Danielle, a 23-year-old New York City resident who didn't want to use her full name, knows the pain and frustration of dealing with an eating disorder.
"I remember my whole life, even back to grade school, always wanting to be skinny," she said.
Her battle with an eating disorder started in college with over-exercising, which is a type of bulimia.
"Then, it was the binging and purging for a long time," she said. "And now, I'm not exactly battling bulimia, but I feel like I went to the other side -- anorexia -- because I don't eat as much as I am required to, nutritionally."
Danielle's struggle with her disorder became so bad one night that she cut the upper part of her thighs with a razor.
"I felt like I wanted to relieve pain and frustration," said Danielle.
Now, a study published in the latest edition of the Journal of Adolescent Health has found a link in adolescents between eating disorders and non-lethal, self-injurious behaviors like cutting and burning. It also found that in most cases, clinicians didn't screen for such behaviors.
"Self-injurious behaviors have been shown to be common in adults with eating disorders and in adolescents with bulimia in small studies," said study author Dr. Rebecka Peebles, formerly an instructor at the Stanford University School of Medicine and now an assistant professor at the Children's Hospital of Philadelphia.
Researchers from the Stanford University School of Medicine reviewed the medical records of nearly 1,500 patients between the ages of 10 and 21 who were diagnosed with an eating disorder at an eating disorder clinic over ann 11-year period. Only about 42 percent of them had documentation that they were screened for self-injurious behaviors when they first were seen in the clinic. Of those who had screening documentation, nearly 41 percent admitted to cutting or burning themselves.
The study suggested eating disorders and behaviors like cutting are linked, and also that people with eating disorders need to be more carefully screened for such behaviors.
Self-Injury a Temporary Escape
Experts said the findings help confirm a long-suspected association between the eating disorders and self-injury, and by doing so may improve screening measures.
"It's generally held that these behaviors are fueled by an underlying level of anxiety and they branch out in many different ways," said Dr. Richard Pesikoff, clinical professor of psychiatry at Baylor College of Medicine. "People do a variety of self-soothing behaviors like rocking, picking or cutting."
That anxiety in people with eating disorders, he said, is often very complex and intense.
"The eating soothes the anxiety, but creates a new set of problems," said Pesikoff. "Then they worry about being fat. Then [they] have to resolve that. Then they cut."
The behavior of cutting -- which he said is typically done to the arms -- offers physical relief from emotional pain.
"Cutting produces endorphins that produce an anti-anxiety effect," said Pesikoff.
The experts also said that cutting and burning are methods people with eating disorders use to punish themselves as a result of self-hatred.
More Widespread Screening Is Needed
Peebles thinks one reason many patients may not have been screened is because they didn't fit a certain profile.
"There's a profile of patients who self-injure from the adult literature that's emerged," Peebles said. "There are higher incidences of self-injurious behavior in adults with eating disorders who binge eat or purge, have bulimia nervosa, have a history of abuse or have abused drugs."
The patients who did have documentation of screening were more likely to fit the profile, Peebles said, although she added other patients were screened who did not fit the profile.
Other experts said many clinicians don't know much about cutting other forms of self-injury.
"For a long time, professionals saw these as distinct issues and diagnoses, and for a long time there was a lack of research on cutting [and] self-injury," said Christopher Willard, a psychologist at Tufts University in Boston. "Nowadays, we see more cutting than we did in the past, which is unfortunate. But we also research it more thoroughly, so that hopefully this will mark a change in how we as professionals screen for these behaviors."
Willard said mental health practitioners often focus their attention on the symptoms of eating disorders and overlook other issues.
Peebles hopes the study will encourage more universal screening for self-injurious behaviors.
"We do know that self-injurious behaviors happen more in adolescents with other issues, such as mood disorders or drug abuse, and people with eating disorders often have the same symptoms, so it makes more sense to screen more universally," she said.
Clinicians also should pay special attention to these behaviors if an eating disorder seems to be improving.
"The eating disorder gets better, but cutting may go up, or if the cutting goes down, substance abuse may go up, et cetera," said Willard.
Danielle's doctors and counselors always have asked whether she wanted to hurt herself, and she's very glad they did.
She said she no longer has any desire to go back to that night when she took a razor to her legs in the shower.
"Now I just cry or yell or do whatever works without physically hurting myself," she said.