The Link Between Dissociation, Eating Disorders, and Self-Harm

Many researchers and psychological professionals believe that there is a link between eating disorders and self-harm, though this has been less widely researched than other correlations such as that between eating disorders and substance abuse. Various studies have also indicated a relationship between these two variables and dissociation independently; however, there does not seem to be a comprehensive study covering the correlations between all three variables. The researcher for this study aimed to test the correlation between eating disorders and self-harm and collect new information on the link between all three to further the available data on this topic. Data were also collected and analyzed in order to determine if certain eating disorders are more highly associated with self-harm and dissociation. A correlation was found between all three variables, and anorexia and bulimia were more closely associated with self-harm than binge eating or healthy eating. The data also indicated that those with anorexia and bulimia were more likely to have dissociative experiences than those without eating disorders. It is hoped that the correlation found between dissociative experiences and eating disorders and selfinjury will serve as an impetus for future experimental research to determine if this link is causal or merely correlational. DISSOCIATION, EATING DISORDERS, AND SELF-HARM 4 Dissociation, Eating Disorders, and Self-Harm There are various types of harmful behavior disorders, including eating disorders and self-harm disorders. Within these two conditions are multiple variations as well. According to the newly updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an eating disorder can fall into four main categories: anorexia nervosa, bulimia nervosa, binge eating, and eating disorder not otherwise specified (EDNOS) (American Psychiatric Association, 2013). Non-suicidal self-injury (NSSI) is not listed as a disorder in and of itself in the DSM-V and is therefore not broken down into further categories (American Psychiatric Association, 2013). However, NSSI presents itself in various ways including injuries to the skin (i.e. cutting, burning), injuries to deeper tissues (i.e. hitting oneself or intentional bashing into objects, interfering with the normal healing process), trichotillomania (pulling out one’s hair), and overdosing without suicidal intent (Whitlock, 2010). Though all eating disorders fall under the same main heading, great variation in the symptoms and underlying reasons for such behaviors may exist. Anorexia nervosa consists of excessive weight loss resulting from self-starvation and usually develops in early to middle adolescence (Kaye, Klump, Frank, & Strober, 2000). Body dysmorphia, a person’s inaccurate perception of their physical self, often accompanies this condition (Santrock, 2012). Though those diagnosed with anorexia must weigh less than 85 percent of what is considered normal for their age and gender, they may still view themselves as being overweight and have an overwhelming fear of weight gain. Amenorrhea, defined in the DSM as missing at least 3 menstrual cycles in a row, is also often an adjunct to the disorder (American Psychiatric Association, 2000). Behaviorally, those with anorexia DISSOCIATION, EATING DISORDERS, AND SELF-HARM 5 appear anxious and obsess over weight, food content (i.e. fat or caloric quantity), and exercise. Their obsessions became so overpowering that the victims begin withdrawing from other areas of their lives, especially hobbies and social interaction with others, including friends (Kaye et al., 2000). Bulimia nervosa is an eating disorder characterized by a binge-purge cycle that generally presents in late adolescence to early adulthood. Unlike those with anorexia, people with bulimia are generally able to maintain a healthy body weight, though there is often great fluctuation in weight by day or week (Kaye et al., 2000). Though the mechanisms differ, the preoccupation with food and weight are shared between bulimia and anorexia. Victims of bulimia, however, tend to have more difficulties with impulse control, shame, and guilt (Thompson-Brenner et al., 2008). Many are unable to respond to their emotions in a healthy manner and turn to food for comfort. Like those with binge eating disorder (BED), people with bulimia will consume large quantities of food during a “binge” (Hartman, 2010). While the amount varies per person and depends more on the person’s perception of the event rather than the actual quantity, a typical binge ranges from 1,500 to 3,000 calories (Rosen, Leitenberg, Fisher, & Khazam, 2006). Some binges are greater than this, with reports of greater than 60,000 calories, while others do not medically qualify as a binge (i.e. one cookie); however, as stated earlier, if the person with bulimia views it as such and it results in purging behavior, it qualifies as a binge (Rosen et al., 2006). The next phase of the cycle is the purge. After bingeing, there is a considerable amount of emotional discomfort in addition to the physical distress caused by the binge. Many people report feelings of disgust and guilt. In order to counteract these feelings and avoid drastic weight gain, those with bulimia force themselves to DISSOCIATION, EATING DISORDERS, AND SELF-HARM 6 vomit or take laxatives and diuretics (Hay & Claudino, 2010). The hope is that these measures will reduce the amount of digestion of all the food consumed. Many patients admit to vomiting five to ten or more times per day, and some use up to 50 laxative pills per day (Mehler, 2003). Other purging behaviors include excessive exercise or fasting following a binge (Kaye et al., 2000). In order to be diagnosed with bulimia nervosa, this binge-purge cycle must take place at least two times per week for three months (Wilson & Sysko, 2009). The final maladaptive behavioral pattern that will be addressed is non-suicidal self-injury. It is estimated that over 20 percent of adolescents in the U.S. engage in selfinjurious behaviors at some time (Wilkinson, 2013). The behaviors themselves are similar to those associated with suicidal ideation, but the underlying thoughts differ between the two. Like eating disorder demographics, self-harm is more prevalent in females than males, though the difference is less drastic than that seen in disordered eating. This difference in prevalence may be due to females’ higher likelihood to internalize rather than externalize conflict. Cutting is the most common form of selfinjurious behavior, though many other forms are also employed, often together (Wilkinson, 2013). These other forms include alternative ways to cause bleeding (i.e. scratching, pinching, ripping, or tearing skin), inflicting bruises by hitting objects, carving words into skin, burning, pulling out hair, or overdosing. Patients seen with NSSI offer a varied host of reasons behind their behavior. One of the most common explanations is that the physical pain inflicted by self-harm is able to distract the user from emotional pain. As an adolescent, the person has yet to develop a healthy way in which to deal with strong emotions and instead turns to self-injury to simply distract. DISSOCIATION, EATING DISORDERS, AND SELF-HARM 7 Another explanation commonly heard is that the physical pain is a way to counteract the emotional numbness felt by the user. The patients report a sense of emptiness and distance from themselves and find that physical pain can bring them back to feeling. Still other reasons exist including punishing oneself to escape guilt, trying to make others feel guilty for their actions, drawing attention to their emotional pain to receive help, or even trying to fit in with their peer group. Adolescents who self-injure often want help to stop these behaviors but find it difficult to ask (Wilkinson, 2013). Research has indicated a strong correlation between eating disorders and selfharm, though not much has been done to investigate the link between self-harm and specific eating disorders. This study aimed to highlight any similarities or differences between the correlation of self-harm and anorexia nervosa and that of self-harm and bulimia nervosa. It is believed that these two behavioral disorders (eating disorders and NSSI) are highly linked due to similar underlying conditions such as insecurity, shame, and an inability to deal with emotions in a healthy manner. Further, both appear to be more common in adolescents prone to dissociating in stressful situations, which can often be seen after a traumatic incident. Dissociation is defined in the DSM-IV-R as an interruption in consciousness, identity, environmental awareness, or memory which is normally well integrated in a healthy person (American Psychiatric Association, 2000). Other definitions, like that presented by Pierre Janet in 1889, define dissociation more broadly as the mental mechanism an individual uses after undergoing a serious trauma, indicating its use as a defense mechanism in response to grief (Grave, Rigamonti, Todisco, & Oliosi, 1996). DISSOCIATION, EATING DISORDERS, AND SELF-HARM 8 Dissociative tendencies and states are positively correlated with non-suicidal selfinjury (NSSI) and are a risk factor for its development (Gratz, Conrad, & Roemer, 2002). In fact, a recent study found a statistically significant correlation (rs = .36-.44) between the two (Rallis, Deming, Glenn, & Nock, 2012). Patients commonly share that their behaviors have stemmed from feelings of “dissociation” or “emptiness,” and that they engage in NSSI as a way to feel again (Rallis et al., 2012). Many studies have found that a large portion of adolescents engaging in self-injurious behaviors have been abused during childhood. Other studies found evidence of a connection between abuse during childhood and dissociative tendencies (Yates, Carlson, & Egeland, 2008). It is hypothesized that early abusive experiences “may preclude one from opportunities to learn how to effectively understand, integrate, and use emotional information” (Rallis et al., 2012). With a lack of ability to handle emotions in a healthy manner, children may learn to dissociate in order to cope with the abuse. Altogether, it seems that dissociation is the link between child abuse and the development of NSSI, especially in cases where NSSI is used a tool to regulate emotions and create a sense of affective generativity (Rallis et al., 2012). In the past two decades with the surge in eating disorder awareness, researchers have focused more attention on these issues and have found that those with past traumatic experiences are more likely to develop eating disorders (Vanderlinden & Vandereycken, 1997). As discussed above, when children are abused, they are much more likely to experience dissociative symptoms. Like those engaging in NSSI, people with eating disorders experience dissociative episodes more often than those without eating disorders (Grave et al., 1996). More specifically, dissociation seems to play an especially large role DISSOCIATION, EATING DISORDERS, AND SELF-HARM 9 in patients with bulimia nervosa, possibly due to the binging aspect of the condition (Grave et al., 1996). Many patients admit to feeling separate from their bodies (i.e. dissociating) during episodes of bingeing (La Mela, Maglietta, Castellini, Amoroso, & Lucarelli, 2010). Overall, the objective of this study was to test whether there were statistically significant correlations between dissociative tendencies, intentional self-injury, and eating disorders. The researcher also hoped to obtain results indicating whether or not certain eating disorders were more closely related to self-harm and/or dissociative experiences. The two eating disorders that were focused on are anorexia nervosa and bulimia nervosa, with emphasis also placed on the binge-eating component of bulimia. Research Questions 1. Is there a correlation between dissociation, self-harm, and eating disorders? a. Is there a link between eating disorders and self-harm? b. Are certain eating disorders more closely associated with higher rates of self-harm? c. Is there a link between dissociative tendencies and eating disorders? d. Is a proclivity toward dissociating more closely associated with certain