Bulimia nervosa is a serious and possibly life-threatening feeding and eating disorder characterized by chaotic patterns in eating, including periods of caloric restriction/self-starvation and episodes of binging and purging. The prevalence of bulimia nervosa in females ranges from estimates as low as 0.45% to 8.7% in females. In contrast, bulimia nervosa rarely presents in males, with prevalence estimates under 1%.
Individuals diagnosed with bulimia nervosa also experience other mental health concerns that can negatively impact the likelihood of eating disorder recovery. Mood disorders, such as major depressive disorder, commonly co-occur (meaning individuals are diagnosed with both) with eating disorders. In addition, substance use disorders are also frequently diagnosed among individuals with eating disorders, with data from the National Comorbidity Survey Replication indicating that 37% of patients with bulimia nervosa also met diagnostic criteria for a substance use disorder. In addition to diagnoses of mood and substance use disorders, individuals with bulimia nervosa commonly engage in self-harming behaviors.
Self-harm can be defined as the deliberate destruction of body tissue in the absence of conscious suicidal intent. Given how broad this definition is, self-harm can include intentional self-injury via cutting and burning, as well as more culturally sanctioned behaviors such as tattooing and piercing the body. Some authors even consider eating disorder behaviors such as self-induced vomiting, laxative abuse, and exercise to the point of injury to be forms of self-harm. For the purposes of this article, self-harm will be defined as intentional injury to the body via cutting, scratching, and burning that occurs in the absence of suicidal intent. As stated previously, self-harm is common among individuals with eating disorders (including bulimia nervosa); while one in five females and one in seven males will engage in self-harm in a calendar year in the United States, up to 49% of patients with eating disorders engage in self-harm.
Given that such a large proportion of individuals with bulimia nervosa engage in self-harm, it is likely that disordered eating and self-harm share a common function in that they both help individuals cope with difficult emotions. Early traumatic experience could cause difficulties with emotion regulation, and individuals diagnosed with bulimia nervosa often have a history of traumatic experiences such as childhood sexual abuse or emotional abuse. Similarly, a history of trauma is a risk factor for later self-harm. Victims of trauma, particularly victims of sexual trauma/abuse, often experience deep-seated shame and self-hatred as a result of the trauma. Intense feelings of shame could lead to self-punishing behaviors, especially as individuals with bulimia nervosa and individuals who engage in self-harm tend to struggle to process emotions verbally and tend to manifest their pain in physical terms such as through self-harm.
Binge/Purging and Self-harming to Cope with Pain
Bingeing, purging, self-starvation, and self-harm may all serve to numb or “turn the volume down” on emotional pain. While these behaviors may be somewhat “effective” in the moment for numbing difficult emotional experiences or distracting from those feelings, these behaviors can be overutilized and lead to future emotional consequences. For instance, an individual feeling intense anxiety may binge to temporarily distract from the anxiety, but then need to purge to cope with thoughts about the calories consumed. After bingeing and purging, the individual may experience intense shame about “losing control” overeating which then can lead to additional binge/purging or self-harm. If these behaviors serve as an escape from emotion, individuals may eventually struggle to cope with difficult feelings without these self-destructive behaviors. In addition, since bingeing/purging and self-harm are often regarded as shameful, this can perpetuate a vicious cycle where these behaviors, which are used to cope with negative emotions, also cause negative emotional experiences.
This theory of eating-disordered and self-harming behaviors as a means to escape or avoid painful emotions is referred to as the Experiential Avoidance Model. Experiential avoidance, broadly defined, includes any outward or internal behaviors that allow an individual to distract from or escape from unwanted thoughts, emotions, and external experiences. For individuals who binge, purge, and/or self-harm, these behaviors can be a way of distracting from or numbing difficult emotional experiences, and the escape from emotional pain can be powerfully reinforcing. Thus, these behaviors can become an automatic response to difficult emotions or, in the case or purging, difficult physical sensations related to being uncomfortably full.
Common Traits: Intense Emotions and Impulsive Reactions
In fact, individuals with bulimia and individuals who engage in self-harm may share common traits when it comes to coping with emotions. Certain individuals have a tendency to experience emotions at a higher-than-average intensity, with a slow return to normal. For individuals who experience intense and out-of-control emotions, many develop an unwillingness to tolerate emotional distress, which then leads to problematic behaviors intended to control emotions. Given that many individuals with bulimia nervosa also have problems with their moods, it is reasonable to assume that individuals with bulimia nervosa may struggle with controlling emotions. Similarly, individuals who self-harm report experiencing heightened levels of physiological arousal (e.g., racing heartbeat, sweating, shaking, etc.) in response to emotionally intense events. In addition to a general tendency to experience emotions as overwhelming, individuals may develop beliefs that emotions “will not stop” without engaging in problematic behaviors.
In addition to having heightened emotional experiences, individuals with bulimia nervosa and/or self-harming behaviors may have difficulty implementing coping skills at times of high emotional arousal. This can present a problem in psychological treatment; if individuals exhibit normal mood and low anxiety during therapy sessions (where they are learning new skills), these newly learned skills may not be able to be implemented later at times of emotional distress. Individuals in emotional distress may experience a breakdown in problem-solving and have difficulty recalling new coping skills; if they cannot remember the needed coping skills, individuals may revert to quick and automatic strategies to cope with difficult emotions, including bingeing, purging, and/or self-harm. Furthermore, a number of studies have suggested that individuals with bulimia nervosa have difficulties with identifying and recognizing different emotions during times of distress, as do individuals who engage in self-harm which can also make implementing new coping skills difficult; in many forms of therapy, recommended coping skills are emotion-specific and, if individuals cannot identify the emotions they are experiencing, they may not know which coping skill or skills are most appropriate. For instance, coping skills that help with anger may not be effective for someone experiencing intense loneliness; if an individual struggles to identify or misidentifies emotions, he or she may end up selecting coping skills that are unlikely to be helpful in that time of distress.
Moving beyond emotion regulation strategies, individuals with bulimia nervosa and individuals who engage in self-harm share a common temperamental feature of impulsivity. High levels of impulsivity are associated with seeking small but immediate rewards over larger but delayed rewards; thus, in a state of high emotional arousal, the immediate relief associated with engaging in purging or self-harm may outweigh the greater victory of waiting out the urge and learning to tolerate emotions without engaging in self-destructive acts. In fact, individuals with high trait impulsivity may spend less time weighing the negative consequences of a behavior before engaging in it. In addition, one particular aspect of impulsivity, urgency (or the reduced capability to resist impulses during times of emotional distress), has been linked to a variety of experientially avoidant strategies, including both self-harm and bulimic symptoms.
A Solution: Naming and Taming Emotions
While the consequences of bulimia nervosa and self-harm can be severe, hundreds of research studies have identified effective interventions. Recovery is possible if individuals are able to learn and implement coping skills related to understanding emotions and regulating emotions. Recovery is best achieved and maintained with the aid of a therapist or psychologist with training in evidence-based interventions such as cognitive-behavioral therapy or dialectical behavior therapy. A thorough description of the process of recovery from self-harm and/or bulimia symptoms is beyond the scope of this article; only three key interventions will be identified.
A first step is to be able to identify and describe emotions and their associated action urges. An action urge is defined as what the emotion makes someone “want” to do; for instance, the emotion of anger has an action urge to approach, yell, and/or push someone, whereas the emotion of sadness has the action urge to withdraw from others. Individuals struggling with bulimia and/or self-harm can benefit from self-monitoring these behaviors and which emotions typically trigger them. Identifying the emotion and its action urges could inform an alternative way of coping. For instance, instead of cutting in response to feelings of loneliness, the individual could call a friend or go out to a public place where interaction with others could take place. Put another way, it is critical that an individual is able to identify the function of the bulimia symptoms and/or self-harm. For instance, are these behaviors used as calming techniques during times of high anxiety? Or to communicate frustration to others? Once these functions are identified, the individual can begin to utilize alternative coping skills, such as taking a bath or a long walk to calm anxiety or journaling about frustration.
A second key intervention in the treatment of self-harm and bulimia symptoms includes both urge surfing and mindfulness. As mentioned previously, individuals with a long history of self-harm and bulimia nervosa often respond quickly and automatically to stress with these behaviors, believing these behaviors are the only way to make the emotions “stop.” In truth, the majority of emotional experiences, even very intense ones, dissipate within an hour or so. Thus, if an individual is able to “wait out” or “surf” the urge to engage in self-harm or bulimia symptoms, the urge to engage in these behaviors will fade with time. Certain activities can assist in urge surfing, such as playing a musical instrument, crafting, calling a friend to discuss his/her day, or light exercise. It is recommended that these activities be active and engaging and not focused on emotions. For instance, watching a television show is too passive, and calling a friend to discuss the intense emotions of the moment could amplify the emotions. Daily mindfulness activities, where an individual learns to sit quietly and watch thoughts and feelings come and go, reinforce the learning that all moods are temporary.
Finally, individuals who engage in frequent self-harm or bulimia symptoms can learn emotion regulation strategies that reduce vulnerability to times of high emotional arousal. Reducing vulnerability to high emotional arousal involves accumulating positive life experiences that bring joy and fulfillment, mastery of new skills (which improves self-esteem and self-confidence) and “coping ahead.” Coping ahead refers to identifying future stressors that may be triggering and developing a coping plan (ideally, a written one) so the individual will be able to override the automatic impulse to engage in self-harm or bulimia symptoms.
In sum, bulimia nervosa and self-harming behaviors often co-occur, due in no small part to common experiences of intense emotions, difficulties with identifying and regulating emotions, and impulsivity, among other shared characteristics beyond the scope of this article. Individuals engaging in such self-destructive behaviors represent a high-risk and high-needs population. It is clear that individuals who self-harm and individuals with bulimia nervosa share a common difficulty with regulating emotions. Recovery outcomes are promising if individuals are able to access psychological treatment focusing on developing and using coping skills that replace the functions of both sets of problematic behaviors.
About The Author:
Dr. Ashley Higgins is an assistant professor in the Department of Psychology and Counseling at Immaculata University.
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Written – 2018