164 Chapter 8 INTRODUCTION Empirical evidence and clinical observation suggest a strong link between eating disorders (EDs) and non-suicidal self-injurious behavior (NSSI). Up to 72% of patients with EDs also engage in NSSI, and 25-54% of patients that engage in NSSI report comorbid disordered eating (1). In addition, NSSI and EDs share clinical risk factors and there is overlap in motivational and behavioral aspects of both disorders (2), suggesting shared underlying (neurobiological) mechanisms. In our recent study on deep brain stimulation (DBS) as a potential new treatment option for anorexia nervosa (AN) we saw an increase in self-destructive behavior when the eating-disorder symptoms lost their rewarding properties (3) This rose the question how AN and self-destructive behavior are linked, whether there is a shared pathogenesis, and why this potential shared pathogenesis leads to different clinical expressions. On a more fundamental level, we wondered whether the self-starvation of AN-patients, which seems to be an ultimate form of self-destruction, could be considered primarily self-destructive. In this review self-destructive or self-injurious behavior is narrowed down to NSSI and suicidal intent is excluded. As is common in psychiatric practice, therapeutic options often aim at either eating disorder pathology or self-injurious behavior (4, 5). If NSSI and EDs share etiopathogenetic mechanisms, acknowledging them may improve understanding, diagnosis and treatment efficacy. However, research is scarce and there is currently no overview on the neurobiological association between EDs and NSSI. Although all EDs evidently show pathological eating behaviors with related cognitions and emotions, suggesting a common root, there are also significant clinical and etiopathogenic differences between EDs. Since the clinical overlap between self-destructive behavior and one particular eating disorder, namely anorexia nervosa, seems to be the most striking, and most neurobiological evidence is available for AN, we will focus this review on AN. With this narrative review we summarize the literature on the psychopathology and neurobiology of anorexia nervosa (AN) and NSSI and shed new light on their links (6). We propose a new conceptualization of the overlap between AN and NSSI and suggest new approaches to better characterize their relation. Thereby we aim at providing a groundwork for future research and the development of new biological treatment options for AN and NSSI, especially if they are occurring simultaneously.
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