A prospective study of the influence of the UPPS model of impulsivity on the co-occurrence of bulimic symptoms and non-suicidal self-injury
Highlights
► Baseline negative urgency contributed unique variance to BN and NSSI. ► Lack of persistence at baseline was related to binge eating at eight month follow up. ► Purging at baseline contributed significant variance to NSSI at follow-up.
Introduction
A substantial percentage of individuals with bulimia nervosa (BN) endorse self-injurious behavior (Claes et al., 2001, Ross et al., 2009, Solano et al., 2005). For example, ED symptoms, such as fasting and self-induced vomiting, are associated with elevated risk for a later suicide attempt (Crow et al., 2008, Johnson et al., 2002). Both BN symptoms and self-injury are thought to be influenced by impulsive reactions to negative affect (Favazza, 1998, Gratz, 2001, Kamphuis et al., 2007). While suicide has received considerable empirical attention in conjunction with eating pathology (e. g. Franko & Keel, 2006), non-suicidal self-injury (NSSI) has been examined less frequently. NSSI is defined as direct and deliberate self-inflicted harm to body tissue without suicidal intent (Favazza, 1998). NSSI behaviors occur in between 26% and 55.2% of individuals with BN (Svirko & Hawton, 2007).
One proposed link between BN symptoms and NSSI is that the desire to quickly reduce negative affect is an antecedant for both behaviors (Muehlenkamp et al., 2009, Ross et al., 2009, Svirko and Hawton, 2007). NSSI has largely been conceptualized as the result of deficits in impulse control, particularly in response to distress (Favazza, 1998, Klonsky, 2007, Muehlenkamp et al., 2009). Ecological momentary assessment studies indicate that impulsive maladaptive reactions to increases in negative affect characterize BN symptoms such as binge eating and purging (Crosby et al., 2009, Smyth et al., 2007). Similar studies have documented that increases in distress trigger NSSI in women with BN (Muehlenkamp et al., 2009). Researchers also note affect regulation motives for NSSI behaviors (Nock and Prinstein, 2004, Nock et al., 2009), and disordered eating behaviors (Jackson, Cooper, Mintz, & Albino, 2003), with common reasons cited for engaging in NSSI and binge eating as escape from negative mood (Klonsky, 2007). Overall it appears that both NSSI and bulimic behaviors may serve similar negative affect alleviation functions.
Recent advances in the study of impulsivity theoretically clarify the role of reactivity to negative affect in impulsive action. Historically, several aspects of impulsive behavior have been combined under one broad label ‘impulsivity’, which may have obscured the distinctions between different paths to impulsive behaviors. Four primary distinct trait based paths to impulsive behavior have been identified; sensation seeking, lack of premeditation, negative urgency, and lack of perseverance (Smith et al., 2007, Whiteside and Lynam, 2001). Negative urgency is the tendency to act rashly in response to negative affect (Smith et al., 2007, Whiteside and Lynam, 2001). Individuals with high levels of negative urgency may associate negative affect reduction with immediately accessible behaviors, such as binge eating or cutting, thus increasing the likelihood of maladaptive behaviors via negative reinforcement pathways. Additionally, individuals with high levels of negative urgency may not learn other more adaptive strategies to cope with distress, because their rash actions may preclude the opportunity to learn other skills (Fischer & Smith, 2008).
Negative urgency is positively associated with BN symptoms with moderate to high effect sizes, while the relationship of other impulsivity related constructs to BN manifest small effects (Fischer et al., 2003, Fischer et al., 2008). Negative urgency also accounts for significant variance in BN symptoms in a clinical sample (Anestis, Smith, Fink, & Joiner, 2009). Finally, only one study has examined the effect of this trait on BN symptoms prospectively, and indicated that changes in levels of negative urgency over time were associated with changes in BN symptoms (Anestis, Selby, & Joiner, 2007).
Multiple researchers have hypothesized that impulsivity influences NSSI (Paul et al., 2002, Ross et al., 2009). However, data regarding the role of impulsivity on NSSI are mixed. Earlier studies indicate that broadly defined impulsivity does not distinguish individuals with NSSI from those who do not engage in NSSI (Hawton et al., 2002, Herpertz et al., 1997). These mixed findings may be due to the multidimensional nature of impulsivity, and perhaps the use of assessments that do not distinguish specific facets. Recent data, however, indicates that self-injurers are best characterized by negative urgency, or the tendency to act rashly in response to negative mood (Glenn & Klonsky, 2010). Further, individuals who engage in NSSI report higher levels of negative urgency, (lack of) premeditation, and (lack of) perseverance than controls (Lynam, Miller, Miller, Bornolova, & Lejuez, 2011). This finding is consistent with the hypothesis that NSSI functions as a maladaptive coping mechanism in response to emotion dysregulation (Gratz, 2007, Muehlenkamp et al., 2009, Paul et al., 2002, Ross et al., 2009, Svirko and Hawton, 2007), and similar to findings documenting that urgency is more strongly associated with bulimic symptoms than other impulsivity constructs.
We propose that NSSI and BN symptoms tend to co-occur because of their shared variance with negative urgency: that individuals with high levels of negative urgency are vulnerable to co-occurring maladaptive, negatively reinforcing behavior patterns. We utilized structural equation modeling (SEM) to examine the relationships between these variables, as this statistical design allowed us to examine the influence of all four impulsivity facets on both dependent variables (NSSI and BN symptoms) simultaneously. Thus, the first primary aim was to examine the cross-sectional relationships between these variables at baseline assessment by modeling direct paths from sensation seeking, (lack of) perseverance, (lack of) premeditation, and negative urgency to both BN symptoms and NSSI. To our knowledge, this is the first study to examine the influence of these variables on both NSSI and BN simultaneously.
The second primary aim of the study is to examine the incremental predictive utility of the UPPS model of impulsivity on these behaviors over time, beyond the variance accounted for by the presence of symptoms at baseline. Prospective studies of the influence of traits, such as impulsivity, on behaviors over time are important in the development of models of risk for maladaptive behavior patterns. It may be that the large effects of negative urgency on BN, for example, in cross sectional studies reflect the salience of current psychopathology (Widiger & Smith, 2008). Thus, establishing that impulsivity related variables contribute to changes in behavior over time would indicate that these individual differences are potential targets for prevention, and would facilitate our understanding of how personality influences psychopathology. Finally, there is some evidence that suggests that NSSI and eating pathology have reciprocal influences on each other (Nock et al., 2009). The prospective design of the study allows us to examine the influence of these behaviors on each other over time.
We made the following specific hypotheses. First, at baseline assessments, BN symptoms and NSSI would be positively correlated, consistent with data that there are high rates of NSSI in clinical samples of women with BN. Second, that negative urgency, when modeled simultaneously with other impulsivity related traits, would account for significant unique variance in measures of both BN symptoms and frequency of NSSI at baseline. We did not expect that other traits would account for significant variance in BN symptoms at baseline. However, we also examined paths from sensation seeking, (lack of) premeditation, and (lack of) perseverance to these symptoms and NSSI, as previous studies indicate that these traits are associated with self-injury. Third, we hypothesize that individual differences in the four impulsivity factors at baseline would account for significant variance in both BN and NSSI at eight month follow-up, over and above the variance accounted for by symptoms at baseline. Finally, as previous longitudinal studies indicated that eating disorder symptoms are associated with elevated risk for later suicidal behavior, we examined the influence of baseline BN symptoms on NSSI at the follow up period.
Section snippets
Participants
Participants were 489 women enrolled in introductory psychology courses at a large southeastern university. The sample ranged in age from 17 to 24 years (mean = 18.62; sd = 1.03). The majority of participants described themselves as Caucasian (75.8%), with the remainder describing themselves as Asian-American (7.9%), African-American (9.8%), Hispanic (2.1%) or another ethnicity (4.4%).
Eating Disorder Examination Questionnaire (EDE‐Q) (Fairburn & Beglin, 1994)
The EDE-Q is a self-report measure modified from a semi-structured interview (EDE Fairburn & Wilson, 1993) designed
Sample characteristics and attrition
A total of 209 participants completed eight month follow up assessments. While this represents 43% of the original sample, independent samples t-tests indicated that there were no significant differences between women who dropped out of the study and those who completed follow up data on any study variables (ts ranged from .05 to .92). Additionally, we conducted a logistic regression analysis with drop-out vs. completer status as the dependent variable, using all variables assessed at baseline
Discussion
The purpose of this study was to examine the effects of negative urgency, sensation seeking, (lack of) perseverance, and (lack of) premeditation on BN symptoms and NSSI and their co-occurrence. We examined the relative contributions of these variables cross-sectionally at an initial assessment period, and prospectively with an eight month follow-up assessment. Finally, we examined the prospective influence of BN symptoms on NSSI, and the prospective influence of NSSI on BN symptoms.
The results
Role of funding sources
Funding for this study was provided by the University of Georgia Research Foundation (UGARF). UGARF had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
The first author developed the hypotheses for the study. Both the first and second authors conducted literature searches and provided summaries of previous research studies. Both the first and second authors conducted the statistical analysis. Both the first and second authors contributed to and have approved the final manuscript.
Conflict of interest
There are no conflicts of interest.
References (42)
- et al.
The role of urgency in maladaptive behaviors
Behaviour Research and Therapy
(2007) - et al.
Self-injurious behaviours in eating-disordered patients
Eating Behaviors
(2001) - et al.
Daily mood patterns and bulimic behaviors in the natural environment
Behaviour Research and Therapy
(2009) - et al.
Binge eating, problem drinking, and pathological gambling: Linking behavior to shared traits and social learning
Personality and Individual Differences
(2008) - et al.
Another look at impulsivity: A meta-analytic review of types of impulsivity and bulimic symptoms
Clinical Psychology Review
(2008) - et al.
Suicidality in eating disorders: Occurrence, correlates, and clinical implications
Clinical Psychology Review
(2006) - et al.
Impulsivity in self-mutilative behavior: Psychometric and biological findings
Journal of Psychiatric Research
(1997) - et al.
Motivations to eat: Scale development and validation
Journal of Research in Personality
(2003) The functions of deliberate NSSI: A review of the evidence
Clinical Psychology Review
(2007)- et al.
Emotional states preceding and following acts of non-suicidal NSSI in bulimia nervosa patients
Behavior Research and Therapy
(2009)
The five factor model and impulsivity: Using a structural model of personality to understand impulsivity
Personality and Individual Differences
Dysregulated eating and distress: Examining the specific role of negative urgency in a clinical sample
Cognitive Therapy and Research
Comparative fit indexes in structural models
Psychological Bulletin
Assessment of eating disorders: Interview vs. questionnaire
International Journal of Eating Disorders
What is coefficient alpha? An examination of theory and applications
Journal of Applied Psychology
Suicidal behavior in adolescents: Relationship to weight status, weight control behaviors, and body dissatisfaction
International Journal of Eating Disorders
Assessment of eating disorders: Interview or self-report questionnaire?
International Journal of Eating Disorders
Binge eating: Definition and classification
The coming of age of self-mutilation
Journal of Nervous and Mental Disorders
Clarifying the role of impulsivity in bulimia nervosa
International Journal of Eating Disorders
The role of seeing blood in non-suicidal NSSI
Journal of Clinical Psychology
Cited by (52)
Neuroanatomical Correlates of Emotion-Related Impulsivity
2023, Biological PsychiatryThe manifestation of emotional distress: Correlations between self-compassion and self-mutilation in Brazilian women with disordered eating behavior
2022, EncephaleCitation Excerpt :Islam et al. found a prevalence of SMB in suicidal ideation in ED of 20.6% and these higher impulsive behaviors, substance use disorders, and impulse disorders [37]. Peterson and Fischer [38] proposed a model where SMB at baseline was associated with increased purging. Experiencing negative feelings without automatically judging oneself is one of the goals of treatments using the concept of self-compassion.
Multidimensional eating profiles associated with personality traits during emerging adulthood: A cluster-analytic approach
2022, Revue Europeenne de Psychologie AppliqueeMixture Modeling of Nonsuicidal Self-Injury and Binge Eating: Behaviors and Motives
2021, Behavior TherapyImpulsivity as a predictor of self-harm onset and maintenance in young adolescents: a longitudinal prospective study
2020, Journal of Affective Disorders