Non-suicidal Self-Injury and Eating Disorders: Dimensions of Self-Harm

  • Laurence ClaesEmail author
  • Jennifer J. Muehlenkamp


Both non-suicidal self-injury (NSSI) and eating disorders (ED) are considered to be harmful behaviors falling within a behavioral spectrum ranging from self-care to self-harm. The high degree of co-occurrence of these behaviors, along with their shared body focus has motivated researchers to investigate and theorize about the potential shared factors driving their comorbidity. In this chapter, we present a conceptual model based upon the current empirical literature depicting distal and proximal psychosocial risk factors shared by NSSI and ED. This model provides a framework for understanding the co-occurrence of NSSI and ED, with the different components being further elaborated on and discussed with regards to treatment recommendations across the different chapters included in this volume. The chapter concludes with a short introduction and summary of each of the chapters within this book.


  1. American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: APA.Google Scholar
  2. Andover, M. S., & Gibb, B. E. (2010). Non-suicidal self-injury attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178, 101–105.CrossRefPubMedGoogle Scholar
  3. Baetens, I., Claes, L., Muehlenkamp, J., Grietens, H., & Onghena, P. (2012). Differences in psychological symptoms and self-competencies in non-suicidal self-injurious Flemish adolescents. Journal of Adolescence, 35, 753–759.CrossRefPubMedGoogle Scholar
  4. Boone, L., Soenens, B., Braet, C., & Goossens, L. (2010). An empirical typology of perfectionism in early-to-mid adolescents and its relation with eating disorder symptoms. Behaviour Research and Therapy, 48, 686–691.CrossRefPubMedGoogle Scholar
  5. Calogero, R. M., Tantleff-Dunn, S., & Thompson, J. K. (Eds.). (2010). Self-objectification in women. Causes, consequences, and counteractions. Washington, DC: American Psychological Association.Google Scholar
  6. Cassin, S. E., & Von Ranson, K. M. (2005). Personality and eating disorders. A decade in review. Clinical Psychology Review, 25, 895–916.CrossRefPubMedGoogle Scholar
  7. Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, 371–394.CrossRefPubMedGoogle Scholar
  8. Claes, L., Houben, A., Vandereycken, W., Bijttebier, P., & Muehlenkamp, J. (2010). Brief report: The Association between non-suicidal self-injury, self-concept and acquaintance with self-injurious peers in a sample of adolescents. Journal of Adolescence, 33, 775–778.CrossRefPubMedGoogle Scholar
  9. Claes, L., Klonsky, E. D., Muehlenkamp, W., Kuppens, P., & Vandereycken, W. (2010). The affect-regulation function of non-suicidal self-injury in eating- disordered patients: Which affect states are regulated? Comprehensive Psychiatry, 51, 386–392.CrossRefPubMedGoogle Scholar
  10. Claes, L., & Muehlenkamp, J. (2013). The relationship between the UPPS-P impulsivity dimensions and non-suicidal self-injury characteristics in male and female high school students. Hindawi Psychiatry Journal, Special Issue NSSI. Google Scholar
  11. Claes, L., Muehlenkamp, J., Vandereycken, W., Hamelinck, L., Martens, H., & Claes, S. (2010). Comparison of non-suicidal self-injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit. Personality and Individual Differences, 48, 83–87.CrossRefGoogle Scholar
  12. Claes, L., Smits, D., & Bijttebier, P. (2013). The Dutch version of the Emotion Reactivity Scale: Validation and relation with temperament, coping and self-harming behaviors in a sample of high school students. European Journal of Psychological Assessment. Google Scholar
  13. Claes, L., Soenens, B., Vansteenkiste, M., & Vandereycken, W. (2012). The scars of the inner critic: Perfectionism and nonsuicidal self-injury in eating disorders. European Eating Disorders Review, 20, 196–202.CrossRefPubMedGoogle Scholar
  14. Claes, L., & Vandereycken, W. (2007). Self-injurious behavior: Differential diagnosis and functional differentiation. Comprehensive Psychiatry, 48, 137–144.CrossRefPubMedGoogle Scholar
  15. Claes, L., Vandereycken, W., & Vertommen, H. (2001). Self-injurious behaviors in eating-disordered patients. Eating Behaviors, 2, 263–272.CrossRefPubMedGoogle Scholar
  16. Claes, L., Vandereycken, W., & Vertommen, H. (2002). Impulsive and compulsive traits in eating disordered patients compared with controls. Personality and Individual Differences, 32, 707–714.CrossRefGoogle Scholar
  17. Claes, L., Vandereycken, W., & Vertommen, H. (2003). Eating-disordered patients with and without self-injurious behaviors: A comparison of psychopathological features. European Eating Disorders Review, 11, 379–396.CrossRefGoogle Scholar
  18. Claes, L., Vandereycken, W., & Vertommen, H. (2004). Family environment of eating-disordered patients with and without self-injurious behaviors. European Psychiatry, 19, 494–498.CrossRefPubMedGoogle Scholar
  19. Claes, L., Vandereycken, W., & Vertommen, H. (2005). Impulsivity-related traits in eating disorder patients. Personality and Individual Differences, 39, 739–749.CrossRefGoogle Scholar
  20. Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress tolerance in eating disorders. Eating Behaviors, 8, 91–97.CrossRefPubMedGoogle Scholar
  21. Croll, J., Neumark-Sztainer, D., Story, M., & Ireland, M. (2002). Prevalence and risk and protective factors related to disordered eating behaviors among adolescents: Relationship to gender and ethnicity. Journal of Adolescent Health, 31, 166–175.CrossRefPubMedGoogle Scholar
  22. Crosby, R. D., Wonderlich, S. A., Engel, S., Simonich, H., Smyth, J., & Mitchell, J. E. (2009). Daily mood patterns and bulimic behaviors in the natural environment. Behaviour Research and Therapy, 47, 181–188.CrossRefPubMedGoogle Scholar
  23. Diliberto, T. L., & Nock, M. K. (2008). An exploratory study of correlates, onset, and offset of non-suicidal self-injury. Archives of Suicide Research, 12, 219–231.CrossRefGoogle Scholar
  24. Ghaderi, A., & Berit, S. (2000). Coping in dieting and eating disorders: A population-based study. Journal of Nervous & Mental Disease, 188, 273–279.CrossRefGoogle Scholar
  25. Glassman, L. H., Weierich, M. R., Hooley, J. M., Deliberto, T. L., & Nock, M. K. (2007). Child maltreatment, non-suicidal self-injury, and the mediating role of self-criticism. Behaviour Research and Therapy, 45, 2483–2490.CrossRefPubMedGoogle Scholar
  26. Glenn, C. R., & Klonsky, E. D. (2010). A multimethod analysis of impulsivity in nonsuicidal self-injury. Personality Disorders: Theory, Research, and Treatment, 1, 67–75.CrossRefGoogle Scholar
  27. Glenn, C. R., & Klonsky, E. D. (2011). Prospective prediction of nonsuicidal self-injury. A I-year longitudinal study in young adults. Behavior Therapy, 42, 751–762.CrossRefPubMedGoogle Scholar
  28. Gollust, S., Eisenberg, D., & Golberstein, E. (2008). Prevalence and correlates of self-injury among University Students. Journal of American College Health, 56, 491–498.CrossRefPubMedGoogle Scholar
  29. Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary data on the Deliberate Self-Harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23, 253–263.CrossRefGoogle Scholar
  30. Halmi, K. A., et al. (2005). The relation among perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder in individuals with eating disorders. International Journal of Eating Disorders, 38, 371–374.CrossRefPubMedGoogle Scholar
  31. Haynos, A., & Fruzetti, A. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science & Practice, 18, 183–202.CrossRefGoogle Scholar
  32. Heath, N. L., Toste, J. R., Nedechava, T., & Charlebois, A. (2008). An examination of nonsuicidal self-injury among college students. Journal of Mental Health Counseling, 30, 137–156.Google Scholar
  33. Hilt, L. M., Nock, M. K., Lloyd-Richardson, E. E., & Prinstein, M. J. (2008). Longitudinal study of an interpersonal model of non-suicidal self-injury among young adolescents. Journal of Early Adolescence, 28, 455–469.CrossRefGoogle Scholar
  34. Hoff, E. R., & Muehlenkamp, J. J. (2009). Nonsuicidal self-injury in college students: The role of perfectionism and rumination. Suicide and Life-Threatening Behavior, 39, 576–587.CrossRefPubMedGoogle Scholar
  35. Hudson, J. I., et al. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61, 348–358.CrossRefPubMedGoogle Scholar
  36. Hutchinson, D. M., & Rapee, R. M. (2007). Do friends share similar body image and eating problems? The role of social networks and peer influences in early adolescence. Behaviour Research and Therapy, 45, 1557–1577.CrossRefPubMedGoogle Scholar
  37. Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, E. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. Journal of Clinical Child and Adolescent Psychology, 37, 363–375.CrossRefPubMedGoogle Scholar
  38. Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.Google Scholar
  39. Kingston, J., Clark, S., & Remington, B. (2010). Experiential avoidance and problem behavior: A mediational analysis. Behavior Modification, 34, 145–163.CrossRefPubMedGoogle Scholar
  40. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.CrossRefPubMedGoogle Scholar
  41. Klonsky, E. D. (2009). The functions of self-injury in young adults who cut themselves: Clarifying the evidence for affect-regulation. Psychiatry Research, 260–268.Google Scholar
  42. Klonsky, E. D. (2011). Non-suicidal self-injury in United States adults: Prevalence, socio-demographics, topography and functions. Psychological Medicine, 41, 1981–1986.CrossRefPubMedGoogle Scholar
  43. Klonsky, E. D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis. British Journal of Psychiatry, 192, 166–170.CrossRefPubMedGoogle Scholar
  44. Klonsky, E. D., Muehlenkamp, J. J., Lewis, S. P., & Walsh, B. (2011). Nonsuicidal self-injury. Canada: Hogrefe.Google Scholar
  45. Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37, 1183–92.CrossRefPubMedGoogle Scholar
  46. Lofthouse, N., Muehlenkamp, J., & Adler, R. (2009). Non-suicidal self-injury and co-occurrence. In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential guide to assessment and treatment (pp. 59–78). New York: Routledge.Google Scholar
  47. Low, G., Jones, D., MacLeod, A., Power, M., & Duggan, C. (2000). Childhood trauma, dissociation and self-harming behavior: A pilot study. British Journal of Medical Psychology, 73, 269–278.CrossRefPubMedGoogle Scholar
  48. Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6(10), 1–9.Google Scholar
  49. Muehlenkamp, J. J., Claes, L., Peat, C., Smits, D., & Vandereycken, W. (2011). Non-suicidal self-injury in eating disordered patients: A test of a conceptual model. Psychiatry Research, 188, 102–108.CrossRefPubMedGoogle Scholar
  50. Muehlenkamp, J. J., Engel, S. G., Wadeson, A., Crosby, R., Wonderlich, S. A., Simonich, H., et al. (2009). Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients. Behaviour Research and Therapy, 47, 83–87.CrossRefPubMedGoogle Scholar
  51. Muehlenkamp, J. J., & Kerr, P. L. (2010). Untangling a complex web: How non-suicidal self-injury and suicide attempts differ. Prevention Researcher, 17, 8–10.Google Scholar
  52. Muehlenkamp, J. J., Kerr, P. L., Bradley, A. R., & Larsen, M. A. (2010). Abuse subtypes evidence and non-suicidal self-injury. Preliminary evidence of complex emotion regulation patterns. Journal of Nervous and Mental Disease, 198, 258–263.CrossRefPubMedGoogle Scholar
  53. Muehlenkamp, J. J., Peat, C., Claes, L., & Smits, D. (2012). Self-injury and disordered eating: Expressing emotion dysregulation through the body. Suicide & Life-Threatening Behavior, 42, 416–425.CrossRefGoogle Scholar
  54. Muehlenkamp, J. J., & Saris-Baglama, R. N. (2002). Self-objectification and its psychological outcomes for college women. Psychology of Women Quarterly, 26, 371–379.CrossRefGoogle Scholar
  55. Muehlenkamp, J. J., Swanson, J. D., & Braush, A. (2005). Self-objectification, risk taking, and self-harm in college women. Psychology of Women Quarterly, 29, 24–32.CrossRefGoogle Scholar
  56. Nada-Raja, S., Skegg, K., Langley, J., Morrison, D., & Sowerby, P. (2004). Self-harmful behaviors in a population-based sample of young adults. Suicide and Life-Threatening Behavior, 34, 177–186.CrossRefPubMedGoogle Scholar
  57. Najmi, S., Wegner, D. M., & Nock, M. K. (2007). Thought suppression and self-injurious thoughts and behaviors. Behavior Research and Therapy, 45, 1957–1965.CrossRefGoogle Scholar
  58. Nelson, A., & Muehlenkamp, J. J. (2012). Body attitudes and objectification in non-suicidal self-injury: Comparing males and females. Archives of Suicide Research, 16, 1–12.CrossRefPubMedGoogle Scholar
  59. Neumark-Sztainer, D., Story, M., Hannan, P. J., Beuhring, T., & Resnick, M. D. (2000). Disordered eating among adolescents: Associations with sexual/physical abuse and other familial/psychosocial factors. International Journal of Eating Disorders, 28, 249–258.CrossRefPubMedGoogle Scholar
  60. Nock, M. K. (2009). Understanding nonsuicidal self-injury. Origins, assessment and treatment. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  61. Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–72.CrossRefPubMedGoogle Scholar
  62. Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology, 76, 28–38.CrossRefPubMedGoogle Scholar
  63. Nock, M. K., Wedig, M. M., Holmberg, E. B., & Hooley, J. M. (2008). The emotion reactivity scale: Development, evaluation, and relation to self-injurious thoughts and behaviors. Behavior Therapy, 39, 107–116.CrossRefPubMedGoogle Scholar
  64. Paxton, S. J., Schutz, H. K., Wertheim, E. H., & Muir, S. L. (1999). Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls. Journal of Abnormal Psychology, 108, 255–266.CrossRefPubMedGoogle Scholar
  65. Peat, C., & Muehlenkamp, J. J. (2011). Objectification, disordered eating, and depression: A test of mediational pathways. Psychology of Women Quarterly, 35, 441–450.CrossRefGoogle Scholar
  66. Peebles, R., Wilson, J. L., & Lock, J. D. (2011). Self-injury in adolescents with eating disorders: Correlates and provider bias. Journal of Adolescent Health, 48(3), 310–313.CrossRefPubMedGoogle Scholar
  67. Preti, A., Girolamo, G., Vilagut, G., Alonso, J., Graaf, R., Bruffaerts, R., et al. (2009). The epidemiology of eating disorders in six European Countries: Results of the ESEMeD-WMH project. Journal of Psychiatric Research, 43, 1125–1132.CrossRefPubMedGoogle Scholar
  68. Prinstein, M. J., Guerry, J. D., Browne, C. B., & Rancourt, D. (2009). Interpersonal models of nonsuicidal self-injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment (pp. 79–98). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  69. Prinstein, M. J., Heilbron, N., Guerry, J. D., Franklin, J. C., Rancourt, D., Simon, V., et al. (2010). Peer influence and nonsuicidal self-injury: Longitudinal results in community and clinically-referred adolescent samples. Journal of Abnormal Child Psychology, 38, 669–682.CrossRefPubMedGoogle Scholar
  70. Rodham, K., & Hawton, K. (2009). Epidemiology and phenomenology of nonsuicidal self-injury. In M. K. Nock (Ed.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association.Google Scholar
  71. Rosenvinge, J. H., Martinussen, M., & Ostensen, E. (2000). The comorbidity of eating disorders and personality disorders: A meta-analytic review of studies published between 1983 and 1998. Eating and Weight Disorders, 5, 52–61.PubMedGoogle Scholar
  72. Serpell, L., Livingstone, A., Neiderman, M., & Lask, B. (2002). Anorexia nervosa: Obsessive–compulsive disorder, obsessive–compulsive personality disorder, or neither? Clinical Psychology Review, 22, 647–669.CrossRefPubMedGoogle Scholar
  73. Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive-behavioural analysis. Behaviour Research and Therapy, 40, 773–791.CrossRefPubMedGoogle Scholar
  74. Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14, 406–414.CrossRefPubMedGoogle Scholar
  75. Smolak, L., & Murnen, S. K. (2002). A meta-analytic examination of the relationship between sexual abuse and eating disorders. International Journal of Eating Disorders, 31, 136–150.CrossRefPubMedGoogle Scholar
  76. Soenens, B., Vansteenkiste, M., Vandereycken, W., Luyten, P., Sierens, E., & Goossens, L. (2008). Perceived parental psychological control and eating-disordered symptoms. Maladaptive perfectionism as a possible intervening variable. The Journal of Nervous and Mental Disease, 196, 144–152.CrossRefPubMedGoogle Scholar
  77. St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-suicidal self-injury: Evidence for a distinction. Psychiatry Research, 197, 78–84.CrossRefPubMedGoogle Scholar
  78. Svirko, E., & Hawton, K. (2007). Self-injurious behavior and eating disorders: The extent and nature of the association. Suicide and Life-Threatening Behavior, 37, 409–421.CrossRefPubMedGoogle Scholar
  79. Swanson, S. A., Crow, S. J., LeGrange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents in the National Comorbidity Survey Replication, Adolescent Supplement. Archives of General Psychiatry, 68, 714–23.CrossRefPubMedGoogle Scholar
  80. Taliaferro, L.A., Muehlenkamp, J.J., Borowsky, I.W., McMorris, B.J., & Kugler, K.C. (2013). Risk factors, protective factors, and co-occurring health-risk behaviors distinguishing self-harm groups: A population-based sample of adolescents. Academic Pediatrics.Google Scholar
  81. Treuer, T., Koperdak, M., Rozsa, S., & Füredi, J. (2005). The impact of physical and sexual abuse on body image in eating disorders. European Eating Disorders Review, 13, 106–111.CrossRefGoogle Scholar
  82. Vanderlinden, J., Vandereycken, W., & Claes, L. (2007). Trauma, dissociation, and impulse dyscontrol: Lessons from the eating disorder field. In E. Vermetten, M. Dorahy, & D. Spiegel (Eds.), Traumatic dissociation: Neurobiology and treatment (pp. 317–333). Arlington: American Psychiatric Publishing.Google Scholar
  83. Walsh, B. W. (2012). Treating self-injury: A practical guide (2nd ed.). New York, NY: Guilford.Google Scholar
  84. Ward, A., Ramsay, R., & Treasure, J. (2000). Attachment research in eating disorders. British Journal of Medical Psychology, 73, 35–51.CrossRefPubMedGoogle Scholar
  85. Washburn, J. J., Juzwin, K. R., Styer, D. M., & Aldridge, D. (2010). Measuring the urge to self-injury: Preliminary data from a clinical sample. Psychiatry Research, 178, 540–544.CrossRefPubMedGoogle Scholar
  86. Wedig, M. M., & Nock, M. K. (2007). Parental expressed emotion and adolescent self-injury. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1171–1178.CrossRefPubMedGoogle Scholar
  87. Whiteside, S. P., & Lynam, D. R. (2001). The five-factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences, 30, 669–689.CrossRefGoogle Scholar
  88. Whitlock, J. L., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117, 1939–1948.CrossRefPubMedGoogle Scholar
  89. Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Abrams, G.B., Barreira, P., et al. (2013). Non-suicidal self-injury as a gateway to suicide in young adults. Journal of Adolescent Health, 52, 486–492.Google Scholar
  90. Whitlock, J., Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G. B., et al. (2011). Non-suicidal self-injury in a college population: General trends and sex differences. Journal of American College Health, 59, 691–698.CrossRefPubMedGoogle Scholar
  91. Wonderlich, S. (2007). The effects of childhood trauma on daily mood lability and comorbid psychopathology in bulimia nervosa. Journal of Traumatic Stress, 20, 77–87.CrossRefPubMedGoogle Scholar
  92. Yates, T. M., Carlson, E. A., & Egeland, B. (2008). A prospective study of child maltreatment and self-injurious behaviour in a community sample. Development and Psychology, 20, 651–671.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Faculty of Psychology and Educational SciencesUniversity of LeuvenLeuvenBelgium
  2. 2.Psychology DepartmentUniversity of Wisconsin Eau ClaireEau ClaireUSA

Personalised recommendations