1 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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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 (SIBs) 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 SIBs among people with AB. While the rate of SIBs 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 SIBs 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 SIBs 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 SIBs 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 Disorders

It 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. In Self 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 selfinjury 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 Nutzingers 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 SIBs 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 Anorexia

Favazza 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 releasenot 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 didnt 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 Disorders

Another 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

5 THE RELATIONSHIP BETWEEN ANOREXIA AND BULIMIA AND 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 patients sense of reality (2011). When the interviewee spoke about her feelings about self herm, her responses were typical of a disassociated individual. When Im thinking about *cutting,+ I start to feel as though I dont 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 dont understand my body. I dont 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 dont understand it, and I dont like it. It feels so outside of my control. Ive 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 didnt 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 bulimicthrowing 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. Im 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 patients 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 releasenot 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 bulimicsomething 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 didnt 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 lifein this case, AB and SIB. Peebless 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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Conclusion
It 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 Cited
Favazza, 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