European Eating Disorders Review Er. Eat Disonders Ree. 1, 379-36 (2008) abiched online 9 Apel 2003 n We InterScience (www.tercenes. wiley com). BOK 10002/n1510, Paper Eating-disordered Patients With and Without Self-injurious Behaviours: A Comparison of Psychopathological Features Laurence Claes*, Walter Vandereycken and Hans Vertommen Department of Psychology, Catholic University of Leuven, Leuven, Belgium Objective: A considerable numer of eating-disordered patients also display all kinds of self-injurious behaviours (SIB), which might be viewed as an indicator of psychopathological severity Method: To test this hypothesis in 70 females admitted to a specialized treatment programme for eating disorders, a wide spectrum of psychopatho- logical features toas studied by means of self-reporting questionnaires: clinical symptomatology, personality disorders, aggression regulation, trauma history, dissociation and body experience. A comparison was made between patients with (n= 27) and without SIB (n= 43), as well as between patients with one (n=13) versus more types (n= 14) of SIB. Results: In general, patients with STB reported significantly more complaints or signs of anxiety, depression, hostility, cluster B personality disorders, feelings of anger, traumatic experiences, dissociation and negative appreciation of body size. The presence of more than one type of SIB cus linked to a more pronounced clinical symptomatology and trauma history. Copyright © 2003 John Wiley & Sons, Ltd and Eating Disorders Association. INTRODUCTION Like other authors (e.g. Herpertz, 1995) we use the term self-injurious behaviour (SIB) for moderate derangements of the body surface, such as cutting, carving and buming of the skin, Such SIB is defined as a direct, socially unacceptable behaviour that causes minor to moderate physical injury, while the individual is in a psychologically distressed state but is, Correspondence to: Laurence Claes, Catholle University Leuven, Department of Peychology, “Tieneestrant 102, 3000 Leven, Belgiam. Tel 3216-8261 53, Foe + 82-16-32 5916 "Buropean ating Disorder Reo Coprsghe © Ja Wey Sone, Ll aed Eng Detar Asscttn. 5) 379-596 0015)aes etal, Eur. Eat. Disorders Rev. 11, 379-996 (2003) not attempting suicide nor responding to a need for self-stimulation or a stereotyped behaviour (as found in mental redardation or autism). In a considerable frequency SIB has been described in eating-disordered patients (e.g. Favara & Santonastaso, 1998, 2000) for whom it may have many different meanings or functions (Suyemoto, 1998). Those anorectics and bulimics who admitted SIB reported higher levels of general psychopathological dysfunctioning (Claes, Vandereycken, & Vertommen, 2001; Favaro & Santonastaso, 1999). Hence, from a lini ‘viewpoint it is relevant to assume that the presence of SIB could be an indicator of the severity of the psychopathology, as suggested by, Newton, Freeman, and Munro (1993), To test this hypothesis, we have assessed clinical symptomatology, personality disorders, trauma his- ory, dissociation, body experience and aggression regulation in a clinical sample of eating-disordered patients with and without a history of self-injury. Because of the wide variety in forms and frequency of SIB a differentiation within this subgroup is warranted, We did not choose the option of comparing ‘compulsive’ SIB (eg. scratching, nail biting) with ‘impulsive’ SIB (e.g. burning, cutting), as proposed by Favaro and Santonastaso (1998), because of the questionable distinction and the fact that a previous study showed that many patients displayed both types of SIB (Claes et al., 2001). Therefore we decided to split the group according to a clear-cut criterion: the number of reported SIBs. With respect to those patient characteristics thought to be worthy of study, we were inspired by the following findings or questions. With respect to clinical symptomatology, research in other patient samples showed a relation between SIB and antisocial behaviour (e.g. Simeon etal, 1992), increased number of physical illnesses and complaints (e.g. Herpertz, 1995), current sexual dysfunction (e.g, Dulit et al., 1994), and sexual behaviour at high risk for HIV (Diclemente, Ponton, & Hartley, 1991). The finding that SIB is linked to anger and anxiety (e.g. Simeon et al., 1992) has not been confirmed by other researchers (eg, Dulit et al., 1994; Herpertz, 1995). An association with depressive symptomatology is also controversial (e.g. Herpertz, 1995). Although SIB is clearly differentiated from suicide, self-injurers tend to report more suicidal ideation and past suicide attempts independent of their SIB (e.g. Dulit et al,, 1994); this is especially true for those with a borderline personality disorder (Herpertz, 1995). Of all personality disorders the latter is most often associated with SIB (e.g. Langbehn & Pfohl, 1993). Although this association may induce a diagnostic bias (Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992), SIB may be viewed asa marker for severe personality disorder (Simeon et al., 1992). With respect to traumatic experiences and related problems, research has supported an association with SIB: at least half of these patients experience depersonalization and a sense of Copyright 208 Jahn Wiley & Sons id and Eating Disorders Associaton, 380Eur, Eat, Disorders Rev. 11, 379-296 (2008) Self-njurious Behaviours analgesia during the act (Leibenluft, Gardner, & Cowdry, 1987). Furthermore, selfinjurers are more likely to come from families characterized by divorce, neglect, or emotional deprivation (e.g. Pattison, & Kahan, 1983), and often report a history of physical or sexual abuse i childhood (eg. Langbehn & Pfohl, 1993). Last but not least, selft destructiveness and interpersonal violence are two types of aggression. Self-destructiveness is the deliberate attempt to inflict physical harm on oneself and interpersonal violence is the deliberate attempt to cause serious physical injury to other. In spite of the need for studies on the coexistence of these behaviours, the relationship between self-destruc- tiveness and interpersonal violence has received little scientific attention (Hillbrand, 1995), METHOD. Subjects We have gathered data from 70 female inpatients (mean age=21.7 years, ‘SD =6.2 years) admitted to a specialized unit for the treatment of eating disorders. By means of a clinical interview supplemented by the Eating Disorder Evaluation Scale (EDES; Vandereycken, 1993) patients were diagnosed according to DSM-IV criteria (American Psychiatric Associa~ tion, 1994): 32.9 per cent (n= 23) as anorexia nervosa restrictive subtype (AN-R), 25,7 per cent (i= 18) as anorexia nervosa bingeing-purging, subtype (AN-P), and 41.4 per cent (n= 29) as bulimia nervosa (BN). Instruments The following set of self-report instruments was used to assess SIB, clinical symptomatology, personality disorders, trauma history and related problems, and aggression regulation, Questionnaires were completed at admission as a part of the routine assessment. Self-Injury Questionnaire To assess SIB we made use of a newly developed self-reporting instrument, the Self-Injury Questionnaire (SIQ; Claes et al., 2001; see also Vanderlinden & Vandereycken, 1997), Subjects are asked if they have deliberately injured themselves in the past year (hair pulling, scratching, bruising, cutting, burning); if so, they are to specify —for each behaviour separately—how often this happened, if they felt some pain, and what kind of emotional experiences they had at the moment of self-injury (being nervous, bored, angry, sad, scared, or some other feeling). Additionally, they were asked to give some information about the age of (Copyright © 2005 abn Wiley Song, id and Eating Dioner Assocation. 381Eur. Eat. Disorders Rev. 11, 379-896 (2008) injury, the first time such behaviour occurred (calculated from the moment of admission: e.g. in the last 6 months, between 6 and 12 months earlier), the body parts that were injured (e.g. arms and /or hands, legs and /or feet) and, finally, how the self-injurious act was considered (e.g. as an uncontrollable act or as a planned act). Symptom Checklist The Symptom Checklist (SCL-90; Dutch version: Arrindell & Ettema, 1986) is a well-known measure for the assessment of a wide array of psychiatric symptoms. Along with a global measure for psychoncuroti- cism, it measures complaints of (general/phobic) anxiety, depression, somatization, obsessions /compulsions, paranoid ideation and inter- personal sensitivity, hostility, and sleeplessness. Munich Alcohol Test The Munich Alcohol Test (MALT; Dutch version: Walburg & van Limbeek, 1985) was administered to assess several aspects of alcohol abuse such as the admission of alcohol abuse, withdrawal symptoms, and psychological as well as social problems due to the abuse. Suicidal Ideation Scale The 10-item Suicidal Ideation Scale of Rudd (1989) was added to assess suicide risk. ADP-IV questionnaire Aimed at assessing personality disorders, the Dutch ADP-IV ques- tionnaire (Schotie, De Doncker, Vankerckhoven, Vertommen, & Cosyns, 1998) consists of 94 items, which represent the 80 criteria of the 10 DSM- IV personality disorders in a randomized order. The ADP-IV produces a dimensional trait score and a categorical personality diagnosis. The dimensional trait scores (which will be used in this study) are computed by adding the item scores for each of the personality disorders separately, for the three clusters of personality disorders (Cluster A: Paranoid, Schizoid, Schizotypal; Cluster B: Antisocial, Borderline, Histrionic, Narcissistic; Cluster C: Avoidant, Dependent, Obsessive- Compulsive) and for a total trait score Leiden Impulsiveness Scale ‘The Leiden Impulsiveness Scale (State/Trait) (LIS; developed by R. J. Verkes) comprises 25 items: 11 items, supposed to measure impulsive- ness conceived asa trait, were selected out of the Eysenck Impulsiveness ‘Scale (I; Eysenck, Pearson, Easting, & Allsopp, 1985); 14 items focus on impulsiveness as a state and ask which of several impulsive behaviours ‘Copyright © 2008 ohn Wily Sons, Le and Eatog Disondens Aeration, 382Eur, Eat. Disorders Reo. 11, 379-396 (2003) Selfinjurious Behaviow:s were shown during the last week. The behaviours of interest are for example gambling, drinking too much alcohol, fighting, bingeing, and self-injuring (in our data analysis, the latter has been left out of course, to ‘measure impulsiveness in patients with SIB). ‘Traumatic Experiences Questionnaire ‘The Traumatic Experiences Questionnaire (TEQ; Nijenhuis, van der Hart, & Vanderlinden, 1995) lists several kinds of emotional neglect and abuse, physical abuse, sexual abuse (by family members and others), serious family problems (such as alcohol abuse, poverty, psychiatric problems of a family member), decease or loss of a family member, bodily harm, and war experiences. For 28 items the subject is asked to indicate whether he or she has had this kind of experience Dissociation Questionnaire ‘The Dissociation Questionnaire (DIS-Q; Vanderlinden, Van Dyck, Vandereycken, Vertommen, & Verkes, 1993) aims at assessing dissocia- tive experiences: identity confusion and fragmentation (referring to experiences of depersonalization and derealization), loss of control (over behaviour, thoughts and emotions), amnesia (memory lacunas), and absorption Body Attitude Test The Body Attitude Test (BAT; Probst, Vandereycken, Van Coppenolle, & Vanderlinden, 1995) consists of 20 items to be scored on a 6-point scale from ‘always’ (score=5) to ‘never’ (score=0). The higher the score, the more abnormal the body experience. Meaningful subscales are: negative appreciation of body size, lack of familiarity with respondent's own body, and general body dissatisfaction. StateTrait Anger Scale The State-Trait Anger Scale (STAS; Spielberger, Krasner, & Solomon, 1988) includes separate scales measuring two different notions of anger. State~Anger is defined as an emotional state consisting of subjective feelings of tension, annoyance, irritation, fury and rage. The State- Anger seale includes 10 items to be rated on a 4-point Likert scale, where the respondents answer how they feel at a specific moment. Trait-Anger is defined in terms of individual differences among, people in their disposition to perceive a wide range of situations as annoying or frustrating and in their tendency to respond to such situations with marked elevations in State-Anger. The Trait-Anger scale also includes 10 items to be rated on a 4-point Likert scale but here the respondents answer how they feel in general. ‘Copyright 200 Joke Wiley & Son Lid ud Eating Disorders Asoc, 383L. Claes etal ur. Fat. Disorders Rev. 11, 579-396 (2003) Anger Expression Seale The Anger Expression Scale (AX; Spielberger et al., 1988) is designed to judge how people usually react when they feel angry or furious. The scale consists of 24 items, to be rated on a 4-point Likert scale. Two subscales (each of eight items) discriminate between individual differences in the tendency to express anger against other people or objects in the environment (AX/Out) and experiences or feelings of anger which are suppressed (AX/In). The third subscale (eight items) refers to control over feelings of anger and is named AX/Control Aggression Questionnaire The Aggression Questionnaire (AQ; Buss & Perry, 1992) represents an updated and psychometrically improved version of the Buss-Durkee Hostility Inventory (Buss & Durkee, 1957). The final questionnaire consists of 29 items measuring four concepts: physical aggression, verbal aggression, anger, and hostility. Hostility and Direction of Hostility Questionnaire ‘The Hostility and Direction of Hostility Questionnaire (HDHQ; Caine, Foulds, & Hope, 1967) was designed to sample a wide, though not exhaustive, range of possible manifestations of aggression, hostility or punitiveness. It consists of 51 items and comprises five subscales: Urge to Act Out Hostility (AH), Criticism of Others (CO), Projected Delusional or Paranoid Hostility (PH), Self-Criticism (GQ, and Delu- sional Guilt (DG). The first three subscales are summed to form an extrapunitive (blaming others) score, and the latter two added to yield an intropunitive (inwardly directed hostility) score. Furthermore, a Direction of Hostility score (DH) score may be obtained from a formula in which the sum of the three extrapunitive scales (AH +CO-+PH) is balanced by subtracting it from the sum of twice the SC score and the DG score: Direction of Hostility (DH) = (2SC + DG) - (AH + CO + PH). Positive scores thus indicate intropunitiveness, while scores in a negative direction indicate extrapunitiveness. Data analysis To find out whether the proportions of a particular self-injurious act among the different ED subgroups are equal or not, we made use of the likelihood-ratio chi-square statistic (L?; Mood, Graybill, & Boes, 1974). ‘This statistic tested the model with equal proportions among the groups against the model with different proportions among the groups. When the value of L? under the x” distribution proves to be significant, one can reject the null hypothesis that the proportions among the different ‘groups are equal. Differences among the ED patients with and without Copyright © 208 John Wy & Song, Land Rating Dieters Ascton 34Eur. Eat, Disorders Rev. 11, 379-396 (2003) Self-injurious Behaviours SIB with respect to the interval scaled variables were calculated by means of ANOVAs. Post oc comparisons were made by means of Scheffé’s post-hoc tests as provided by SPSS (version 10). RESUI TS Table 1 shows the frequency of the different types of SIB in the three ED subgroups. A total of 27 patients (38.6 per cent)—including six AN-R, five AN-P and 16 BN—admitted to having carried out at least one form of SIB. Nine patients (12.9 per cent) reported hair pulling, 10 scratching. (14.3 per cen), five bruising (7.1 per cent), 22 cutting (31.4 per cent) and eight burning (114 per cent). The differences between the two (hair pulling, bruising) or three (scratching, cutting, burning) diagnostic subgroups for each of these self-injurious acts were not significant (hair pulling: L?=2.27, di 0.13; scratching: L?= 1.70, df=2, p=0.43; bruising: L? = 0.04, df= 1, p=0.84; cutting: L?=2.46, df=2, p=0.29; burning: [= 4.23, df=2, p= 0.12) ‘About half of the 27 self-injurious patients (n= 13) reported only one form of SIB, while the others admitted two or more. At the time of admission, 11.1 per cent (=3) of the patients had injured themselves less than a month ago, 22.2 per cent (1 =6) between 1 and 12 months ccarlier, 29.6 per cent (n =8) between 1 and 5 years previously, and 37 per cent (nt =10) more than 5 years ago. Parts of the body that were mostly injured were arms and hands (n= 19; 704 per cent), head and neck (1=5; 18.5 per cent), legs and feet (= 1, 37 per cent), trunk and belly (n=1, 3,7 per cent), and genitals (x= 1, 3.7 per cent). Only one patient reported that her SIB was planned, whereas the others considered the self-injurious acts as uncontrollable and /or unexpected. 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HL ee aL sys a Ww a Ww a W a WwW — a wae a se) (PEE) US ON ©) as ToL, (@ as t< aust IS OHM a1 EM L. Claes etal araprostp-Gupeo 30) [HGH pue DVddl “XV ‘SVLS 2tn wo IS mom pue pe syOHd yelaap prepueys) saxoos uvat aup jo uostreduto °s a1qUJ, Copyight © 2003 ohn Wiiky Sons, Ll and Eating Disorders Associaton,Self-njurious Behaviours & g = 1509 uae wa a Susp : 00> dy 1150 >in 5004s lec 9 ue 19 Jonson §[ su su 9 G9) ec rs ‘sor ner Hon ow se DOs Dt Ts mp su Lore s 03 18 @D o6 & soaks Bose ace ro) eek sa salud ou uw It wD 6T on ee $T Avmnsoy payafory Bl ors atey 2 Gc @d os v9 sao 0 ws 391 {Copyright © 200 John Way & Sons, Land Rating DiscrersAsssetonL. Claes etal Eur. Bat. Disorders Rev. 179-396 (200) anger-out and anger-control reactions. Furthermore, patients with SIB did not display more verbal or physical aggression on the BPAV than patients without SIB. On the contrary, on the acting-out hostility scale of the BDHI, patients with SB showed higher scores. However, if we climinate the item in this scale which refers to SIB, this statistical significance disappears. Therefore, we can conclude that patients with SIB experienced more angry feclings, but did not show more direct (physical, verbal) aggressive behaviours against others or things. With respect to hostility, described by Buss and Perry (1992) as the cognitive component of aggression, the groups were not differentiated from each other. However, patients with SIB showed much more self-criticism and guilt, and were thus more intropunitive than patients without SIB. A comparison of patients with one versus more types of SIB did not reveal significant differences with respect to anger, hostility and (verbal/ physical) aggressive behaviours against others. The subgroups only differed with respect to anger-control, which was higher in patients with more types of SIB. One should keep in mind here that this concerns control of angry reactions against others but not necessarily against themselves. DISCUSSION ‘The present study shows the frequency of self-injury in different subtypes of ED patients. Thirty-eight per cent of the total group reported atleast one form of SIB: in AN-R 26.1 per cent, in AN-P 27.8 per cent, and in BN 55.2 per cent. These results are in line with other research findings. Jacobs and Isaacs (1986) noted that 35 per cent of AN patients show SIBs, and Mitchell et al. (1986) reported SIB in 40.5 per cent of BN patients. Furthermore, in accord with several other authors (eg. Favaro & Santonastaso, 2000; Welch & Fairburn, 1996), our results do not show any significant differences in SIB frequencies among the AN and BN subgroups. In contrast to other authors (e.g. Favaro & Santonastaso, 2000), who show that impulsive SIB such’as skin cutting is more frequent in AN-P than in the AN-R, we did not find any significant difference between the AN-R and the AN-P group. Eating-disordered patients with SIB show more clinical symptoma- tology—anxiety, depression, and hostility—than patients without SIB. Furthermore, within the SIB group, the highest scores on clinical symptomatology were found among those patients who carried out more than one type of SIB. Therefore, we may conclude that the number of SIBs can be considered an index for the severity of clinical symptomatology. This finding is also confirmed by the fact that patients Copyright 200 Joh Wey & Sons 1 and Eating Disorder Asin, 392Eur, Bat, Disorders Rev. 11, 379-396 (2003) Selfinjurious Behaviours with STB report more suicidal ideation than those without SIB. This was also noted by Hillbrand (1995): ‘In spite of the differences between SIB and suicidal behaviour, these two forms of aggression against sclf coexist frequently. Suicidal behaviour has been estimated to occur in 50 per cent to 90 per cent of self-injurious individuals’. Furthermore, we found that cating-disordered patients with SIB show more cluster B (borderline, antisocial) personality disorders than those without SIB. However, within the SIB group, no difference was found between those with one or more types of SIB. Herpertz (1995) found that the borderline personality disorder was present in 52 per cent of the SIB patients. The histrionic personality disorder was the second most frequent diagnosis but occurred in only 23 per cent of the subjects. The patients in Herpertz’s study did not show a high degree of aggression although antisocial personality disorder was diagnosed in 15 per cent of the subject ‘Thesame can be said about our patients withSIB: they show more features of the antisocial personality disorder, but on direct measures of aggressive behaviour they do not score higher than the patients without SIB (as will be discussed below). This can be explained by the fact that patients with SIB indeed do not display more aggressive behaviours against others than patients without SIB. On the other hand, the phenomenon of social desirability might have distorted our findings: it is to be expected (and perhaps even more soin eating-disordered patients who value being liked by others) that aggressive behaviours are underreported (On our measures of aggression, SIB patients report much more anger than those without SIB. But with respect to the aggressive behaviours against others, they do not differ from patients without SIB except for the acting-out hostility scale of the BDHI, which was higher for the SIB patients. However, if we eliminate the item which refers to SIB this statistical significance disappears. The same results concerning anger ‘were found by Hillbrand (1995) who reported that selF-injuring patients are generally more angry as well as more verbally and physically aggressive than non-SIB patients (based on observational assessments). ‘Again, the fact that we found less aggressive behaviour in our patients can be due to the fact that our results are based on a self-report questionnaire, in which social desirability can play a distorting role. Furthermore, we found—in the same way as Bennum (1983)—that self injurious patients show a stronger degree of self-abasement and self- criticism, including guilt and self-punitiveness, than patients without SIB. From these findings one may conclude that SIB patients tum their anger against themselves (and not against others) because of guilt feelings and self-punitiveness as is often described in the literature (imeon & Hollander, 2001). However, one can also hypothesize that patients feel guilty and have to punish themselves after they have injured [Copyright 208 John Wiley & Sons Lid and Eating Diarders Associaton 3931, Claes etal Bur. Eat. Disorders Reo. 11, 379-396 (2008) themselves. Therefore, we think it is important in further research to clearly differentiate between feelings before and after self-injury. Our findings provide further confirmation of the strong association between self-destructive behaviour and childhood histories of emo- tional, physical and sexual abuse (Simeon & Hollander, 2001): the more SIB the greater the likelihood of self-reported traumatic experiences in the past, especially sexual abuse. Furthermore, patients with SIB report many more dissociative experiences. Although it is difficult to elucidate the real nature of the linkage, our findings seem to converge into some association between SIB, dissociative experiences and trauma history (see also Vanderlinden & Vandereycken, 197). According to Herpertz (1995), SIB itself includes overwhelming affect: dysphoria, anger, despair, anxiety etc. that cannot be controlled and mastered. She tends to conclude that SIB develops out of strong uncontrolled affect rather than out of urging drives and impulses to act. She therefore supports the concept of sclf-damaging acts as a form of affect regulation. In Herpertz’s view poor affect regulation in SIB patients is the underlying psychopathological dimension resulting in dysphoria and rejection sensitivity as well as severe disturbance of personality such as borderline personality disorder and co-morbidity with eating disorders, substance abuse or other behaviour control problems. Our own research points in the same direction: the eating-lisordered SIB patients report more angry feelings, psychiatric symptoms, borderline and antisocial personality features, and more severe trauma histories, Last but not least we have to consider the hypothesis of impulse ‘dyscontrol as the basic mechanism, because our patients with SIB report higher impulsiveness measured as a trait (‘acting without thinking’). This is supported indirectly by the tendency to show more borderline features and the fact that SIB is more often found in bulimic patients, compared to restricting anorectics (Favaro & Santonastaso, 1998; Favazza, De Rosear, & Conterio, 1989; Lacey, 1993; Welch & Fairburn, 1996). But the impulse dyscontrol hypothesis seems to be contradicted by a lack of difference in scores on measures of aggressiveness. This, however, could be due to an underreporting of socially disapproved behaviours especially in patients who wish to please others and avoid criticism. 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