Intrusive Thoughts of Self-Harm in Eating Disorders

Fascinating and little known fact:
everyone experiences intrusive thoughts of self-harm.

The distinguishing feature is whether you are distressed about the thoughts or not.

Ask anyone who has walked across a bridge whether the thought of jumping entered their heads and you’ll find almost everyone has experienced those thoughts. Or ask anyone who has a blender in their home if they have thoughts about sticking their hand in it while it is running, and again you’ll find almost everyone has these thoughts. Same for handling sharp knives, running a lawnmower...the list is long.

The thoughts of doing damage to oneself are universal, however it’s the emotional importance and intensity of the thought that has someone with a history of anxiety experiencing a level of horror and panic that may trigger a trauma-induced dissociative state. It’s in that state where actual self-harm may occur. There are a myriad other reasons for its reinforcement and perseveration from there.

Those with anxiety disorders (that includes eating disorders) are prone to thought-induced traumatic states because the amygdala (a structure that is part of the limbic system in the brain responsible for emotions) hijacks the ability to apply conscious thought while registering the intrusive thought.

One empirical examination of the urge to jump when in a high place suggests that this drive to think about harm is really an expression for reinforcing an urge to live. 1 I would frame it more as a drive to increase care and attention, thereby avoiding unnecessary injury or death. The advantage of the intrusive thoughts of self-harm is that they have called needed attention to the person’s actions in and around dangerous objects or places.

Slicing yourself with the knife you carelessly yank from a dishwasher; not paying attention to a ledge when you are on a high cliff; slinging around bits and pieces when you have the blender whirring; or being careless while you whiz around the lawn with a lawnmower, would leave you at greater risk of harm.

Non-anxious people don’t worry when they find themselves thinking about sticking their hand in the blender. They don’t feel rising panic that they would actually do it or any particular horror that the thought has popped up at all. Their dominant conscious thought tends to be “Huh, weird.” or “Intriguing”.

For the anxious person, the intrusive thought takes on a life of its own in the limbic system (the emotional centre of the brain). The limbic system fires up massive a threat response; sends rapid and repeat messages to the orbitofrontal cortex in the brain to scan the environment; and effectively overwhelms cognitive decision-making to the point that the anxious person freezes. It’s as if the harm is already happening to him or her and there is a desperate effort to suppress the highly distressing thought altogether.

That a compulsion might build to follow through on self-harm may occur as an amygdala hijack is a physiologically hyper-aroused state that cannot be maintained. It feels akin to sticking your hand in ice water and being told to hold it submerged as long as possible—eventually you yank that hand out.

In conjunction with being prone to getting lost in one’s own thoughts, negative intrusive thoughts are correlated with subsequent self-harm. 2 But more tellingly, it is the effort to suppress unwanted and intrusive thoughts that correlates strongly with non-suicidal self-injury. As Dr. Sadia Najmi and colleagues at the Harvard Department of Psychology identified:

“People who are highly emotionally reactive experience a high magnitude of aversive thoughts and emotions. To cope with these, they may use any of a host of mental control strategies in the attempt to alleviate the distress associated with these thoughts and emotions…Thought suppression is often a counterproductive strategy...”  3

As the distress and horror builds and the frantic efforts to suppress the intrusive thought exhaust the ability to think, then an inevitable increased drive to resolve the misery results: “Might as well get this over with.”

Thankfully, numerous treatment approaches are helpful in addressing distressing intrusive thoughts of self-harm. Cognitive behavioral therapy is helpful in developing the skill to fire up meta-cognition long before you are in a hyper-aroused dissociative state. 4 Meta-cognition, as a reminder, is our ability to think about our thinking and our feeling as we are experiencing those thoughts and feelings.

Dialectical behaviour therapy and exposure and response prevention are two approaches that have data to support their use in specific sub-populations and reasonable initial data to support their use in navigating the extreme distress of intrusive thoughts of self-harm. 5, 6

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1. Hames, Jennifer L., Jessica D. Ribeiro, April R. Smith, and Thomas E. Joiner. "An urge to jump affirms the urge to live: An empirical examination of the high place phenomenon." Journal of affective disorders 136, no. 3 (2012): 1114-1120.

2. Batey, Helen, Jon May, and Jackie Andrade. "Negative Intrusive Thoughts and dissociation as Risk Factors for Self‐Harm." Suicide and Life-Threatening Behavior 40, no. 1 (2010): 35-49.

3. Najmi, Sadia, Daniel M. Wegner, and Matthew K. Nock. "Thought suppression and self-injurious thoughts and behaviors." Behaviour research and therapy 45, no. 8 (2007): 1957-1965.

4. Slee, Nadja, Nadia Garnefski, Rien van der Leeden, Ella Arensman, and Philip Spinhoven. "Cognitive–behavioural intervention for self-harm: randomised controlled trial." The British Journal of Psychiatry 192, no. 3 (2008): 202-211.

5. Klonsky, E. David, Thomas F. Oltmanns, and Eric Turkheimer. "Deliberate Self-Harm in a Nonclinical Population: Prevalence and Psychological Correlates." Am J Psychiatry 160, no. 8 (2003): 1501-1508.

6. Anderson, Charles B., Frances A. Carter, Virginia V. McIntosh, Peter R. Joyce, and Cynthia M. Bulik. "Self-harm and suicide attempts in individuals with bulimia nervosa." Eating Disorders 10, no. 3 (2002): 227-243.