167 Psychopathological and neurobiological overlap between anorexia nervosa and self-injurious behavior Based on these findings, O’Hara e.a. (2015) (25) formulated a reward-based model of AN. In this model the etiopathophysiology of AN is described as an increased reward responsiveness for and habit formation of anorectic behavior. AN is thought to originate in striatal reward dysfunction, reflected by reward-based learning of stimulus-driven bottom-up processes. Illness-compatible cues become positively associated with reward, while food-related healthy cues lose their rewarding properties, and instead become punishing, a process the authors call ‘reward contamination’. Non-suicidal self-injurious behavior Psychopathology of NSSI As opposed to AN, non-suicidal self-injurious behavior (NSSI) is no disorder or disease category. NSSI is defined as ‘any socially unaccepted behavior involving deliberate and direct destruction of bodily tissue without suicidal intent’ (28-30). Examples of NSSI are skin-cutting, self-hitting, self-burning and scratching. In the DSM-III, NSSI was described as a symptom of emotional and developmental disorders like borderline personality disorder (BPD) and impulse control disorder (31). The DSM-5 has included NSSI in the category ‘Conditions for Further Study’ (7), which, according to Cipriano e.a. (2017) (32), is a first step towards recognizing NSSI as a separate disorder. One of the criteria of NSSI in the DMS-5 is that the behavior attempts to diminish inter- as well as intrapersonal psychological discomfort. Since self-injurious behavior is often studied simultaneously with suicidal behavior, it is difficult to separate findings for NSSI from suicidality. Moreover, self-injurious behavior has been studied under various acronyms (e.g. (non-suicidal) self-injury, self-mutilation, self-harm, deliberate self-harm, parasuicidal behavior) with varying in- and exclusion criteria (with the most prominent variation being the in- or exclusion of suicidal intent), which complicates interpretation of the literature. In this review self-injurious behavior is narrowed down to NSSI and suicidal intent is excluded. NSSI has an onset in early adolescence (12-14 years) and a higher prevalence in women than in men (29, 32). According to a recent systematic review by Cipriano e.a. (2017) (32), NSSI has a prevalence of 4-23% in adults and 7.5-46.5% in adolescents, with wide ranges due to differences in samples and methods. The prevalence rates of NSSI in psychiatric populations are higher: 20% in adult psychiatric populations and 40-80% in adolescent psychiatric populations (29, 33). Because of the association of NSSI with psychiatric conditions (borderline personality disorder, depressive disorder, anxiety disorders, post-traumatic stress disorder, substance abuse and eating disorders) individuals engaging in NSSI are part of a diagnostically heterogeneous population.
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