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Análise Psicológica (2022), 2 (XL): 157-170 doi: 10.14417/ap.1906

Eating disorders and non-suicidal self-injury: Cluster analysis considering

eating pathology, emotion dysregulation, and negative urgency
Sónia Gonçalves* / Sofia Ramalho* / Bárbara C. Machado** / Ana Isabel Vieira***
*
Unidade de Investigação em Psicoterapia e Psicopatologia, Centro de Investigação em Psicologia
(CIPsi), Escola de Psicologia, Universidade do Minho, Braga, Portugal; ** Centro de Investigação
para o Desenvolvimento Humano, Faculdade de Educação e Psicologia, Universidade Católica
Portuguesa, Porto, Portugal; *** Faculdade de Psicologia e de Ciências da Educação, Universidade
do Porto, Porto, Portugal

Abstract: Research on the interplay between eating pathology, emotion dysregulation and negative
urgency is needed to inform intervention approaches for patients with eating disorders and non-suicidal
self-injury. This study aimed to investigate the characterization of patients with eating disorders and
non-suicidal self-injury considering eating pathology, emotion dysregulation and negative urgency.
This cross-sectional study evaluated 73 outpatients with eating disorders and non-suicidal self-injury
(14-55 years; 68 women). A cluster analysis was performed using eating pathology, emotion
dysregulation and negative urgency. Differences between clusters were explored on sociodemographic/
psychological variables, eating disorder diagnostics and past/current non-suicidal self-injury
engagement. Three clusters were identified. Cluster 1 (n=29) (moderate severity) was characterized
by high levels of eating pathology, but moderate emotion dysregulation and negative urgency. Cluster
2 (n=29) (high severity) was characterized by the highest scores in eating pathology, emotion
dysregulation and negative urgency, and included more patients with current non-suicidal self-injury.
Cluster 3 (n=15) (low severity) was characterized by the lowest levels of eating pathology, emotion
dysregulation and negative urgency, and included more patients with past non-suicidal self-injury.
These profiles highlight the importance of emotion dysregulation and negative urgency as treatment
targets for eating disorders patients with current non-suicidal self-injury.
Keywords: Eating disorders, Self-injurious behavior, Emotion regulation, Negative urgency, Cluster
analysis.

Introduction

Definition and prevalence of non-suicidal self-injury in the context of eating disorders

Non-suicidal self-injury (NSSI) is a deliberate self-inflicted damage to the body without suicidal
intent (Klonsky et al., 2011) and it is associated with different forms of mental illness including
eating disorders (ED). According to a meta-analysis published by Cucchi et al. (2016), the average
percentage of patients with a lifetime history of NSSI was 21.8% for anorexia nervosa (AN) and
32.7% for bulimia nervosa (BN). On the other hand, among those with NSSI, 19.4% also reported

Correspondence concerning this article should be addressed to: Sónia Gonçalves, Unidade de Investigação em
Psicoterapia e Psicopatologia, Centro de Investigação em Psicologia (CIPsi), Escola de Psicologia, Universidade
do Minho, Campus de Gualtar, Braga, Portugal. Email: sgoncalves@psi.uminho.pt

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ED symptoms (Muehlenkamp et al., 2012). NSSI is more frequent in binge-eating/purging-type

ED than restricting‐type ED (Davico et al., 2019). Claes and Muehlenkamp (2014) argued that
eating disordered behaviors exist on the continuum of harmful acts with NSSI, with a higher
frequency of NSSI, a greater variety of NSSI methods, and a medical treatment of NSSI being
related to greater ED severity.
According to Claes and Muehlenkamp (2014) the frequent co-occurrence between ED and
NSSI is based on common conditions that include the onset in adolescence or early adulthood and
a female preponderance, difficulties in emotion regulation (Lavender et al., 2015) and impulsivity
(Claes et al., 2015).

Emotion regulation, NSSI and ED

Emotion regulation is a psychological process or capacity involving several dimensions such
as awareness or understanding of one’s emotions, acceptance of emotions experienced, behavioral
control during negative emotional states, and flexible use of emotion modulation strategies (Gratz
& Roemer 2004). The absence of any or all of these dimensions suggests emotion dysregulation
(Gratz & Roemer 2004). Recent evidences regarding emotion dysregulation and NSSI showed
that higher levels of emotion dysregulation were associated with an increased risk of NSSI) among
individuals across different contexts, regardless of age or sex (Wolff et al., 2019; You et al., 2018).
Indeed, a predominant function of NSSI seems to be negative reinforcement. NSSI serves to
provide relief or escape from emotional distress and help to regulate emotions (Nock & Prinstein
2004). In the same line, the Experiential Avoidance Model of NSSI is based on the idea that NSSI
is a negatively reinforced strategy for reducing or ending uncomfortable emotional arousal
(Chapman et al., 2006).
Also, ED are linked to emotion dysregulation. Individuals with ED have been found to show
higher levels of emotion dysregulation compared to healthy controls, specifically lower levels of
emotional awareness, clarity, and recognition (e.g., Lavender et al., 2015; Monell et al., 2018). In
addition, Pisetsky et al. (2017) found that cognitively-oriented symptoms of ED were associated
with emotion dysregulation. Although less studied than NSSI, evidence indicates that some ED
symptoms also serve emotion regulation functions by providing a sense of control over body and
emotions states (Lavender et al., 2015).
Moreover, previous research supports the idea that eating disordered behaviors and NSSI may
act as inadequate forms to regulate emotions. Indeed, both ED and NSSI provide negative
reinforcement in the form of escape from, or distraction from, aversive emotional states (Klonsky
et al., 2011).
In sum, there is some evidence of functional equivalence between ED and NSSI. Findings
revealed that similar intrapersonal such as affect regulation, and interpersonal functions, such as
interpersonal boundaries and autonomy, may be involved in the development and maintenance of
both NSSI and ED behaviors (Muehlenkamp et al., 2019) and previous models of NSSI and ED
behaviors highlight the role of similar emotion regulation deficits (e.g., Muehlenkamp et al., 2012).

Negative urgency, NSSI and ED

Negative urgency refers to the tendency to act impulsively while experiencing extreme aversive
emotions (Whiteside et al., 2005). Individuals with high levels of negative urgency intent to reduce
negative affect with specific behaviors such as binge eating or cutting, increasing the likelihood
of inadequate behaviors through negative reinforcement pathways (Peterson & Fisher 2012).
Therefore, NSSI has been conceptualized as the result of difficulties in impulse control, particularly

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in response to distress (Favazza 1998; Muehlenkamp et al., 2009). Additionally, in a recent study,
negative urgency and difficulties in emotion regulation appeared as predictors of disordered eating
and NSSI (Hasking & Claes 2019).

The present study

Taken together, the existing literature indicates a high co-occurrence of ED behaviors and NSSI,
as well as a considerable mechanistic similarity between these behaviors. However, it is important
to evaluate the meaningful interrelationships between ED, NSSI and some underlying mechanisms
in an integrated model. In addition, the same patients with ED and a history of NSSI may
experience different clinical symptoms and levels of disordered eating, emotion dysregulation and
negative urgency. Therefore, the current study aimed to provide a clinical characterization of
patients with ED and lifetime NSSI behaviors when considering eating pathology, emotion
dysregulation and negative urgency, to explore empirically the severity of cluster of participants
and to investigate how the clinical features and diagnosis were distributed among them.
Exploration of the clusters of patients with both ED and NSSI, based on eating pathology, emotion
dysregulation and negative urgency is relevant, as it can inform targeted and individualized
interventions.
We expect to find distinct clusters of patients with ED who also endorsed in NSSI currently or
in the past. Moreover, we hypothesized that eating pathology, emotion dysregulation and negative
urgency would differentiate the clusters. We intend to contribute to the study of ED and NSSI
considering the role of difficulties in emotion regulation and negative urgency at the presented
ED symptomatology and severity, providing a clinical characterization of ED outpatients.

Method

Participants

Participants of the current study were 73 outpatients with ED who reported a history of
engagement in NSSI. The age of participants ranged between 14 and 55 years old (M=26.42,
SD=9.35) and the mean BMI was 20.30 kg/m2 (SD=5.45). Most participants were women (n=68,
93.2%), single (n=53, 73.6%), students (n=35, 49.3%), had secondary education (n=47, 65.3%)
and related current psychiatric medication use (e.g., benzodiazepines and antidepressants; n=61,
83.6%). The distribution of the sample according to diagnostic group was 25 (32.2%) with AN
restricting type, 7 (9.6%) with AN binge eating/purging type, 20 (27.4%) with BN, 6 (8.2%) with
binge eating disorder (BED), and 15 (20.5%) with other specified ED (OSFED). Forty-five
participants (61.6%) reported engaging in NSSI within the previous several months or more than
a year ago and 28 (38.4%) had injured themselves during the preceding week or month of the
study. On average, participants used more than one method of NSSI (M=2.52, SD=1.43).

Measures

Sociodemographic and Clinical Questionnaire. This questionnaire aims to collect information

on gender, age, marital status, education, occupation, psychiatric medication use, weight, height,
duration of treatment (months; “How long have you been attending to eating behavior

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consultations at the Hospital?”) and duration of the ED (months; “How long has your eating
problem been?”).

Eating Disorder-15. The ED‐15 (Tatham et al., 2015; Portuguese version Rodrigues et al., 2019)
is a brief questionnaire developed to assess eating attitudes over the preceding week through 10
items, using a Likert-type scale ranging from 0 (not at all) to 6 (all the time). Two attitudinal
subscales – weight and shape concerns and eating concerns – and a total attitudinal score are
obtained. Higher scores suggest greater levels of eating psychopathology. Five additional
behavioral items are assessed: binge-eating episodes, self-induced vomiting episodes, laxative
misuse days, eating restraint days and excessive exercise days. In this study, Cronbach’s α were
as follows: total score, α=.92; weight and shape concerns, α=.90; and eating concerns, α=.81.

Difficulties in Emotion Regulation Scale. The Difficulties in Emotion Regulation Scale (DERS;
Gratz & Roemer 2004; Portuguese version Coutinho et al., 2010) is a 36-item questionnaire
developed to assess difficulties within the following dimensions of emotion dysregulation: limited
access to emotion regulation strategies (Strategies); non-acceptance of emotional responses (Non-
acceptance); lack of emotional awareness (Awareness); difficulties controlling impulsive behaviors
when experiencing negative emotions (Impulses); difficulties engaging in goal-directed behavior
when experiencing negative emotions (Goals); and lack of emotional clarity (Clarity). Participants
are asked to indicate how often the items apply to themselves, with responses ranging from 1
(almost never) to 5 (almost always). It is possible to obtain a total score (adding all the 36 items)
and a score for each subscale. Higher scores indicate greater difficulties in emotion regulation. In
this study, we obtained the following Cronbach’s α for the subscales of strategies, α=.92, non-
acceptance, α=.92, awareness, α=.80, impulses, α=.91, goals, α=.90, and clarity, α=.80. Cronbach’s
α for the total score was .96.

UPPS-P Impulsive Behavior Scale – Negative Urgency Subscale. The UPPS-P Negative
Urgency Subscale (Whiteside et al., 2005; Portuguese version Lopes et al., 2013) is a 12‐item
subscale that assesses the tendency to engage in impulsive behaviors under negative affect. Items
are scored on a 4‐point Likert‐type scale ranging from 1 (agree strongly) to 4 (disagree strongly).
Higher scores indicate higher negative urgency. Cronbach’s α in this study was .87.

Self-Injury Questionnaire – Treatment Related. The Self-Injury Questionnaire – Treatment

Related (SIQ-TR; Claes & Vandereycken 2007; Portuguese version Gonçalves 2008) is a self-
report measure that assesses the presence of five methods of NSSI: scratching, bruising, cutting,
burning, and biting (or other). For each method, it is asked how long ago the participant had
engaged in this form of NSSI: a week; a month; several months; more than a year; and never.

Procedure

This study was authorized and approved by the University of Minho Ethics Commission‐
Subcommittee of Ethics for Social and Human Sciences and the Ethics Committee São João
Hospital Centre/Faculty of Medicine, University of Porto. Participants were recruited from an
initial and larger sample of patients with ED. Data collection took place in a public psychiatric
service that provides specialized treatment for ED in the north of Portugal. Participants were all
outpatients and referred for the data collection by clinicians. They were invited to complete self-
report questionnaires by a research assistant before or after the psychiatric consultation.
Information about the research aims and data confidentiality was assured. Participants provided

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written informed consent before participating. Based on the data obtained through the SIQ-TR,
the sample was divided into participants who reported absence of NSSI over their lifetime and
participants with current or past NSSI. For the present study, only participants who reported current
or past NSSI were considered, that is, a total of 73 participants.

Statistical analyses

The statistical analyses were conducted with IBM SPSS Statistics 27.0 (SPSS, Inc., Chicago,
IL). Descriptive statistics examined demographic and clinical characteristics of the sample,
including ED diagnoses and NSSI. A cluster analysis was performed with the total scores of
ED-15, DERS and UPPS-P negative urgency to identify different groups based on eating
psychopathology, difficulties in emotion regulation and negative urgency. First, a hierarchical
cluster analysis, using the between-groups linkage and the squared Euclidean distance, was
performed to estimate the probable number of clusters. Second, a non-hierarchical procedure, the
K-means cluster analysis, was performed to find the optimal cluster solution. In this analysis, the
number of clusters determined by the hierarchical procedure was pre-specified. The Silhouettes
coefficient was also used to measure the goodness of the final cluster solution. This coefficient
allows to verify if the elements within a cluster are similar or cohesive to each other, while the
clusters themselves are different or separated. The Silhouette values range from -1 to +1. In a
good solution, the coefficient close to the value of 1.
One-way analyses of variance (ANOVA) were used to determine differences among the clusters
regarding total scores of ED-15, DERS and UPPS-P negative urgency, as well as regarding age,
BMI, durations of the ED or treatment, and number of methods of NSSI. One-way multivariate
analyses of variance (MANOVA) were used to analyze differences among the clusters in eating
attitudes and dimensions of emotion dysregulation. Kruskal-Wallis tests (χ2) were also used to
analyze differences among the clusters in eating behaviors (ED-15). Finally, Chi-Square tests (χ2)
were conducted to determine the distribution of current (in the preceding week or month of the
study) and past (within the previous several months or more than a year ago) NSSI across clusters.
The relevant assumptions of all statistical analyses were tested; p values<.05 were considered
significant.

Results

Cluster analysis

Based on the total scores of ED-15, DERS and UPPS-P negative urgency, three clusters were
estimated by the hierarchical cluster analysis, which coincided with the optimal solution chosen
by the K-means cluster analysis. The Silhouettes coefficient was used as a measure of the goodness
of the final cluster solution and its mean value was .301 (min. -.086; max. .508), suggesting a fair
fitting. Cluster 1 comprised 39.7% of the sample (n=29), Cluster 2 also included 39.7% of the
sample (n=29) and Cluster 3 represented 20.5% of the participants (n=15). The standardized scores
for the three clusters are presented in Figure 1. Cluster 1 represented the participants with high
ED-15 total scores relative to the sample mean, as well as the participants with lower-than-average
total scores of DERS and UPPS-P negative urgency. Cluster 2 was characterized by participants
with the highest scores in the three variables relative to the sample means. Cluster 3 represented
the participants with the lowest scores in the three variables relative to the sample means.

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Figure 1. Clusters characterized by standardized total scores of ED-15, DERS and UPPS-P
negative urgency
Note. DERS=Difficulties in Emotion Regulation Scale; ED-15=Eating Disorder-15.

Comparison among the clusters

A series of one-way ANOVAs were conducted to test differences among the clusters in the
main variables (Table 1). The results revealed significant differences among the three clusters in
the total scores of ED-15, F(2,70)=22.18, p<.001, DERS, F(2,32)=63.22, p<.001, and UPPS-P
negative urgency, F(2,32)=48.30, p<.001. In pairwise comparisons, the ED-15 total score in
Cluster 1 was significantly higher than in Cluster 3 (mean difference=2.09, p<.001), and the
ED-15 total score in Cluster 2 was also significantly higher than in Cluster 3 (mean
difference=2.59, p <.001). No differences were found between the Clusters 1 and 2 in ED-15 total
score (mean difference=-.50, p=.34). For DERS total score, Cluster 1 scored significantly lower
than Cluster 2 (mean difference=-40.43, p<.001) and scored significantly higher than Cluster 3
(mean difference=19.91, p=.04). Cluster 2 scored significantly higher than Cluster 3 (mean
difference=60.34, p<.001). For UPPS-P negative urgency, Cluster 1 also scored significantly lower
than Cluster 2 (mean difference=-6.38, p<.001) and scored significantly higher than Cluster 3
(mean difference=9.07, p=.04). Cluster 2 scored significantly higher than Cluster 3 (mean
difference=15.45, p<.001).
Additionally, the differences among the clusters in attitudes and eating behaviors, as well as in
the dimensions of emotion dysregulation were analyzed (Table 1). Regarding eating attitudes, the
MANOVA revealed a significant overall effect of the clusters on the subscales of the ED-15,
F(4,138)=9.83, p<.001; Wilk’s λ=.61, partial η2=.22. Univariate ANOVAs indicated that both
weight and shape concerns, F(2,70)=21.29, p<.001, and eating concerns, F(2,70)=14.41, p<.001,
were significantly different among clusters. Post-hoc comparisons suggested that weight and shape
concerns in Cluster 1 were significantly higher than those in Cluster 3 (mean difference=2.19,
p<.001). Weight and shape concerns in Cluster 2 were also significantly higher than those in
Cluster 3 (mean difference=2.73, p<.001). Additionally, eating concerns in Cluster 1 were
significantly higher than those in Cluster 3 (mean difference=1.96, p<.001), as well as eating
concerns in Cluster 2 were significantly higher than those in Cluster 3 (mean difference=2.41,
p<.001). No differences were found between the Clusters 1 and 2 in weight and shape concerns
(mean difference=-.54, p=.35) or eating concerns (mean difference=-.46, p=.54).

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 Table 1
Differences among the clusters in the main variables
Cluster 1 Cluster 2 Cluster 3
(n=29) (n=29 (n=15) Post hoc tests
Cluster 1 Cluster 1 Cluster 2
vs. vs. vs.
M SD M SD M SD Test value Cluster 2 Cluster 3 Cluster 3
ED-15 total score 3.84 1.19 4.35 1.32 1.75 1.21 22.18***a ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
DERS total score 103.71 18.46 144.14 14.11 83.80 26.18 63.22***b Cluster 1<Cluster 2 Cluster 1>Cluster 3 Cluster 2>Cluster 3
UPPS-P negative urgency 33.20 2.980 24.13 6.13 33.88 7.04 48.30***b Cluster 1<Cluster 2 Cluster 1>Cluster 3 Cluster 2>Cluster 3
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ED-15 Weight and shape concerns 3.94 1.37 4.47 1.30 1.74 1.37 21.29***c ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
ED-15 Eating concerns 3.71 1.24 4.16 1.72 1.75 1.20 14.41***c ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
ED-15 Binge-eating episodes 2.35 4.69 3.38 5.12 .07 .26 9.28**d ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
ED-15 Vomiting episodes 3.24 5.91 1.66 3.17 .00 .00 10.40**d ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
ED‐15 Laxative misuse days .86 1.77 .79 2.02 .00 .00 4.00d - - -
ED‐15 Eating restraint days 2.45 2.69 3.34 3.13 .93 2.28 8.74*d ns Cluster 1>Cluster 3 Cluster 2>Cluster 3
ED‐15 Exercise days 1.59 2.49 2.76 3.10 .40 1.30 8.47*d ns ns Cluster 2>Cluster 3
DERS Strategies 23.86 6.16 3.,41 4.01 17.27 6.38 55.44***c Cluster 1<Cluster 2 Cluster 1>Cluster 3 Cluster 2>Cluster 3
DERS Nonacceptance 16.45 5.44 25.69 4.41 15.00 6.87 28.87***c Cluster 1<Cluster 2 ns Cluster 2>Cluster 3
DERS Awareness 17.90 5.14 20.10 5.35 17.07 5.60 2.03c - - -
DERS Impulse 15.69 5.238 24.48 4.06 12.00 5.82 39.05***c Cluster 1<Cluster 2 ns Cluster 2>Cluster 3
DERS Goals 17.31 4.61 21.62 3.74 12.60 4.97 21.86***c Cluster 1<Cluster 2 Cluster 1>Cluster 3 Cluster 2>Cluster 3
DERS Clarity 13.28 4.17 17.83 3.19 9.87 4.02 24.10***c Cluster 1<Cluster 2 Cluster 1>Cluster 3 Cluster 2>Cluster 3
Age 24.21 7.52 28.21 11.40 27.27 7.67 1.42ª - - -
BMI 21.06 5.73 20.16 5.34 19.11 5.22 .65ª - - -
Duration of treatment 29.97 46.20 27.17 46.79 31.33 40.60 .05ª - - -
Duration of the ED 71.69 65.29 83.14 81.43 104.13 72.67 .96ª - - -
Note. DERS=Difficulties in Emotion Regulation Scale; ED-15=Eating Disorder-15. aANOVA (post hoc Gabriel); bANOVA (Welch’s F and post hoc Games-Howell); cMANOVA with
pairwise univariate contrasts (post hoc Gabriel); dKruskal-Wallis test (Mann-Whitney tests with Bonferroni correction). *p<.05; **p<0.01; ***p<.001.

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For eating behaviors, Kruskal-Wallis tests showed significant differences among the clusters
in binge-eating episodes, χ2(2)=9.28, p=.010, vomiting episodes, χ2(2)=10.40, p=.006, eating
restraint days, χ2(2)=8.74, p=.013, and excessive exercise days, χ2(2)=8.47, p=.015. No significant
differences were found among the clusters on laxative misuse days, χ2(2)=4.00, p=.135. Mann-
Whitney tests with Bonferroni correction suggested that participants from Cluster 1 scored
significantly higher than those from Cluster 3 in binge-eating episodes, U=144.50, p=.021,
vomiting episodes, U=120.00, p=.003, and restraint days, U=135.50, p=.026. For excessive
exercise days, no differences were found between the Clusters 1 and 3, U=160.00, p=.077.
Participants from Cluster 2 scored significantly higher than those from Cluster 3 in binge-eating
episodes, U=112.00, p=.002, vomiting episodes, U=112.50, p=.002, eating restraint days,
U=108.00, p=.004, and excessive exercise days, U=117.00, p=.005. No differences were found
between the Clusters 1 and 2 in all eating behaviors.
With respect to the dimensions of emotion dysregulation, the MANOVA revealed a significant
overall effect of the clusters on the six subscales of the DERS, F(12,130)=10.65, p<.001; Wilk’s
λ=.25, partial η2=.50. Except for awareness, F(2,70)=2.03, p=.139, univariate ANOVAs indicated
that strategies, F(2,70)=55.44, p<.001, nonacceptance, F(2,70)=28.87, p<.001, impulse,
F(2,70)=39.05, p<.001, goals, F(2,70)=21.86, p<.001, and clarity, F(2,70)=24.10, p<.001,
were significantly different among clusters. Post-hoc comparisons suggested that participants
assigned to Cluster 1 scored significantly lower than those assigned to Cluster 2 in strategies
(mean difference=-10.55, p<.001), nonacceptance (mean difference=-9.24, p<.001), impulse
(mean difference=-8.79, p<.001), goals (mean difference=-4.31, p<.001) and clarity (mean
difference=-4.55, p<.001). On the other hand, the Cluster 1 scored significantly higher than the
Cluster 3 in strategies (mean difference=6.60, p<.001), goals (mean difference=4.71, p=.003) and
lack of emotional clarity (mean difference=3.41, p=.016). Finally, the Cluster 2 scored significantly
higher than the Cluster 3 in strategies (mean difference=17.15, p<.001), nonacceptance (mean
difference=10.69, p<.001), impulse (mean difference=12.48, p<.001), goals (mean
difference=9.02, p<.001) and clarity (mean difference=9.02, p<.001).
No significant differences were found among the clusters regarding age, BMI and durations of
the ED or treatment (Table 1). Regarding the distribution of the DSM-5 ED diagnostics into each
cluster (Table 2), Cluster 1 included equal proportions of patients with AN restricting type, BN
and OSFED. Most patients in Cluster 2 were diagnosed with BN, followed by patients with AN
restricting type. Cluster 3 did not include participants with AN binge eating/purging-type and most
of the patients in this cluster were diagnosed with AN restricting type.

Table 2
Distribution of the DSM-5 ED diagnostics into each cluster
Cluster 1 Cluster 2 Cluster 3

Diagnosis n % n % n %

OSFED 08 027.6 02 006.9 05 33.3

AN restricting type 08 027.6 09 031.0 08 53.3
AN binge eating/purging type 02 006.9 05 017.2 00 000.0
BN 08 027.6 11 037.9 01 006.7
BED 03 010.3 02 006.9 01 006.7
Total 29 100.0 29 100.0 15 100.0

Note. AN=Anorexia Nervosa; BN=Bulimia Nervosa; BED=Binge Eating Disorder; OSFED=Other Specified Feeding or
Eating Disorders.

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Characteristics of NSSI in each cluster

Chi-square tests were conducted to determine the distribution of current (in the preceding week
or month of the study) and past (within the previous several months or more than a year ago) NSSI
across clusters. A significant relationship was found between cluster membership and engagement
in current or past NSSI, χ2(2)=14.37, p=.001. While in Cluster 2, most participants (n=17, 58.6%)
reported NSSI during the preceding week or month of the study, in Clusters 1 (n=18, 62.1%) and
3 (n=15, 100%), more participants reported NSSI within the previous several months or more
than a year ago.
There were no significant differences among the clusters in number of methods of NSSI,
F(2,70)=.24, p=.79. As outlined in Table 3, the most common method of NSSI in the three clusters
was cutting.

Table 3
Distribution of the methods of NSSI into each cluster
Cluster 1 Cluster 2 Cluster 3
n % n % n %
Method of NSSI Scratching 15.00 51.70 170 58.60 7 46.70
Bruising 13.00 44.80 140 48.30 9 60.00
Cutting 15.00 55.20 180 62.10 9 60.00
Burning 03.00 10.30 050 17.20 4 26.70
Biting 13.00 44.80 120 41.40 5 33.30
Other 10.00 34.50 070 24.10 7 46.70
M SD M SD M SD
Mean number of methods of NSSI 02.41 01.32 02.52 01.55 2.73 01.44
Note. NSSI=Non-suicidal self-injury.

To sum up, Cluster 1, compared to the sample mean, included participants with higher levels
of eating pathology. It was also characterized by lower emotion dysregulation and negative urgency
than Cluster 2, but both higher than Cluster 3. The most frequent diagnoses in this cluster were
AN restricting type, BN and OSFED. Finally, Cluster 1 included more participants with past NSSI.
Cluster 1 was labeled in this study as the “moderate severity cluster”.
Cluster 2 included the participants with the highest scores in the main variables, namely greater
levels of eating pathology, emotion dysregulation and negative urgency than the other clusters.
The most frequent diagnoses in this cluster were BN and AN restricting type. Cluster 2 also
included more participants with current NSSI. It was labeled as the “high severity cluster”.
Cluster 3 included the participants with the lowest levels of eating pathology, emotion
dysregulation and negative urgency. The most frequent diagnosis was AN restricting type, and
this cluster included more participants with past NSSI. Cluster 3 was labeled in this study as the
“low severity cluster”.

Discussion

The aim of the present study was to explore empirical severity clusters with outpatients with
ED and lifetime NSSI regarding ED symptomatology, emotion dysregulation and negative

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urgency. A three-cluster structure has emerged based on the factors considered. These clusters
ranged from a less dysfunctional cluster (low severity) to moderate and highly severity clusters
of patients.
The first cluster, the “moderate severity” cluster, included participants with high levels of eating
pathology but moderate levels of emotion dysregulation and negative urgency. This cluster
included more participants with past NSSI (more than one year) These moderate difficulties,
concerning potential mechanisms underlying ED and NSSI found in this cluster, may be explained
by higher ED symptomatology precisely when NSSI is not a current symptom. In fact, no
differences were found between the clusters 1 (“moderate severity” cluster) and 2 (“high severity”
cluster) on ED-15 total score and on all eating disordered behaviors evaluated (e.g., binge-eating).
The second cluster, the “high severity” cluster, was characterized by high difficulties in emotion
regulation, high ED symptomatology as well as by high negative urgency. Within this cluster there
was the highest prevalence of patients with current NSSI. Although all the patients in this study
reported some kind of NSSI across the lifespan, we found that present NSSI is related with highest
severity in ED symptomatology, what is in accordance with prior literature (Claes &
Muehlenkamp, 2014; Islam et al., 2015). Additionally, within this “high severity” cluster there
was the highest prevalence of patients with BN. This is also consistent with previous studies that
showed that NSSI can be a part of a spectrum of multi-impulsive behaviors that include binging
and purging behaviors, and both NSSI and eating disordered behaviors may represent attempts to
deal and regulate negative emotions (Gómez-Expósito et al., 2016; Muehlenkamp et al., 2012;
Wolff et al., 2019). In sum, the “high severity cluster” might be driven by the comorbid ED
symptomatology. Furthermore, the pathology of this cluster may be related to personality features,
as those with both ED and NSSI seem more likely to have certain comorbidities, such as borderline
personality disorder (Jacobson & Luik, 2014). It also appears that borderline personality disorder
and ED (particularly, binge-eating/purging-type ED) share common risk factors, including
childhood trauma (Sansone & Sansone, 2007), impulsivity and urges of self-harm (Sansone &
Sansone, 2011), and emotion dysregulation (Selby et al., 2009). Then, more studies are needed to
examine personality features as playing a role in the etiology and risk for EDs and NSSI. When
considering treatment for patients who are in this cluster, it is also important to target not only
eating symptomatology but also factors that may be responsible for the current maintenance of
NSSI. Addressing emotion regulation and impulsivity could be an important focus of treatment
in this “high severity” cluster.
The third cluster, the “low severity” cluster, was the one with the lowest scores on ED
symptomatology, emotion dysregulation and negative urgency. This cluster also included more
participants with past NSSI and the highest percentage of patients with AN restricting type. These
results are in line with previous research (e.g., Cucchi et al., 2016) that showed that NSSI is more
prevalent among patients with BN and with AN binge eating/purging type compared to patients
with AN restrictive type.
In sum, the results of the current study describe a three-cluster structure that range from a less
severity and less dysfunctional cluster to a higher severity and dysfunctional cluster. Our intent
was to contribute to a better understanding of NSSI in the context of ED and to a better
individualization of treatment by identifying possible mechanisms underlying both conditions and
levels of severity, such as emotion dysregulation and negative urgency.
This study has several limitations. First, the small number of participants and consequently the
small dimension of participants in each cluster. Second, the sample included most women and
only outpatients with both ED and NSSI. So, the results cannot be generalized to men, to inpatients
or to individuals without NSSI. Future research using cluster analysis may also include ED patients
without NSSI and patients with other types of treatment (e.g., inpatient treatment) to compare
clinical presentations and to understand the impact of treatment on differences among the clusters.

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Third, the fair fitting of the cluster solution and the cross-sectional nature of the study, which
allows us only to draw correlational conclusions from the current results; for future studies, with
larger samples, it will be important to replicate current analyses and to explore longitudinally how
the behaviors and mechanisms evaluated interact during time. Finally, the use of self-report
measures to evaluate behaviors such as NSSI and ED symptoms, as these measures are open to
several biases (e.g., social desirability); for future studies, it will be important to use semi-
structured interviews to better explore and understand both conditions. Despite the limitations, as
far as we know, this study is the first to investigate different clusters among Portuguese outpatients
with ED who have also engaged in NSSI. Thus, this study provides important information about
the distinct features of subgroups with ED and lifetime history of NSSI, and the results suggest
that emotion regulation and impulse control should also be assessed and incorporated in the
interventions, especially among individuals with a more severe ED and current NSSI.

Ethics approval

This study was authorized and approved by the University of Minho Ethics Commission‐
Subcommittee of Ethics for Social and Human Sciences and the Ethics Committee São João
Hospital Centre/Faculty of Medicine, University of Porto.

Declaration of conflicting of interests

The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding

This study was supported by Fundação para a Ciência e a Tecnologia (FCT) through the
Portuguese State Budget (UIDB/01662/2020).

Authors contribution

Conceptualization: SG, BCM, AIV; Methodology: SG, SR, BCM, AIV; Statistical analysis:
SR, AIV; Writing – Review and edit: SG, BCM, AIV.
All the authors read and approved the final manuscript.

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Perturbações do comportamento alimentar e ferimentos autoinfligidos: Análise de clusters

considerando a patologia alimentar, a desregrarão emocional e a urgência negativa
Resumo: A investigação na interação entre patologia alimentar, desregulação emocional e urgência
negativa é necessária para informar as abordagens de intervenção para pacientes com perturbações do
comportamento alimentar e ferimentos autoinfligidos sem intenção suicida. Este estudo teve como
objetivo investigar a caracterização de pacientes com perturbações do comportamento alimentar e
ferimentos autoinfligidos, considerando a patologia alimentar, a desregulação emocional e a urgência
negativa. Este estudo transversal avaliou 73 pacientes em ambulatório com perturbações do
comportamento alimentar e ferimentos autoinfligidos (14-55 anos; 68 mulheres). Uma análise de
clusters foi realizada usando a patologia alimentar, a desregulação emocional e a urgência negativa.
As diferenças entre os clusters foram exploradas nas variáveis sociodemográficas/psicológicas, nos
diagnósticos de perturbação do comportamento alimentar e no envolvimento em ferimentos
autoinfligidos no passado/atualmente. Três clusters foram identificados. O cluster 1 (n=29) (gravidade
moderada) foi caraterizado por elevados níveis de patologia alimentar, mas moderada desregulação
emocional e urgência negativa. O cluster 2 (n=29) (elevada gravidade) foi caraterizado pelas maiores
pontuações na patologia alimentar, na desregulação emocional e na urgência negativa, e incluiu mais
pacientes com ferimentos autoinfligidos atualmente. O cluster 3 (n=15) (baixa gravidade) foi
caraterizado pelos níveis mais baixos de patologia alimentar, desregulação emocional e urgência
negativa, e incluiu mais pacientes com ferimentos autoinfligidos no passado. Estes perfis destacam a
importância da desregulação emocional e da urgência negativa como alvos de tratamento para pacientes
com perturbações do comportamento alimentar e ferimentos autoinfligidos atualmente.
Palavras-chave: Perturbações do comportamento alimentar, Ferimentos autoinfligidos sem intenção
suicida, Regulação emocional, Urgência negativa, Análise de clusters.

Submitted: 05/07/2021 Accepted: 25/01/2022

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