Cuts both ways: Binge/purge and self-harming behaviors in adolescents
Besides the (obvious) binge/purge behaviors, one of the most common features of bulimia is self-harm. A recent study of adolescent ED outpatients found that, overall, around 40% of patients engaged in self-injuring behaviors (Peebles, Wilson, & Lock, 2011). When they broke the data down, the researchers found that approximately 60% of patients with BN self-harmed, as did 60% of patients with a history of sexual and physical abuse. Rates of self-harm were roughly half of that in patients with restrictive EDs only (no binge OR purge behaviors) and no history of abuse. That being said, a prevalence of 30% is still really, really high. As well, adolescents who regularly self-harm are at higher risk of EDs, especially those with binge/purge features (Ross, Heath, & Toste, 2009).
So what drives these behaviors? Are they triggered by similar events or emotions? What’s more, given the high overlap of self-injury and binge/purge behaviors, can you classify bulimic behaviors as a type of self-harm?
Rebecca Shingleton, an ED researcher and PhD student at Boston University, along with other scientists in the Boston area (including Kamryn Eddy at Harvard) used a technique known as ecological momentary assessment to examine factors that preceded self-harm or ED behaviors (Shingleton et al., 2013). The premise of EMA is simple: a small, handheld digital device prompts you to record your thoughts, feelings, and behaviors at various points throughout the day. You can also manually input data as well. The idea is to gather information about behaviors and their accompanying cues at the time that they are happening. Our brains like to filter data- asking someone what might have preceding binge eating or purging several days later may be our revised account of what happened. In the moment, the information is still fresh, less processed, and we remember it better.
Shingleton and colleagues recruited 30 adolescents (age 12-19) who were also participating in a study about self-harm and also included questions about binge eating and purging. Almost all of the participants were white females. Half had diagnoses of major depression, 25% were diagnosed with generalized anxiety, 23% with alcohol abuse, and 20% with PTSD. Three of the adolescents had a diagnosis of bulimia.
The researchers wanted to measure the frequency of binge/purge thoughts in this group, as well as with what other self-harming behaviors, if any, they occurred. The teens were followed for two weeks and were instructed to upload their data to a secure computer each evening.
Each time the study participants recorded an event in their palm pilot, they were asked questions about what they were doing when they had the thought, and what led to the thought. A variety of thoughts and behaviors were assessed, including “suicide thoughts and behaviors, NSSI thoughts/behaviors, binge/purge (BP) thoughts/behaviors, and “other” self-destructive thoughts/behaviors (unsafe sex, substance use, impulsive spending, etc.).”
Self-harming thoughts were by far the most common reported, the researchers found, occurring three-quarters of the time. Not surprising, given that the participants were recruited based on problems with self-harm rather than ED issues. Roughly one-quarter of the time, self-harming thoughts occurred in isolation (that is, the person wasn’t thinking about cutting AND purging or cutting AND drinking AND binge eating). Thoughts of binge/purge behaviors and self-harm occurred at 17% of the uploaded recordings, 58% of the uploads were of self-harm thoughts without binge/purge thoughts, and 8.7% of the records indicated binge/purge thoughts without self-harming thoughts.
Binge/purge and self-harm behaviors were identified in 11.4% of the recordings, 49% of the recordings had self-harm behaviors alone, and 9.6% of the recordings had only binge/purge behaviors. It’s important to note that not all participants showed signs of binge/purge behaviors.
Thoughts of binge eating were three to four times more likely to occur with other thoughts rather than alone. Purging thoughts were twelve times more likely to occur with other thoughts. Thoughts of binge eating and purging were more likely to occur while eating (kind of obvious). Feeling criticized or insulted were significant triggers of binge/purge, as were feeling rejected/hurt, and sad/worthless.
Most of the participants reported that binge/purge behaviors were intended to rid them of an unwanted or uncomfortable feeling. Anxiety was at the top of the list, but other common feelings were anger, sadness, and a lack of control. Many patients said they just wanted to feel anything or escape their current circumstances.
The authors acknowledged several limitations to the study, namely the population from which the participants were recruited, which was primarily Caucasian females. These results may not be generalizable to males, other ethnicities or socioeconomic groups. There were also missing data, and it was probable that not all self-harming thoughts and behaviors were recorded. As well, the researchers had to rely on the participant’s interpretation of what happened. However fresh that might be, it’s still vulnerable to filtering. Still, they said, it’s one of the only studies to use EMA to assess binge/purge thoughts and behaviors in what is a high-risk sample.
The researchers conclude that
Although participants typically either binged or purged (but not both) over the data collection period, BP thoughts rarely occurred in isolation. Thus, if self-injurious adolescents are experiencing BP thoughts, it is likely they are experiencing other self-destructive thoughts as well. These results highlight that BP symptoms are common among adolescents who engage in NSSI and their self-report may represent an affect regulation strategy or an expression of impulsivity. Finally, because the majority of participant responses focused on thoughts rather than behaviors, the current data may also provide insight into potential contextual settings to counter maladaptive thoughts before they transition to behaviors.
Those who actually engaged in NSSI (i.e., participants in the NSSI and NSSI+BP behavior groups) most frequently cited a desire to rid themselves of a thought/feeling as the reason for their behavior, which aligns with the theory that self-injurious behavior is a maladaptive mechanism for reducing negative feelings. In comparison, the reasons for BP behaviors were more ambiguous. These adolescents may be turning to self-injury more frequently to regulate negative emotions, and may be engaging in BP behaviors because of other types of stress or feelings (e.g., lack of control) not captured in the EMA options. Across behavior groups, these data must be interpreted with caution because the participants may not have had insight into the specific antecedents that preceded their behavior. Rather, these descriptions may simply reflect their accounts or explanations.
I would be interested to see similar studies done in AN and other ED patients. Much of what they found does coincide with my own experience of self-harm, that is largely triggered (for me, anyway) by anxiety and anger and a need to “punish” myself for something. It was my volume control on these thoughts and feelings, especially when they occurred when I was already using ED behaviors or when I was unable to turn to ED behaviors for whatever reason (I was at work, too busy, too broke, being monitored too closely, etc). I’d also be curious to see this study replicated in people with BN and self-harm issues, so there’s a better overlap of behaviors in the study sample.
Ross, S., Heath, N. L. and Toste, J. R. (2009), Non-Suicidal Self-Injury and Eating Pathology in High School Students. American Journal of Orthopsychiatry, 79: 83–92. doi: 10.1037/a0014826
Shingleton, R. M., Eddy, K. T., Keshaviah, A., Franko, D. L., Swanson, S. A., Yu, J. S., Krishna, M., Nock, M. K. and Herzog, D. B. (2013), Binge/purge thoughts in nonsuicidal self-injurious adolescents: An ecological momentary analysis. Int. J. Eat. Disord.. doi: 10.1002/eat.22142
Peebles, R., Wilson, J.L., and Lock, J.D. (2011), Self-Injury in Adolescents With Eating Disorders: Correlates and Provider Bias. J. Adolesc Health, 48(3): 310–313. doi: 10.1016/j.jadohealth.2010.06.017