175 Psychopathological and neurobiological overlap between anorexia nervosa and self-injurious behavior Figure 2b NSSI as a symptom of AN (like it can be a symptom of boulimia nervosa (BN) or borderline personality disorder (BPD)) Alternatively, yet in line with this view, the eating-disordered behavior seen in AN might be seen as a form of NSSI. In this perspective, NSSI would be considered a separate disorder with multiple (interchangeable) expressions. Purging, starvation, food restriction and over-exercising will in this model be in the same line with other forms of self-destructive behavior like for example self-cutting or self-burning. Self-destructive behavior is rewarding and reinforcing (e.g. in providing a relief of negative affect). This reinforcement is enhanced in AN due to the effects of starvation, which might explain why people engaging in eating disordered self-destructiveness tend to stick with the eating disordered behavior instead of changing to other forms of self-destructive behavior. In this model, AN, or the anorexia-related behaviors, can be considered as a form of internalized and positively reinforcing self-destructiveness or NSSI (see figure 2c). Figure 2c AN as a symptom of NSSI (with NSSI being considered as a separate disorder with multiple (interchangeable) expressions) Based on the commonality in epidemiology, comorbidity, clinical features, functionality and neurobiological mechanisms a more fundamental relationship between NSSI and AN does not seem completely arbitrary. If a nosographical approach is conducted there seems to be considNeurobiology Psychology NSSI Neurobiology AN Etiological factors Psychology Excessive excercising Cutting Hair pulling Burning Purging Disorder Clinical expressions Emaciation Cutting Burning Hair pulling Disordered eating behavior (purging etc.) Neurobiology NSSI Etiological factors Psychology Disorder Clinical expressions Emotion regulation Addiction Reward regulation Neurobiology, etiopathogenesis Self-destructiveness General construct Emaciation Purging Burning Intoxication Excessive excercising Clinical expressions Cutting Neurobiology Psychology Common factors Hair pulling Burning Cutting NSSI Neurobiology AN Etiological factors NSSI AN Psychology Excessive excercising Cutting Hair pulling Burning Purging Disorder Clinical expressions Emaciation Cutting Burning Hair pulling Disordered eating behavior (purging etc.) Neurobiology NSSI Etiological factors Psychology Disorder Clinical expressions Emotion regulation Addiction Reward regulation Neurobiology, etiopathogenesis Self-destructiveness General construct Emaciation Purging Burning Intoxication Excessive excercising Clinical expressions Cutting
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