172 Chapter 8 The reward-centered model of AN (25) describing increased activation in striatal (bottom-up) networks and decreased activation in controlling cognitive (top-down) networks, is not only applicable for the engagement in anorectic behavior but also for NSSI. A study into the motivational processing of AN-compatible cues revealed that striatal DA modulation was relevant in the development of automated behavior regulated by the cortico-striatal circuit (58). This is consistent with the reward-based learning model of anorectic behavior and illness compatible cues proposed by the same authors. Furthermore, the model of Liu (2017) (41) shows similarities with the model of O’Hara et al. (2015) (25), since both NSSI and anorectic behavior are initially a way to regulate negative affect, while repeated NSSI and AN-behavior is linked to habitual behavior or reward-associated learning. Figure 1 Claes and Muehlenkamp (2014) distinguish ‘distal’ risk factors that include temperament (high emotional reactivity, negative mood intolerance, anxiety sensitivity) and personality traits (impulsivity, obsessive-compulsive traits, perfectionism), cultural factors, family factors, and traumatic interpersonal experiences, and ‘proximal’ risk factors that include emotion dysregulation, cognitive distortions, low body regard, dissociation, peer pressure/contagion and comorbid psychiatric disorders. It is hypothesized that these risk factors interact with each other and with stressful events and that the internal distress caused by these interactions is regulated by behaviors of NSSI and/or EDs, which in turn can influence or reinforce the proximal risk factors. Stressful Life Event NSSI & Eating Disorder Distal Factors Proximal Factors Behavior Individual Predisposing Factors Temperament High Emotional reactivity Negative Mood Intolerance Anxiety Sensitivity Personality Impulsivity Obsessive-Compulsive Traits Perfectionism Social Predisposing Factors Family Environment Low Emotional Support High Control & Criticism Low Connectedness Traumatic Experiences Emotional, Physical, Sexual Abuse Peer Bullying Cultural Pressures Self-Objectification Unrealistic Body Stereotypes Individualist Cultural Pressures Specific Risk Factors Emotion Dysregulation Low Distress Tolerance Cognitive Distortions Self-Criticism/Guilt Low Self-Esteem Low Body Regard Body esteem/Body Dissatisfaction Body Competence Interceptive Awareness/Alexithymia Body Integrity Dissociation Peer Influence/Contagion Best Friend/Peer Engagement Socialization & Selection Effects Psychiatric Disorders Mood/Anxiety Disorders Post Traumatic Stress Disorder Substance related Disorders Axis II Personality Disorders Figure 1 Claes and Muehlenkamp (2014) distinguish‘distal’risk factors that include temperament (high emotional reactivity, negative mood intolerance, anxiety sensitivity) and personality traits (impulsivity, obsessive-compulsive traits, perfectionism), cultural factors, family factors, and traumatic interpersonal experiences, and ‘proximal’ risk factors that include emotion dysregulation, cognitive distortions, low body regard, dissociation, peer pressure/ contagion and comorbid psychiatric disorders. It is hypothesized that these risk factors interact with each other and with stressful events and that the internal distress caused by these interactions is regulated by behaviors of NSSI and/or EDs, which in turn can influence or reinforce the proximal risk factors.
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