Not All Eating Disorders are the Same When it Comes to Deliberate Self-Harm

Cynthia Bulik, Ph.D.

Cynthia Bulik, Ph.D.

A link between eating disorders (ED) and suicidal behavior has been reported; yet the link is poorly understood. Dr. Cynthia Bulik used her AFSP Distinguished Investigator Grant to learn more by comparing people with different types of eating disorders in terms of deliberate self-harm with or without suicide intent.

Dr. Bulik studied a database from Sweden that included all Swedish-born twins alive in 2005. Combining these data with data sets from the national medical database (National Patient Registry) and the Cause of Death Register, she was able to describe over 13,000 people in terms of eating disorders, other mental health disorders and deliberate self-harm. One unique feature of this study is that the sample size was large enough to look at different types of eating disorders including anorexia, bulimia, binge eating disorder and purging disorder.


• People with eating disorders are at increased risk of deliberate self-harm

• Depression, anxiety, alcohol and substance problems often accompany eating disorders

• Binging and purging are associated with higher risk of deliberate self-injury

• A comprehensive mental health evaluation is an essential component of evaluating and treating people with eating disorders


Deliberate self-harm risk relates to type of eating disorder

People with eating disorders were 1.5–10 times more likely to have been treated for deliberate self-harm than those without an eating disorder. Individuals with anorexia-restricting type had the lowest risk while those with a history of both anorexia and bulimia were at the highest risk. People with bulimia had more deliberate self-harm, were more likely to engage in violent deliberate self-harm behaviors and their self-harm behavior tended to fluctuate with their weight.

Depression, anxiety and alcohol problems are common with DSH

Major depression (MDD) was widespread. Sixty percent of people with anorexia-restricting type had MDD. In the other groups almost 100% of people with deliberate self-harm had depression. People without deliberate self-harm were much less likely to have depression. Deliberate self-harm was also more likely to co-occur with anxiety, alcohol, and other substance use disorders.

Related Publications:

  • Pisetsky EM, Thornton LM, Lichtenstein P, Pedersen NL, Bulik CM. (2013) Suicide attempts in women with eating disorders. J Ab Psychol, 122(4): 1042-1056.
  • Runfola CD, Thornton LM, Pisetsky, Bulik CM, Birgegård. Self-image and suicide in a Swedish national eating disorders registry. Comp Psych, in press.

Dr. Bulik has over 450 published scientific papers.

Dr. Cynthia M. Bulik is the Distinguished Professor of Eating Disorders in the Department of Psychiatry in the School of Medicine at the University of North Carolina at Chapel Hill, a Professor of Nutrition in the Gillings School of Global Public Health, and the Director of the UNC Center of Excellence for Eating Disorders.