Brief report
Self-injurious behavior and attempted suicide in purging bulimia nervosa: Associations with psychiatric comorbidity

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Abstract

Background

Few studies, to date, have investigated the relationship between self-damaging behavior and the presence of comorbid psychiatric diagnoses in eating disorders. The aim of the present study was to investigate the axis I and II comorbidity in subjects with bulimia nervosa who report self-injurious behavior and/or suicide attempt.

Methods

The subjects were 95 patients with purging type bulimia nervosa who underwent a clinical evaluation assessing the presence of self-injurious behavior and suicide attempts, comorbidity for axis I and II psychiatric disorders and temperament.

Results

No axis I diagnosis was associated with any type of self-injurious behavior, whereas social phobia and bipolar disorder were linked to attempted suicide. Significant independent predictors of impulsive self-injurious behavior were the presence of childhood sexual abuse, high harm avoidance scores, and high self-transcendence scores, whereas childhood sexual abuse, the presence of a cluster B personality disorder, and a low self-directedness were predictors of suicide attempts. Compulsive self-injurious behavior was significantly associated with harm avoidance and cluster C personality disorders. Harm avoidance was also associated with skin picking.

Conclusions

Personality disorders are a frequent correlate of the presence of SIB in purging bulimia nervosa. However, temperament seems to play a more important role. Further studies on larger samples are necessary to confirm our findings in bulimia nervosa and to extend them to other patient populations.

Introduction

Eating disorders (ED) are associated with a significantly increased risk for self-injurious behavior (SIB) and suicide attempts (Welch and Fairburn, 1996, Favaro et al., 2007). Few studies, to our knowledge, have investigated the relationship between suicidal and other self-damaging behavior and the presence of comorbid psychiatric diagnoses in ED. Suicide attempts are more frequently reported by ED subjects who purge and those with a comorbidity with affective disorders, substance use disorders, and cluster B personality disorders (Favaro and Santonastaso, 1997, Franko et al., 2004, Milos et al., 2004, Stein et al., 2004). Dimensional studies have found that nonsuicidal SIB can be grouped into two main dimensions: impulsive and compulsive (Favaro and Santonastaso, 1998, Favaro and Santonastaso, 2000). It is probable that the first dimension is linked with impulse-control disorders and/or cluster B personality disorders and the second with obsessive–compulsive disorder and/or cluster C personality disorders. However, no studies to date have explored the psychiatric comorbidity of ED samples with SIB. In a recent study performed on a community sample of young women, Favaro et al. (2007) found that a group of behaviors – skin picking and self-biting – loaded on a third dimension. Although skin picking has many characteristics in common with the other types of compulsive SIB (Lochner et al., 2002), it also showed important differences. Similarly to impulsive SIB, skin picking causes direct harm to the skin and revealed itself be significantly associated with childhood sexual abuse (Favaro et al., 2007).

The aim of the present study was to investigate the axis I and II comorbidity in subjects with bulimia nervosa (BN) who report SIB and/or suicide attempts.

Section snippets

Subjects

The subjects were 95 ED patients recruited among those consecutively referred to the Outpatients ED Units of the Universities of Naples, Milan, Pisa and Padua (Italy). As described in a previous study (Monteleone et al., 2006), patients were eligible for the study if they met the DSM-IV criteria for lifetime purging type BN, with self-induced vomiting as the main compensatory behavior, and were older than age 18. Mean age was 23.6 years (SD = 4.3) and mean duration of illness 65.5 months (SD = 

Univariate analyses

Table 1 shows the frequency suicide attempts, SIB, axis I and II psychiatric diagnoses. Impulsive SIB was significantly associated with a diagnosis of a personality disorder of the B cluster (65% vs. 33%; χ2(1) = 8.59; p = 0.003), especially the borderline personality disorder (65% vs. 30%; χ2(1) = 10.47; p = 0.001). No axis I diagnosis was significantly associated with impulsive SIB. Hair pulling/nail biting did not show any significant association at univariate analyses, whereas skin picking was

Discussion

The present study confirms some important data about the factors associated with suicide attempts and SIB in BN. In addition, it represents the first study to analyse the axis I and II comorbidity associated with SIB in a sample of ED subjects. We found that none of the different types of SIB was specifically associated with an additional axis I disorder. On the contrary, a history of suicide attempts was associated with social phobia and bipolar disorder. These findings confirmed previous data

Acknowledgment

Funding for this study was provided by MIUR Grant MM06493915; the MIUR had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. (MIUR = Ministero dell'Università e della Ricerca).

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Cited by (0)

All authors contributed to the design of the study and in writing the protocol. All those from the Department of Neurosciences of the University of Padua managed the literature searches and analyses. Angela Favaro and Paolo Santonastaso undertook the statistical analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

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