1. NSSI and Eating Disorders Jessica Garisch & YWS Team © Youth Wellbeing Study

2. Overview Commonalities Research YWS findings to date Shared strategies for therapy Clinical implications Useful resources

3. Commonalities Some researchers include ED in their definition of self-injury Common aetiology? Common (clinically useful) models? Commonalities in therapy? Contagion concerns Societal/media influence Shared (mis)understandings – E.g. “attention seeking” (e.g. “starved for attention” magazine headlines) – “Why don’t you just eat/stop cutting yourself..?” Co-morbidity – Research with eating disordered adult outpatients found 33% reported a history of NSSI (Claes et al., 2013). – Rates of NSSI among adolescent ED outpatients may be higher (e.g. 41%; Peebles, Wilson & Lock, 2010).

4. Theoretical models: Eating Disorders *Key features that cross over with NSSI: PerfectionismLow self-esteem Mood intoleranceSelf-criticism

5. Models of Eating Disorder

6. Eating Disorder: Basic model

7. The Experiential Avoidance Model (EAM) (Chapman, Gratz & Brown 2006)

8. Integrated theoretical model of the development and maintenance of NSSI (Nock, 2010)

9. Physical effects: Anorexia

10. Physical affects of NSSI Tissue damage Insufficient stress response in people who self-injure?* (this research is in it’s infancy) – Reduced cortisol secretion in people who self-injure. Chronic life stressors and trauma can lead to reduced cortisol baseline levels => also reduced baseline levels in individuals who self-injure – Lower in levels of endogenous opioids (and can be restored by NSSI); ?altered stress response. Require more stimulation to attain natural endorphins? Dulled physical response over time? Need to increase severity of NSSI to have similar affects (e.g. on endogenous opioids) (in anorexia there is dulled attention/recognition of physical responses + body adjusts to being low weight..) * See Groschwitz& Plener (2012) for a review

11. Research literature: Some Commonalities Eating DisordersNSSI Perfectionism Self-punishment + low self-esteem Genetic component (have isolated a gene(s))? Genetic component remains unclear Social learning – food rules/body cultureSocial learning? Highest correlate of NSSI is friends/family NSSI ? Modeling of regulation Higher rates of anxiety (related to development of OCD behaviours) Higher rates of anxiety (+ NSSI ↑ Anxiety over time) Increased rates of depression (secondary to eating disorder and as precursor) Increased depressive symptoms among people who self-injure (causality unclear) Bullying a risk factor (teased about weight/shape) Bullying a co-variate (occurs alongside NSSI) Higher in females; peak in teensNo sex differences? Peeks in teen Females more often present to services? Higher rates of trauma or abuse historyNSSI correlated with trauma + abuse history

12. Common themes in therapy Treatment difficulties – Motivation to change (service) identified problem – Ambivalence Including physical assessment Use of CBT/ CBT-E (Fairburn), DBT (Linehan) Chaining techniques (chain incident of NSSI; purge; binge; restricting/skipping meal; body checking, etc.) Use of mindfulness (e.g. mindful eating in bulimia) Focusing on addressing issues of self-worth, perfectionism, secondary/co-morbid issues, incorporating family therapy

13. Clinical Implications Where there is NSSI/ED screen for both Both are coping mechanisms that will need to find a replacement before a client can successfully rid themselves of this behaviour. – In NSSI/ED behaviours change what have they been replaced with? Heterogeneity is key: no one-size-fits all

14. YWS : investigating this relationship We’ve included questions on eating and body concerns in Wave 2 of the longitudinal survey Perhaps this theme will come out in qualitative interviews?

15. Useful Resources (for eating disorder) Central Regional Eating Disorder Service Website http://www.credo-oxford.com www.something-fishy.org Some that EDANZ recommend to families www.feast-ed.org www.aroundthedinnertable.org www.feast-ed.org www.aroundthedinnertable.org www.aedweb.org Here's a short you-tube video on meal support: http://youtu.be/2O9nZAWCkLc

16. Questions? Comments? Thanks for listening