011; Pérez, Ros, Folgado, & Marco, 2019). Eating disorders (EDs) and NSSI typically emerge around adolescence (Muehlenkamp, Claes, Smits, Peat, & Vandereycken, 2011; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011) and share an interactive relationship in which one may catalyze the other. Prevalence estimates of NSSI among adults with EDs are approximately 27% [95% confidence interval (CI) 23.8–31.0%] (Cucchi et al., 2016), whereas NSSI prevalence estimates in nonclinical samples are approximately 17% (95% CI 8.0–26.3) for adolescents, 13% (95% CI 4.5–22.3) for young adults, and 5% (95% CI 1.7–16.3) for adults (Swannell, Martin, Page, Hasking, & St John, 2014). Research in adult samples suggests that NSSI may be twice as prevalent in EDs as in other psychiatric conditions (Muehlenkamp, Peat, Claes, & Smits, 2012). Further, NSSI has been associated with elevated ED severity and longer duration of illness (Claes, Vandereycken, & Vertommen, 2003; Muehlenkamp et al., 2011; Vieira, Ramalho, Brandão, Saraiva, & Gonçalves, 2016). Although the literature is somewhat mixed, substantial evidence suggests that adults with binge eating and/or purging (B/P) behaviors are more likely to engage in NSSI than those who only engage in restricting behaviors (Cucchi et al., 2016; Vieira et al., 2017). This distinction is important because it provides insight into risk factors for NSSI among individuals with EDs, and informs research into shared mechanisms between NSSI and particular EDs.

While elevated prevalence of NSSI in EDs (especially those characterized by B/P behaviors) is documented in adults, data are scant regarding NSSI in child and adolescent samples with EDs, despite increased risk for both conditions during adolescence (Lockwood, Daley, Townsend, & Sayal, 2017). A meta-analysis on NSSI among young adults and adolescents with EDs identified only three studies conducted exclusively in adolescent samples, and these have limitations (Cucchi et al., 2016). For instance, Peebles, Wilson, and Lock (2011) conducted a chart review of patients with EDs and found that those who endorsed binge-eating and purging behaviors were more likely to report NSSI than patients with only one such behavior or restriction alone. However, NSSI screening was documented in fewer than half of the charts reviewed and patients with characteristics typically associated with NSSI (i.e., older patients or those with B/P behaviors) were screened more often.

Further, these studies lack information on the relationship between B/P behaviors and NSSI. Most describe different NSSI prevalence by narrow diagnoses only (i.e., anorexia nervosa [AN] vs. bulimia nervosa [BN]) rather than by ED behavioral subtypes (B/P vs. restricting-only) (Ruuska, Kaltiala-Heino, Rantanen, & Koivisto, 2005; Wiederman & Pryor, 1996). This approach is limiting for two reasons. First, both AN and BN can feature B/P and restrictive symptoms (Elran-Barak et al., 2015); therefore, this approach obfuscates the association of these behaviors and NSSI occurrence. Second, these studies exclude other ED diagnoses that commonly present in childhood and adolescence, (e.g., other specified feeding or eating disorder [OSFED], avoidant/restrictive food intake disorder [ARFID]). Thus, research is needed to identify NSSI prevalence in samples that include these diagnoses.

To address these literature gaps, the present study examined the prevalence of lifetime (lt-NSSI) and past-month NSSI (pm-NSSI) among a transdiagnostic child and adolescent sample in an ED treatment program, particularly comparing the prevalence of NSSI between individuals with (B/P+) and without (B/P-) B/P symptoms. Based on adult research, we hypothesized that both pm- and lt-NSSI would be significantly more prevalent among the children and adolescents in the B/P+ versus B/P- group. Given a paucity of data on pm-NSSI in the literature, no specific hypotheses were made regarding differences in the strength of associations between pm-NSSI and lt-NSSI and B/P behaviors. However, we included both measures because we wished to both be inclusive of all risk for NSSI and identify potential risk of immediate clinical concern that more clearly covaried in time with recent B/P symptoms.

1. Methods

1.1. Participants

Participants were child and adolescent patients (n = 155, Mage = 14.28 years) who presented for clinical evaluation at a Midwestern ED treatment program between August 2012 and February 2019 and consented to research. The program was designed for assessment and treatment of children and adolescents with AN, BN, ARFID, and OSFED, and utilized a family-based treatment approach in a partial hospitalization setting. Patients engaged in daily meals and group therapy, weekly family meetings, and regular medical and psychiatric monitoring.1 Study participants were primarily female and age spanned pre-pubescent to late-adolescent age ranges (See Table 1). Diagnoses included AN (full-criteria or in partial remission), BN, ARFID, and OSFED (purging disorder, atypical AN, or other). Diagnoses were based on DSM-5 criteria and integrated patient and parent information from the medical and psychiatric intake assessments. Diagnoses were coded by two program clinicians (including JLV). Discrepancies were resolved via consensus discussion. Given the lack of a weight cut-off for AN per DSM-5 criteria, a cut-off of ≤89% median BMI for age and sex was utilized, as in prior work (Sawyer, Whitelaw, Le Grange, Yeo, & Hughes, 2016).

Table 1.

Sample characteristics (n = 155).

Variable Mean (SD)/Median or n (%)
Full sample AN (n = 100) BN (n = 8) ARFID (n = 13) OSFED (n = 34)
Sex (% female) 133 (85.8) 90 (90) 8 (100) 5 (38.5) 30 (88.2)
Age (years) 14.28 (1.74)/14.00 14.30 (1.75)/14.00 15.50 (1.41)/16.00 13.46 (2.03)/13.00 14.24 (1.54)/14.50
Body Mass Index (kg/m2) 17.15 (3.30)/16.52 15.86 (2.16)/16.00 24.65 (5.19)/23.32 15.58 (1.35)/15.75 20.00 (1.90)/20.00
EDE global score 2.03 (1.56)/2.05 2.14 (1.55)/1.88 2.94 (2.05)/3.41 0.24 (0.43)/0.00 2.59 (1.56)/3.67
EDE fasting score 0.60 (1.08)/0.00 0.53 (1.02)/0.00 1.75 (1.75)/2.00 0.08 (0.29)/0.00 0.71 (1.06)/0.00
EDE objective binge eating 4.47 (22.27)/0.00 0.89 (8.20)/0.00 68.00 (70.68)/42.00 0.00 (0.00)/0.00 1.77 (4.42)/0.00
EDE self-induced vomiting 12.53 (36.33)/0.00 4.19 (18.57)/0.00 102.75 (59.83)/127.00 0.00 (0.00)/0.00 20.62 (45.31)/0.00
EDE laxative use 0.24 (2.06)/0.00 0.24 (2.40)/0.00 1.00 (2.83)/0.00 0.00 (0.00)/0.00 0.15 (0.86)/0.00
Lifetime NSSI (% endorsing) 63 (40.6) 30 (30) 7 (87.5) 2 (15.4) 24 (70.6)
Past month NSSI (% endorsing) 36 (23.2) 15 (15.8) 3 (50.0) 3 (25.0) 15 (46.9)
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Note: AN = anorexia nervosa; BN = bulimia nervosa; ARFID = avoidant restrictive food intake disorder; NSSI = non-suicidal self-injury; OSFED = other specified feeding and eating disorder; BMI = body mass index; EDE = Eating Disorder Examination. Objective binge eating, self-induced vomiting, and laxative use variables refer to frequency over the prior 3 months. Due to skew of some variables, both means and medians are presented.

1.2. Measures

All assessments were conducted at intake to the treatment program.

1.2.1. ED diagnosis and symptoms

ED symptoms were assessed with the Eating Disorder Examination (EDE; Cooper, Cooper, & Fairburn, 1989; Cooper & Fairburn, 1987), an investigator-based interview that measures severity of eating pathology within the past 3 months. The EDE yields a global score and behavioral frequency scores regarding number of episodes of objective binge eating (i.e., consuming an objectively large amount of food in a short period while experiencing a sense of loss of control over eating), self-induced vomiting, and laxative and diuretic use within the prior three months. Validation studies have demonstrated high interrater reliability of these behavioral frequency scores (Cooper et al., 1989; Cooper & Fairburn, 1987). Individuals who endorsed any episodes of binge eating, purging, or laxative use (no participant endorsed diuretic use) in the past three months were included in the “B/P+” group; individuals who endorsed no B/P behaviors were included in a “B/P−” group.

Additionally, fasting (a specific type of restrictive eating behavior) was assessed through the “Avoidance of Eating” question (“Over the past four weeks have you gone for periods of eight or more waking hours without eating anything?”), which provides a frequency score ranging from 0 = no such days to 6 = every day. This question was selected as a potential covariate because prior research has demonstrated that individuals who engage in B/P behavior also endorse greater restrictive eating than those with an eating disorder who do not engage in B/P (Elran-Barak et al., 2015) and we wished to specifically examine the impact of B/P behaviors on NSSI. As such, the global EDE score, which was also included as a potential covariate in this study, removed the Avoidance of Eating item to avoid redundancy. For this sample, Cronbach’s α of the EDE global score = 0.95.

1.2.2. NSSI

pm-NSSI was assessed using an item on the MINI/MINI-KID suicidality subscale: “In the past month, did you try to deliberately injure yourself without intending to kill yourself?” (Hergueta, Baker, & Dunbar, 1998). Single-item measures are common in studies of NSSI, have yielded consistent estimates of prevalence (Claes, Soenens, Vansteenkiste, & Vandereycken, 2012; Muehlenkamp et al., 2012), and align with recommendations for researching NSSI in children and adolescents (Whitlock, Exner-Cortens, & Purington, 2014). NSSI behaviors included cutting, burning, head banging, hitting, bruising, skin picking, hair pulling, severe scratching, and insertion of sharp objects underneath the skin. To avoid limiting power, responses were grouped according to whether any NSSI was endorsed, rather than type of NSSI.

lt-NSSI was assessed by retrospective chart review and was considered present if the patient’s medical record (at time of intake assessment) indicated NSSI at any point in the patient’s lifetime. Although lt-NSSI was not assessed in a structured interview, it was included as part of the standard clinical note template completed by physicians at intake. Our analytic sample included data from individuals with information on either lt- or pm-NSSI and information on B/P status. There were no missing cases for lt-NSSI and 10 missing for pm-NSSI.

1.3. Statistical analysis

To identify demographic or clinical covariates pertinent to NSSI outcomes for subsequent analyses, independent t-test and chi-square analysis were conducted to determine if age, global EDE score, fasting, and gender differed between B/P+ and B/P− groups. Binary logistic regressions were conducted to determine relations between B/P status, pm-NSSI, and lt-NSSI, controlling for identified covariates. To determine if B/P status added value above ED diagnoses in accounting for likelihood of pm- or lt-NSSI, we repeated logistic regressions with diagnosis as an additional predictor.

2. Results

2.1. Participant characteristics

Forty (25.8%) participants endorsed recent B/P symptoms; 121 (74.2%) did not. A large minority of participants (n = 36; 23.2%)2 endorsed pm-NSSI; more participants reported lt-NSSI (n = 63; 40.6%). There was a small, but significant age difference between B/P+ (M = 14.78, SD = 1.80 years) and B/P- (M = 14.10, SD = 1.69 years) groups, t (153) = −2.13, p = .035, d = 0.40. Global EDE scores were elevated among the B/P+ (M = 3.62, SD = 1.45) relative to the B/P− (M = 1.77, SD = 1.48) group, t (137) = −6.35, p < .001, d = 1.26, as were fasting scores (M = 1.20, SD = 1.24 versus M = 0.38, SD = 0.93), t (151) = −4.37, p < .001, d = 0.81. Therefore, age, EDE Global score, and fasting score were entered as covariates in subsequent analyses. Gender distribution did not vary significantly between groups, χ2(1) = 1.98, p = .196, OR = 2.44, and was not included as a covariate.

2.1.1. NSSI and ED phenotype

Controlling for age and baseline ED and fasting severity, logistic regression analyses revealed a significant association between B/P status, lt-NSSI, and pm-NSSI (See Table 2). A greater percentage of the B/P+ group (76.5%) endorsed lt-NSSI compared to the B/P- group (30.6%), p = .004. Similarly, 55.2% of the B/P+ group endorsed pm-NSSI, compared to 17.2% of the B/P- group, p = .005. After accounting for diagnosis, associations between B/P status and NSSI remained significant for pm-NSSI (p = .010, OR = 4.96) and lt-NSSI (p = .011, OR = 3.77). AN was associated with lower rates of lt-NSSI compared to other diagnoses, p = .001, OR = 0.21; no other significant differences emerged among ED diagnoses.

Table 2.

Hierarchical binary logistic regressions examining the influence of binge eating/purging status on lifetime and past-month non-suicidal self-injury (NSSI).

r2 B SE p OR 95% CI
Lifetime NSSI
Step 1 0.18
 Age −0.02 0.11 0.883 0.98 0.79, 1.23
 Eating Disorder Examination global score 0.42 0.13 0.001* 1.52 1.18, 1.95
 Fasting score 0.45 0.20 0.022* 1.57 1.07, 2.32
Step 2 0.23
 Age −0.07 0.12 0.578 0.94 0.74, 1.18
 Eating Disorder Examination global score 0.28 0.14 0.040* 1.33 1.01, 1.74
 Fasting score 0.38 0.20 0.061 1.46 0.98, 2.16
 Binge eating/purging status 1.48 0.51 0.004* 4.39 1.63, 11.85
Past Month NSSI
Step 1 0.10
 Age −0.24 0.14 0.094 0.79 0.60, 1.04
 Eating Disorder Examination global score 0.42 0.16 0.008* 1.52 1.11, 2.08
 Fasting score 0.22 0.19 0.264 1.24 0.85, 1.81
Step 2 0.16
 Age −0.32 0.15 0.033* 0.72 0.54, 0.98
 Eating Disorder Examination global score 0.22 0.18 0.212 1.25 0.88, 1.77
 Fasting score 0.12 0.21 0.570 1.13 0.74, 1.71
 Binge eating/purging status 1.72 0.61 0.005* 5.57 1.69, 18.32
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*

Denotes findings significant at p < .05.

3. Discussion

Our results revealed high prevalence of lt-NSSI and pm-NSSI in children and adolescents presenting for ED treatment. As hypothesized, NSSI was more prevalent among the B/P+ group, even after accounting for age and ED severity. Individuals in the B/P+ group were nearly four times more likely to have engaged in lt-NSSI and nearly five times more likely to have engaged in pm-NSSI than those in the B/P- group. Our analyses suggest that individuals with AN were less likely to report lt-NSSI; however, differences in pm-NSSI prevalence between B/P+ and B/P- groups remained significant after accounting for ED diagnoses. It may be that a transdiagnostic framework of ED symptomatology may provide clinical utility beyond ED diagnosis in evaluating risk for NSSI; future work is warranted to investigate this prospect more fully.

These results underscore prior research suggesting that B/P behaviors are associated with increased risk for NSSI (Cucchi et al., 2016; Vieira et al., 2017). However, they do not necessarily indicate that restriction confers no risk for NSSI, as approximately 31% of the B/P− group reported lt-NSSI. Further, as previously noted, individuals who engage in B/P behaviors often restrict, possibly more intensely than individuals with restricting-only EDs (Elran-Barak et al., 2015). While our findings were maintained after accounting for fasting, this has not been demonstrated consistently in the literature. For instance, Wang, Pisetsky, Skutch, Fruzzetti, and Haynos (2018) reported a significant association between restrictive eating and NSSI beyond the influence of B/P behaviors in a non-clinical sample. Further work should examine relations between multiple discrete ED symptoms (including different types of restriction) and NSSI.

More information is needed to elucidate factors influencing the relation between B/P behaviors and NSSI, including latent behavioral functions. Substantial evidence suggests that emotion regulation deficits underpin both behaviors (Muehlenkamp et al., 2012). Yet, while function could represent a meaningful target for intervention, other mechanisms could contribute to these behaviors, including impulsivity and compulsivity (Claes et al., 2015; Ross, Heath, & Toste, 2009). Further study of these mechanisms in B/P and restrictive behavior is warranted, and should consider such additional factors as stage of development (adolescence vs. adulthood) and course of ED (early vs. chronic).

This study benefitted from a large clinical pediatric sample with multiple ED diagnoses (including those underrepresented in prior research) and aided by routine assessment of NSSI. However, despite the consistency with which lt-NSSI data were collected, this information was derived via chart review rather than clinical interview, potentially reducing data reliability and validity. The study also used self-reported interview data to assess ED symptoms and NSSI, which may have been subject to underreporting. Finally, although our sample was diagnostically heterogeneous, certain diagnoses (e.g., BN) were relatively underrepresented. Future work would benefit from integrating multiple assessment sources and expanding to even larger, more clinically diverse sample sizes.

Our results contribute to a growing literature concerning NSSI and ED behaviors by demonstrating high rates of comorbidity between NSSI and B/P behaviors in a transdiagnostic child and adolescent sample. While all young individuals with EDs should be screened for NSSI, the presence of B/P behaviors may indicate elevated risk for NSSI.

Footnotes

CRediT authorship contribution statement

Jesse W.P. Dzombak: Conceptualization, Data curation, Writing - original draft, Project administration. Ann F. Haynos: Formal analysis, Writing - review & editing, Visualization, Supervision. Renee D. Rienecke: Investigation, Writing - review & editing, Supervision. Jessica L. Van Huysse: Methodology, Formal analysis, Investigation, Resources, Writing - review & editing, Supervision, Project administration.

1

Additional program details may be found elsewhere (Hoste, 2015).

2

Data were missing for 10 participants on this variable.

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