Other Forms of Self-Harm in Eating Disorders Recognizing the Overlap Between Disordered Eating and Non-Suicidal Self-Injury

When we think of self-harm, we often picture behaviors like cutting or burning — physical acts of injuring the body to cope with emotional pain. But for many individuals with eating disorders, self-harm can take other forms — often hidden, socially normalized, or misunderstood.

In fact, many eating disorder behaviors are self-harming in nature, even when they’re not labeled that way.

Understanding how eating disorders and self-harm intersect is essential for providing safe, compassionate, and effective care. These behaviors are not attention-seeking — they are distress signals, often tied to deep emotional pain, trauma, or a need to feel in control.

What Is Self-Harm?

Non-suicidal self-injury (NSSI) refers to the intentional infliction of physical harm to one’s own body without suicidal intent. It's often used as a way to:

• Express emotional pain

• Regulate overwhelming feelings

• Feel a sense of control

• Release shame, anger, or numbness

Common methods include cutting, burning, or hitting oneself — but self-harm is not limited to these.

In the context of eating disorders, self-harming behaviors can look different — but serve similar emotional functions.

Disordered Eating as Self-Harm

Eating disorders involve a range of behaviors that, while often rooted in body image concerns, also serve as coping mechanisms — and, at times, as punishment or self-injury.

1. Restriction as Punishment

• Skipping meals

• Prolonged fasting

• Denying hunger cues

These behaviors may serve to:

• “Earn” a sense of discipline

• Punish oneself for eating, perceived flaws, or emotional distress

• Numb emotions by entering a starvation-induced fog

“I don’t deserve to eat” or “I have to suffer to feel okay” are common internal narratives.

2. Over-Exercising as Control or Self-Punishment

• Exercising despite injury or illness

• Using exercise to “make up” for food

• Feeling extreme distress when unable to exercise

This can be a socially accepted form of self-harm, masked as discipline but rooted in self-criticism or self-erasure.

3. Bingeing and Purging Cycles

• Consuming large amounts of food rapidly, followed by vomiting, laxative use, or fasting

Purging can act as:

• A physical release for emotional pain

• A symbolic erasure of guilt or shame

• A way to cope with trauma or loss of control

Research shows that binge-purge cycles are linked to increased rates of suicidal ideation and co-occurring self-injury (Muehlenkamp et al., 2012).

4. Body Checking and Manipulation

• Obsessive weighing

• Pinching, squeezing, or hitting parts of the body

• Wearing painfully tight clothing to “feel” control

While not always categorized as NSSI, these behaviors can reflect deep-seated self-hatred and punishment patterns, especially when repeated compulsively and associated with distress.

Why the Overlap Happens

There are several reasons why self-harm and eating disorders frequently co-occur:

• Emotion dysregulation: Both behaviors provide temporary relief from overwhelming emotional states (Gratz & Roemer, 2004).

• Dissociation or numbing: Restriction or pain may help people feel “less present” in their bodies or experiences.

• Control: In situations where people feel powerless (trauma, chaos, abandonment), harming the body can create a sense of agency — even if harmful.

• Shame and self-directed anger: Many individuals use self-harming behaviors to express internalized shame, believing they deserve to suffer.

Studies estimate that 25–35% of individuals with eating disorders also engage in non-eating related forms of self-injury, such as cutting or burning (Claes et al., 2015).

Recognizing Less Visible Forms of Harm

Self-harm in eating disorders is not always dramatic or easily recognized. It may look like:

• Deliberately avoiding medical care

• Drinking excessive water to manipulate weight

• Obsessively measuring or body-checking despite distress

• Delaying bathroom use to “punish” oneself

These behaviors may not be labeled as self-injury, but they stem from the same emotional wounds.

How to Approach This in Treatment

1. Use Nonjudgmental Curiosity

Instead of asking, “Why are you doing this?” try:

• “What does this behavior help you feel or avoid?”

• “When did you first start using this to cope?”

• “What need is this meeting right now?”

This reduces shame and opens the door to deeper understanding.

2. Name the Function, Not Just the Form

Recognizing that restriction, purging, or overexercising may serve the same purpose as cutting helps clients see the underlying need — often emotional regulation, not weight loss.

3. Build New Coping Strategies

Help clients develop tools to:

• Soothe distress (grounding, mindfulness, DBT skills)

• Express emotions safely (writing, movement, therapy)

• Cultivate self-compassion in moments of shame

4. Integrate Trauma-Informed Care

Explore the roots of self-harm with care. Many behaviors trace back to unmet needs, abuse, or chronic invalidation. Safety, trust, and pacing are essential.

Final Thought

Not all self-harm looks like wounds on the skin.
Sometimes it looks like skipped meals, purging in silence, or pushing through pain with a smile.

Eating disorders often carry hidden forms of suffering — ones that deserve to be seen, understood, and met with deep compassion.

Healing means not just stopping the behaviors, but learning to meet pain with care, not punishment. And that is possible, one moment — one new choice — at a time.

References

• Muehlenkamp, J. J., Peat, C. M., Claes, L., & Smits, D. (2012). Self-injury and disordered eating: Expressing emotion dysregulation through the body. Suicide and Life-Threatening Behavior, 42(4), 416–425. https://doi.org/10.1111/j.1943-278X.2012.00100.x

• Claes, L., Vandereycken, W., & Vertommen, H. (2015). Self-injury in patients with eating disorders: A review of the literature. Eating Disorders, 22(3), 200–217.

• Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54.

• Svirko, E., & Hawton, K. (2007). Self-injurious behavior and eating disorders: The extent and nature of the association. Suicide and Life-Threatening Behavior, 37(4), 409–421.

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).