Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients

doi:10.1016/j.brat.2008.10.011

Behaviour Research and Therapy

Volume 47, Issue 1, January 2009, Pages 83-87

https://doi.org/10.1016/j.brat.2008.10.011 Get rights and content

Abstract

Bulimia nervosa and non-suicidal self-injury (NSSI) co-occur at high rates, and both have been conceptualized as maladaptive emotion regulation strategies. Treatments focusing on emotion regulation have been designed for both problem behaviors, yet, there exists very little research examining the temporal emotional states surrounding acts of NSSI. Using ecological momentary assessment (EMA) methodology, the current study examined the temporal association between positive and negative emotional states prior to and consequent to acts of NSSI within a subset of bulimia nervosa patients. Results indicate significant increases in negative affect, and decreases in positive affect, prior to an NSSI act. Post-NSSI, positive affect significantly increased while negative affect remained unchanged. The findings offer partial support for an emotion regulation paradigm to understanding NSSI within bulimic populations and implications for treatment are discussed.

Section snippets

Participants

One hundred thirty one female participants who met DSM-IV criteria for bulimia nervosa (BN) took part in this study. Participants were recruited from the community and local campuses. The participants were selected from a sample of 154 women who appeared to meet study entry criteria based on a phone screening process. Ph.D. level assessors trained in administering the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P; described below) then screened potentially eligible women

Description of sample

The 131 participants included in this sample were predominantly single/never married (64.9%), primarily Caucasian (96.9%), and full-time students (51.1%). Participants were relatively young (M = 25.3 years; SD = 7.6) and were generally of average weight (body mass index = 23.8; SD = 5.25). Of the 131 participants, 19 (14.5%) reported at least one act of NSSI during the study time period. A total of 55 episodes of NSSI were recorded across these 19 participants and used for the current study analyses.

Comparison of NSSI group vs. non-NSSI group

Discussion

Results from the current study partially confirm hypotheses that NSSI serves a real-time emotion regulating function within persons diagnosed with bulimia nervosa (BN). Findings that negative affect increased and positive affect decreased preceding an act of NSSI is consistent with previous self-report data indicating NSSI is used to manage aversive emotional states (Kemperman et al., 1997, Laye-Gindhu and Schonert-Reichl, 2005, Nock and Prinstein, 2004, Osuch et al., 1999). The result that

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Citation Excerpt :
As such, the assessment of their level of PSU is here considered as a comparative mean through which trying and define if these adolescents' state of suffering broadens to other dysfunctional behaviors as a function of their psychological state and (im)maturity. The rationale behind this resides in the conceptualization of the two as regulatory strategies [36,45–47,115–117] thus as means through which a negative and unpleasant emotional state is expressed and modulated. In this respect, it should be noted that PSU had a marginal position within the network, showing the lowest centrality indices, which suggests that PSU severity does not significantly contribute to the NSSI phenomenon overall.
Research has shown an increased risk for Non-suicidal self-injurious (NSSI) behavior as well as Problematic Smartphone Use (PSU) and particularly in adolescence, a developmental period defined by multi-level changes and still poor self-control capacities associating with risk-taking behaviors.
The current study was aimed to assess the pattern of mutual relations characterizing NSSI considering self-control, internalizing and externalizing problems, and investigating how PSU fits within the network since NSSI and PSU are here conceptualized as attempts at emotion regulation. Age and gender differences were also assessed.
Participants were Italian adolescents presenting NSSI behavior (N = 155; Mage = 14.68; SD = 1.647; Range = 11–18; 43.2%-females); the sample is based on community recruitment. A Network Analysis was performed to assess the organizational structure of NSSI; age and gender differences were assessed through multivariate rank tests further applying multiplicity control.
The emerged Network showed the centrality of low self-control and internalizing problems for NSSI. NSSI and PSU were associated through low self-control, and so were PSU and externalizing problems. Significant age differences were observed showing a decrease in NSSI as age increases (stat = −2.86; adj.p = .029). No gender differences have emerged.
The current findings provide support for the consideration and investigation of PSU as regards NSSI behavior in adolescence. Moreover, these findings point to the relevance of prevention practices during this peculiar developmental period, particularly sustaining self-control capacities and the use of more adaptive emotion regulation strategies, thereby limiting the accrue of at-risk behaviors.
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In this daily dairy study of adolescents at elevated suicide risk, we examined proximal associations between nonsuicidal self-injury (NSSI) and suicidal thoughts as well as behaviors. We also investigated the prominence of the anti-suicide function underlying NSSI engagement, relative to intrapersonal and interpersonal motives.
Seventy-eight adolescents (67.9% female; ages 13-17) hospitalized due to suicide risk completed daily surveys assessing NSSI and suicidal thoughts for four weeks after discharge (n=1621 observations). Suicidal behavior (actual, aborted, interrupted suicide attempts) was assessed at 1-month follow-up.
Over and above lifetime NSSI, adolescents who generally experienced more enduring (OR=2.54, p=<.001) and intense (OR=1.87, p=.002) suicidal ideation were more likely to engage in NSSI on a given day. Moreover, NSSI likelihood increased when adolescents experienced more enduring (OR=1.99, p<.001) and intense (OR=1.66, p<.001) ideation relative to their typical levels. This pattern was consistent for those with recent NSSI. The anti-suicide function of NSSI was frequently endorsed at hospitalization and when NSSI occurred daily (65.6% of the time), alongside the intrapersonal-negative motive (to avoid aversive states). Exploratory analyses suggest adolescents with suicidal behavior within the month after discharge experienced higher NSSI levels reported daily over the same period (Hedge's g=1.26, p=<.001).
Daily-level associations were examined concurrently and generalizability of results is limited by sample characteristics.
The notable proximal associations between NSSI and suicidal thoughts and behaviors, as well as the prominence of the anti-suicide function, point to the importance of intervention efforts targeting these intersecting phenomena among adolescents at elevated suicide risk.
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Nonsuicidal self-injury (NSSI) and binge eating frequently co-occur. These behaviors are often used to alleviate distress. Previous studies examining this co-occurrence have used a variable-centered approach. The current study used a person-centered approach (mixture modeling) to examine how individuals cluster in groups based on their past-month NSSI, past-month objective and subjective binge episodes (OBEs and SBEs, respectively), and endorsement of coping motives for NSSI and eating in two large samples of emerging adults. Validators included self-report measures of emotion regulation, impulsivity, and negative affect. In Study 1, additional validators included lifetime history of mental health treatment and suicide attempts. In Study 2, additional validators included child abuse history. In both Study 1 and Study 2, a three-class solution provided the most interpretable fit with classes characterized as (a) low psychopathology; (b) the presence of OBEs and NSSI, and endorsement of NSSI coping motives; and (c) the presence of SBEs and NSSI, and endorsement of high levels of NSSI coping motives. In both studies, eating motives were equivalent in Classes 2 and 3, but NSSI motives were most strongly endorsed by Class 3. In Study 1, Class 2 endorsed higher rates of lifetime suicide attempts than Class 3. In Study 2, both Class 2 and Class 3 endorsed higher rates of child abuse than Class 1, although they did not differ from each other. The class structure and validator analysis were consistent across samples and measures. Results suggest that binge eating and NSSI tend to cluster together in otherwise healthy emerging adults.
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The ability to generate and regulate emotional experiences is critical to psychological well-being. Impairments in emotion regulatory processes have transdiagnostic associations with psychopathology. Nonsuicidal self-injury (NSSI) is prevalent in adolescent populations, especially clinical adolescent populations, and often linked to emotion regulatory deficits. Clinical observations propose a role for NSSI behaviors in regulating affect, suggesting that these behaviors may arise when other emotion regulatory strategies are insufficient or inaccessible. Experimental evidence has begun to explore the psychophysiological and neural underpinnings of emotion processing in NSSI populations. Thus far, a primary focus has been the role of NSSI in regulation of affect in response to stressful or negative states or stimuli, often suggesting enhanced reactivity in such situations. However, recent evidence suggests that NSSI populations may also display heightened reactivity to positive or rewarding stimuli. Here, we highlight this emerging data and how it may be integrated into existing NSSI framework.

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^☆: This project was funded by grant R01-MH-59674 from the National Institute of Mental Health awarded to the Neuropsychiatric Research Institute (Dr. Wonderlich).

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Shorter communicationEmotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients☆

Abstract

Section snippets

Participants

Description of sample

Comparison of NSSI group vs. non-NSSI group

Discussion

Behavior Therapy

Clinical Psychology Review

Behaviour Research and Therapy

Eating Behaviors

Behaviour Research and Therapy

Comprehensive Psychiatry

Clinical Psychology Review

Journal of Adolescent Health

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Behaviour Research and Therapy

Self-harm and suicide attempts in individuals with bulimia nervosa

Eating Disorders: The Journal of Treatment & Prevention

Depression and hostility in self-mutilation

Suicide and Life-Threatening Behavior

Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder

Journal of Abnormal Psychology

Eating-disordered patients with and without self-injurious behaviours: a comparison of psychopathological features

European Eating Disorders Review

The eating disorder examination

Female habitual self-mutilators

Act Psychiatrica Scandinavica

Structured clinical interview for DSM-IV Axis I disorders: Patient edition (SCID-I/P)

Targeting emotion dysregulation in the treatment of self-injury

Journal of Clinical Psychology

Binge eating as escape from self-awareness

Psychological Bulletin

Testing the emotion regulation hypothesis among self-injuring females: evidence for differences across mood states

The Journal of Nervous and Mental Disease

Self-injurious behavior and mood regulation in borderline patients

Journal of Personality Disorders

Antecedents and consequences of binge eating episodes in women with an eating disorder

Eating and Weight Disorders

Self-injury: a research review for the practitioner

Journal of Clinical Psychology

Nonsuicidal self-harm among community adolescents: understanding the ‘whats’ and ‘whys’ of self-harm

Journal of Youth and Adolescence

Cognitive-behavioral treatment of borderline personality disorder

Characteristic and functions on non-suicidal self-injury in a community sample of adolescents

Psychological Medicine

Understanding deliberate self-harm: the patient's views

Crisis

Self-injurious behavior as a separate clinical syndrome

American Journal of Orthopsychiatry

Shorter communication
Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients☆