Self-Harm and Eating Disorders

Self-injurious behavior is a sign of mental distress, however, it is too often minimized as “attention-seeking,” leaving those in need ignored and without support. This is one of many ways in which self-injurious behavior and eating disorders are similar and why they often co-occur.

What is Self-Injury?

Self-injury involves any behavior in which an individual hurts themselves on purpose. These behaviors are often not related to attempts at suicide, although the individual may also struggle with suicidal ideation. Self-injurious behaviors, instead, are often utilized as maladaptive coping skills to cope with distressing emotion states.

Non-suicidal Self-Injury DSM-5 Definition

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides the criteria necessary for an individual to be diagnosed with a mental illness. This resource also specifies “conditions for further study,” which are proposed criteria for “conditions on which future research is encouraged [1].” These are not officially diagnosable disorders yet the criteria presented does allow professionals to identify when concerning behaviors and psychology are presenting. Non-suicidal Self-Injury (NSSI) is included in this category with the following recommended criteria:

1. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain(e.g. Cutting, burning, stabbing, hitting, excessive rubbing) with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is not suicidal intent).
2. The individual engages in the self-injurious behavior with one or more of the following expectations:
   • To obtain relief from a negative feeling or cognitive state,
   • To resolve an interpersonal difficulty,
   • To induce a positive feeling state.
   • Note: The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.
3. Intentional self-injury is associated with at least one of the following:
   • Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act,
   • Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control,
   • Thinking about self-injury that occurs frequently, even when it is not acted upon.
4. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.
5. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.
6. The behavior does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopment disorder, the behavior is not part of a pattern of repetitive stereotypes. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotyped movement disorder with self-injury, trichotillomania [hair pulling disorder], and excoriation [skin picking disorder]) [1].”

Self-Injurious Behavior ICD-10 Code

Similar to the DSM-5 criteria, the ICD-10 code for non-suicidal self-injury is non-billable and non-specific and is only used to signify that an individual has a personal history of self-harm. This code helps to communicate this regardless of the culture or country the individual is seeking care within. The ICD-10 code for non-suicidal self-injury is Z91.5

What are the Signs of Self-Harm?

Self-harming often involves injurious behaviors that leave scarring or wounds. In fact, some individuals may report that the scarring or wounds themselves are part of their maladaptive coping ritual. Signs that a loved one may be engaging in NSSI include:

• Scarring
• Fresh cuts, burns, or scratches
• Rubbing an area excessively
• Having or collecting sharp objects
• Wearing long sleeves or pants even in hot weather
• Reports of depressive symptoms
• Difficulties in interpersonal relationships
• Behavioral and/or emotional instability
• Impulsive tendencies
• Reporting feelings of hopelessness, helplessness, and/or worthlessness.

Causes of Self-Harm

The National Alliance on Mental Illness (NAMI) provides a helpful description of why self-injurious behaviors occur, stating that “self-harm is not a mental illness, but a behavior that indicates a need for better-coping skills [2].” Individuals often engage in self-harming behaviors when they do not have any other, more effective, skills to cope with emotional distress, trauma, or lack of control.

Engaging in self-harming once might reinforce future episodes, as “self-harm may feel like a release. Sometimes, injuring yourself stimulates the body’s endorphins or pain-killing hormones, thus raising their mood [2].”

Individuals that engage in self-injurious behaviors may have a comorbid mental health diagnosis, with the most common co-occurring diagnoses being Borderline Personality Disorder, Major Depressive Disorders, Eating Disorders, Generalized Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD) [2].

Related Reading:

• Depression and Eating Disorders
• Eating Disorder Treatment Help
• Borderline Personality Disorder

The Connection Between Self-Harm and Eating Disorders

As mentioned above, self-injurious behaviors often occur alongside eating disorder behaviors. Both are often used as maladaptive coping skills when an individual does not feel they have the skills to cope with distressing thoughts, feelings, and situations.

Additionally, both self-harming and eating disorder behaviors may be used as an ineffective method of communicating a need for support. Perhaps an individual attempted to communicate their needs and were not heard or listened to until they engaged in these behaviors, reinforcing beliefs that “this is how I receive the support I need.” While harmful and ineffective, this care-seeking makes sense to the individual and they might continue their behaviors out of fear that, if they don’t, they will not receive any care.

Are Eating Disorders Self-Harm?

Many do believe that eating disorders themselves are self-injurious behaviors. The motivations behind eating disorders can be similar to self-harming behaviors, as discussed above.

Further, individuals with eating disorders express beliefs similar to those that engage in self-injurious behavior, such as that they are “not worthy of not harming their bodies” or that they must harm their bodies in order to cope.

The key to whether or not an eating disorder behavior is self-harming is if the individual engages in the behavior with intentions to harm themselves.

Eating Disorders and Self-Harm Statistics

Eating disorders and self-harming are commonly seen occurring simultaneously, therefore, researchers have looked at this dynamic and learned that:

• “Approximately 30% of individuals who participate in binging and purging behaviors also choose to cut themselves or practice another form of self-harm behavior [3].”
• Symptoms of both self-harm and eating disorders occur together in about 25%-50% of individuals who engage in one or the other [4].
• The rate of overlap for eating disorders and NSSI can be upward of 65%. This is higher among individuals with a mental health diagnosis [4].

Eating Disorder and Self-Injury Treatment Options

As the motivations behind engaging in both eating disorders and self-injurious behaviors are similar, treatment of one is often similar to, and will support, treatment of the other.

Medication

Medication can support both eating disorders and self-injury recovery in that it can support reduction of emotional distress. Medications that help to reduce depressive, anxiety, and PTSD symptoms will help an individual to feel less dysregulated when experiencing distressing thoughts, feelings or situations.

The medication itself will not cure the behaviors, however, it can help to stabilize the mood-states that trigger the behaviors.

Therapy

Therapy can provide key behavioral support for eating disorders and self-harming recovery, as therapy will teach the individual how to alter their cognitions and strengthen and use their skills in order to more effectively cope with distress.

Therapies that will support treatment of both include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Interpersonal Psychotherapy (IPT), Exposure and Response Prevention (ERP), and family-based treatments.

Relapse Prevention & Aftercare Support

A key part of preventing eating disorders and self-harm relapse is to continue receiving support even when the behaviors themselves are extinct or occur very rarely. This support may look like bi-weekly therapy sessions, engagement in support groups, or continuing to take prescribed medications. The important part is recognizing that continued work needs to be put into maintaining recovery, as these temptations do not simply “go away” forever.

Your treatment team can support you as you move through the stages of treatment and behavior reduction. Also, consider exploring the support system and lifestyle that best supports your recovered self and work to maintain this.

How Friends and Family Can Help

Helping those who self-harm can be tricky. It is important to help keep the loved one busy, especially during times they are most likely to self-injure. Keeping them away from the area and tools they use to self-injure can also be helpful so there are lessened triggers. Distraction can be powerful and help delay urges to self-harm.

Helping create a list of healthy self-soothing behaviors and support for different uncomfortable emotions can also be beneficial. For example, when feeling angry, squeeze ice, rip up newspaper, use clay or Play-Doh to keep hands busy [5]. Other ideas include taking a warm bath, playing with your pet or friend’s pet, doing something for someone else, or listening to music.

Negative thoughts can also be difficult to combat, but helping challenge unhealthy patterns can be supportive to a loved one who is struggling. If you find that a loved one is having difficulty with thoughts or speech that is negative, help them change their thoughts to something positive from that day or in their life. Help them see what are the facts about their statement versus which is an opinion.

Reframing is also valuable by saying, “I am doing what I need to do to take care of myself, I will work on doing ____next time.” Positive affirmations and coping statements are also a great tool.

Being able to go over and create some together can help a support person know what to say if the loved one contacts them when having strong urges. Working out a support plan for when urges are high, as well as a contact sheet for who can they call if one person does not pick up.

Being able to ask open-ended questions or make comments like those below can help an individual feel supported, not judged, and compassionate toward a support person:

• How are things going for you?
• What are you feeling?
• It seems that you have been stressed lately.
• I am concerned that maybe you feel discouraged.

It is important to remember that self-injury behaviors are not an attempt at suicide, but a way to release the pain that they are otherwise unable to express. If you are concerned that a loved one may be unsafe or suicidal, please take them to the nearest emergency room or call 911.

I am a Parent: What Can I Do?

It can feel overwhelming at first when you are trying to support a loved one who struggles with self-harm urges. Self-injury is typically a very personal act, and there are many methods, as mentioned above, that a person will use to self-harm.

Self-injury covers various behaviors, but all have a key element which is the intent to harm oneself not as a way to commit suicide, but rather a way to cope and survive [6].

Try to avoid ultimatums with self-harm behavior. These can push away your loved one and may cause the perception that the supportive person does not understand, nor is listening to what the loved one is trying to convey.

If you are a parent, it can be hard not to panic when you learn of your child’s self-harm behaviors. Be available to talk to your child in a safe space, and remember that self-injury is a learned behavior and habit-forming.

Work to give your child structured space and privacy, as well as encourage them to talk with you or a profession. Remember to reinforce that the behavior is something you want to help stop and that you love your child unconditionally and will support them.

When a Friend Opens Up About Self-Harm

If you are under the age of 18 and supporting a friend struggling with self-injury, encourage the individual to speak to an adult or counselor at school [6, 7]. You can offer to go with them if they are afraid to talk to an adult alone about their behaviors.

If your friend is unwilling to speak to someone about it, you need to let a trusted adult know if you are concerned they are in danger, especially if they might be suicidal. Remind your friend that telling an adult can be difficult, but it can help them get the help they need.

If you are over 18, be there to listen. Remain calm and patient, even if you are unsure why a loved one is engaging in those behaviors. Let your friend know that they are not alone, and encourage them to share this with another trusted adult, or get involved with a professional counselor and/or group support.

In conclusion, it is important to keep a non-judgmental and empathetic stance when supporting a loved one with self-harm urges. Being able to support the person by providing healthy self-soothing skills, distraction techniques and grounding tools can help ward off urges becoming behaviors.

References

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
[2] Unknown (2021). Self-harm. National Alliance on Mental Illness. Retrieved from https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Self-harm.
[3] Discovery Contributor (2021). The connection between eating disorders and self-injury. Center for Discovery. Retrieved from https://centerfordiscovery.com/blog/connection-eating-disorders-self-injury/.
[4] Ernhout, C., Babington, P., & Childs, M.. What’s the relationship? Non-suicidal self-injury and eating disorders. Cornell Research Program on Self-Injury and Recovery. Retrieved from http://www.selfinjury.bctr.cornell.edu/perch/resources/whats-the-relationship-nssi-and-ed-1.pdf.
[5] Retrieved (n.d.) April 25, 2017, from http://www.selfinjury.bctr.cornell.edu/perch/resources/distraction-techniques-pm-2.pdf
[6] Retrieved (n.d.) April 25, 2017, from http://www.lifesigns.org.uk/guidance-for-others/
[7] Retrieved (n.d.) April 25, 2017, from http://www.mentalhealthamerica.net/self-injury

Author: Margot Rittenhouse, MS, LPC, NCC
Page Last Reviewed on January 1, 2022 and Updated By: Jacquelyn Ekern, MS, LPC