the relationship between anorexia and bulimia and other self-injurious behavior

7/30/2019 The Relationship Between Anorexia and Bulimia And other Self-Injurious Behavior

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RUNNING HEAD: THE RELATIONSHIP BETWEEN ANOREXIA AND BULIMIA AND

The Relationship between Anorexia and Bulimia and

Other Self-Injurious Behavior

Emily Ryan

Larry Bachman Psychology Hour 5



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THE RELATIONSHIP BETWEEN ANOREXIA AND BULIMIA AND

Abstract This paper explores the drives behind anorexia and bulimia, and their relationship to other self injurious

behaviors. Using information from published works as well as an interview of an anonymous patient

diagnosed with anorexia and bulimia, this essay will examine the complex similarities between Anorexia

and Bulimia (AB) and other forms of intentional self-injurious behaviors (SIB’s) such as non-lethal

cutting, burning, scratching, skin picking, and so forth; and to identify a similar purpose between the two

dysfunctions. It will also describe the prevalence of SIB’s among people with AB. While the rate of SIB’s

in general psychiatric patients is estimated to be somewhere between 4%-10%, a study of 376 women in

inpatient treatment for an eating disorder revealed that the occurrence of SIB’s for these patients was

34.6% (Paul, Schroeter, Dahme, Nutzinger, 2002). Various similar psychological features have been

observed between people with AB and those who self injure, and the interviewee for this assignment

described her eating disorder and SIB’s as ‘synonymous.’ (Anonymous, personal communication,

December 11, 2012). Looking at the comorbidity of these disorders, clinical studies of symptom use, and

the thoughts and feelings expressed by the interviewee (who has had a lifelong history of self harm, a

stretch of anorexia followed by a bout with bulimia, and then treatment), this paper strives to

understand how AB can interact with SIB’s and vice-versa. For the purpose of this paper, we will use the

definition of SIB as stated in Bodies Under Siege: Self-Mutilations, Nonsuicidal Self-Injury and Body

Modification in Culture and Psychiatry: “self-injury is the deliberate, direct destruction of healthy body

tissue without an intent to die.”



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The Prevalence of Self-Injurious Behavior in Eating DisordersIt is suggested that eating disorders such as AB have astounding rates of comorbidity with other

SIB. However, since few researchers have invested time to study in depth the specific relationship

between these two phenomena, the information that does exist is often pulled from other studies, and

therefore includes extra variables and as a result may be less accurate. InSelf Harm Behavior and Eating

Disorders: Dynamics, Assessment and Treatment, it is stated that, “Favazza asserts that as many as 50%

of self mutilators have a history of anorexia or bulimia nervosa. Levenkron maintains that, in our society,

the percentage of cutters and the percentage of individuals with anorexia nervosa is similar. Conterio

and Lader found that 61% of self-injurers reported a current or past eating disorder, while Walsh and

Rosen found that, compared with non-mutilators, self-mutilating teenagers were significantly more

likely to have an eating disorder. As for the psychological relationship between self-injury and eating

disorder symptoms, Contario and Lader, Miller, and Favazza view eating disorder symptoms as self-

injury equivalents,” (Levitt, Sansone, Cohn, 2004) so although the specifics of such studies may be in

question, there is a definite correlation between SIB and AB. Even with such sparse information

specifically related to this topic, when examined closely, trends become clear. Paul, Schroeter, Dahme,

and Nutzinger’s study showed that of 376 eating disordered patients, 34.6% reported ever having

injured themselves intentionally, and among the self injuring patients, 38.5% had exhibited SIB in the

past 30 days. 49.2% of the self-injurers reported that the SIB’s began after the onset of their eating

disorder, and for a lesser 25.4% of the self-injurers, the behavior began before the onset of their eating

disorder. (2002) This suggests that the development of AB may trigger an individual to begin self harm,

even if they otherwise would not. Among psychiatric patients without eating disorders, the rate of self

harm is estimated to be somewhere between 4%-10%. (Paul, Schroter, Dahme, and Nutzinger, 2002)

Statistically, it is clear that SIB is much more prevalent in people with eating disorders.



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A Higher Prevalence in Bulimia than AnorexiaFavazza and Conterio gathered data on 290 female self-mutilators. Of the sample, a significantly

higher number of people listed themselves as having a history with bulimia (22%) than anorexia (15%) or

both (13%). (Favazza, 2011. pg 45) One possible explanation for this, as given by the interviewee is as

follows: “Vomiting and cutting were basically the same feelings for me. It was a buildup of feelings,

anger, hatred . . . and a desire to conquer those feelings. Then it was a release—not only of bodily fluids

but of the emotions too. When I would cut or vomit it felt like everything came out. I felt clean

afterward, like I had been poisoned by my emotions or by the food I ate, and purging or cutting would

give me a clean slate.” She describes the stretch of time when she was anorexic as an attempt to control

her emotions, intake, and the world around her. (Anonymous, personal communication, December 11,

2012) Claes conducted a study comparing eating disorder patients with and without SIB. The patients

who self-harmed exhibited much higher measures of impulsivity (drug abuse, binging and purging,

shoplifting, suicide attempts etc.), more dissacociative experiences, personality disorders, and a history

of abuse. (Favazza, 2011.) Another reason anorexic patients may have a lower rate of self harm is

because anorexia itself is already a physically painful condition. The data collected from the interview

also supports this notion. She said that during the stretch of anorexia, she seldom used SIB to cope. “I

didn’t need to; the hunger pangs were pretty constant,” she said. “I was already doing something that

hurt, and that showed physical results.” (Anonymous, personal communication, December 11, 2012.)

Favazza states, “*Anorexia+ Is a form of indirect self -injury in which the patient achieves victory over real

and fantastic enemies through fasting.” (2011)

Depersonalization In Eating DisordersAnother fascinating reason the interviewee cited for the cessation of SIB after the onset of her

anorexia was that cutting herself became “less satisfying” when she was anorexic because her low blood

pressure caused a slower flow of blood. There is little information available regarding the fascination



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with blood in self-injuring patients, but Favazza suggests that the sight of blood may interrupt episodes

of depersonalization and is effective in restoring a patient’s sense of reality (2011). When the

interviewee spoke about her feelings about self herm, her responses were typical of a disassociated

individual. “When I’m thinking about *cutting,+ I start to feel as though I don’t exist at all, like the

emotions I have get to be so much that I go numb. That was also how I felt during the ‘binge’ part of

‘binge and purge.’ I would get so angry, and then I would feel underwhelmed by the impact my anger

had on the rest of the world.” When she spoke about her relationship with her body, she described

confusion about the physical world. “I understand my mind, but I don’t understand my body. I don’t

understand why things exist that we can see and feel. *…+ It gives me a huge sense of distress to think

about my existence, physically. I don’t understand it, and I don’t like it. It feels so outside of my control.

I’ve always had control issues with my body because of this.” While the patient describes her bulimia

and self harm as a way to feel attached with reality, she says her bout with anorexia was the complete

opposite. “It felt better for me to take control of how my body looked than to just sit and feel powerless.

Not-eating made me feel like I was transcending reality, a little bit. I felt less human than everybody else

because I didn’t need to eat, and it felt good to embrace that and to pretend it was a good thing.”

(Anonymous, personal communication, December 11, 2012.) This suggests that it is almost as if the

anorectic patient experiences a higher level of disassociation than the bulimic—throwing themselves

into the depersonalization with full force. However, this speculation is inconsistent with the findings of

Paul, Schroeter, Dahme, and Nutzinger, who found that bulimics score higher on a depersonalization

scale. (2002) The interviewee said that anorexia drove her to be a very manipulative person. “It felt very

good to be cruel to people when I was anorexic. I’m not that person any more. I think that being so far

into my anorexia like I was at that point made me lose sight of anything except power. I felt like God.”

(Anonymous, personal communication, December 11, 2012.)



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Emotional Blockage and Punishment Another recurring theme in the interview was the patient’s feelings of anger. She cites her

childhood as a possible cause for the buildup of anger she struggles with. She said that when she was

younger, anger was met with a negative response, so she “learned” not to be angry at people. She

described vomiting and cutting as, “a buildup of feelings, anger, hatred . . . and a desire to conquer

those feelings. Then it was a release—not only of bodily fluids but of the emotions too. *…+I felt clean

afterward, like I had been poisoned by my emotions or by the food I ate, and purging or cutting would

give me a clean slate.” The interviewee also spoke about cutting and vomiting as modes of punishment

for the way that she acted as an anorexic, but also as a punishment for BEING bulimic—something she

used to look down upon. “One time, on an impulse I cut myself on my face, because I desperately

wanted to stop myself from ever being beautiful again. I didn’t think I deserved to be beautiful, because

of how much I had manipulated people in the past. I thought it was misleading.” During her stretch of

anorexia, the interviewee says that she would come up with punishments for herself if she ate.

(Anonymous, personal communication, December 11, 2012.) This sort of phenomenon is common and

well documented in studies of both AB and SIB. In the study of Paul, Schroeter, Dahme, and Nutzinger,

patients rated self-punishment as one of the most important functions of self-injurious behavior. (2002)

“I know that cutting and burning myself is a way I take care of *built up+ anger,” said the interviewee. If

our interviewee is any indication of a typical AB self-injurer, our interview shows some indication that

emotional suppression as a child can lead to later problems in life—in this case, AB and SIB. Peebles’s

research indicates that among adolescents with eating disorders, the adolescents are much more likely

to self harm if they have a history of abuse. (Pekar, 2013)



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ConclusionIt is clear that the connections between AB and SIB are vast and complex. More extensive

research about the relationship between these disorders would be helpful in understanding the mind of

self-injuring AB patients, and may lead to more effective modes of therapy. A study by Dr. Rebecka

Peebles revealed that out of 1,432 patients in treatment for an eating disorder, only 42.7% of patients

were screened for SIB by their clinicians. (Pekar, 2013) It is apparent that although these disorders go

hand in hand, many treatment centers do not acknowledge the correlation when screening patients,

which may lower the effectiveness of treatment. By recognizing the associations between eating

disorders and self injury, clinicians may be able to treat these disorders more effectively.



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Sources CitedFavazza, Armando R. Bodies under Siege: Self-mutilation, Nonsuicidal Self-injury, and Body Modification

in Culture and Psychiatry Baltimore: The Johns Hopkins University Press 2011. E-Book

Levitt, John L. Randy A. Sanstone, and Leigh Cohn. Self-Harm Behavior and Eating Disorders: Dynamics,

Assessment and Treatment New York, Brunner-Routledge2004. E-Book.

Paul, Thomas, Kirsten Schroeter, Bernhard Dahme, Detlev Nutzinger “Self-Injurious Behavior in Women

with Eating Disorders” The American Journal of Psychiatry, VOL. 159, No. 3 2002

Pekar, Tetyana “Self-Harm is Common Among Adolescents with Eating Disorders” The Science of Eating

Disorders n.p. January 2, 2013 Website

Anonymous, personal communication December 11, 2012

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