Emotional dysregulation, self-harm and eating disorders: a mechanistic investigation

As many as one in six teenagers have self-harmed at some point, and self-harm is the strongest known risk factor for suicide. Eating disorders are also common, affecting over one-in-twenty adolescent girls. Both self-harm and eating disorders are linked to early death.
Up to half of those with an eating disorder also self-harm. However, we know little about why these mental health conditions often occur together.
One reason might be that some risk factors for eating disorders and self-harm are the same. One characteristic, seen in both conditions, is difficulty managing emotions. However, we do not know whether individuals with an eating disorder find managing emotions difficult because they have an eating disorder, or whether difficulty managing emotions is one of the reasons they develop an eating disorder. Similar gaps in our knowledge exist in relation to people who engage in self-harm; we do not know for certain whether difficulties managing emotions occur before self-harming behaviour starts. One study in adolescents in China suggests difficulty in managing emotions leads to later self-harm, however, little else is known about this area. It is also likely that a number of other factors link difficulties in managing emotions with later self-harm and eating disorders. These factors include difficulties in understanding social situations, difficulties in reading facial expressions, and the experience of being bullied.
To enhance our understanding about the development of self-harm and eating disorders, we have assembled a team of outstanding scientists from two universities.
The proposed research comprises three studies:
1. An analysis of existing data from the Avon Longitudinal Study of Parents and Children (ALSPAC). ALSPAC is a study of over 13,000 children born in and around Bristol in 1991-1992 and followed up since birth with regular questionnaires and clinics. Very few studies have such a large number of people, with such detailed questions collected over time. We will use ALSPAC data to study whether early childhood difficulties in managing emotions is associated with later self-harm and eating disorders. We will also use it to investigate whether ability to understand social situations, to recognise emotions, or the experience of being bullied, are involved in the relationship between difficulties in managing emotions and later self-harm and eating disorders.
2. A two-week, real-time study of patients investigating how emotions are linked, in real-time, to self-harm and eating disorders. We will invite 12-25 year olds who self-harm or have an eating disorder to take part. Participants will complete questions about their self-harm and eating disorders, as well as their ability to recognize emotions. They will then carry a smart phone for a fortnight, to record their experience of emotions and behaviour via a specially designed app. They will be prompted, three times a day, to answer three short questions about their emotions. Each day they will also complete some short questions about their thoughts and behaviours around self-harm and eating disorders. After two weeks, they will return the phone, and after three months they will attend an interview to complete follow-up questions. With their permission, we will use their data to investigate whether difficulty managing emotions in the first fortnight predicts self-harm and eating behavior three months later.
3. A detailed interview study with a sample of Study 2 patients. We will use guided interview techniques to learn about lived experiences of managing difficult emotions, and how this relates to eating disorders and/or self-harm.
These studies will enhance understanding of why people develop eating disorders and/or self-harm. The research could help identify early signs that someone is at risk of self-harm or an eating disorder. It may also help identify to identify new treatment targets for young people who self-harm or have an eating disorder.

Self-harm has a prevalence of 13 - 18% in adolescence. It is associated with a range of adverse outcomes, including increased risk of suicide. Eating disorders have a prevalence of 6% in adolescent girls and a standardised mortality ratio of 2 - 6. There is significant comorbidity: up to 50% of those with an eating disorder self-harm, and 25% of the excess mortality in anorexia nervosa is due to suicide. Yet, we know little about why these mental health conditions co-occur. One possible common precursor is emotional dysregulation, the inability to be aware of, accept, regulate, and modify emotional reactions.

To enhance knowledge about possible aetiological links between emotional dysregulation, eating disorders and self-harm, we propose a mixed-methods investigation with three studies.

Study 1: Using existing data from a large population-based cohort study (ALSPAC), we will investigate associations between childhood emotional dysregulation and later self-harm and eating disorders. We will also investigate three plausible mediators in the pathway between emotional dysregulation and later self-harm and eating disorders: facial emotion recognition, social cognition and bullying.

Study 2: A longitudinal Ecological Momentary Assessment study, in 12-25 year olds with self-harm and/or an eating disorder. Participants will be asked to rate their emotions, thoughts and behaviours on a smart phone, at 4 times each day for a fortnight. They will be followed-up 3 months later.

Study 3: A longitudinal qualitative study, nested within Study 2. We will explore young peoples' experiences of managing difficult emotions, and how these relate to their self-harm and eating disorder behaviour.

This work will advance knowledge of the aetiology of self-harm and eating disorders, and could lead to novel approaches for prevention and treatment.

1) Scientific advancement and impact upon the research community:
The aim of this research is to enhance understanding about the aetiology of eating disorders and self-harm, and particularly how they relate to a common precursor of emotional dysregulation. Given that the personal and economic burden of eating disorders and self-harm is substantial, there is a pressing need for more effective strategies for treatment and prevention. We envisage that the research will assist in the identification of novel treatment targets, as well as potential prognostic markers. The use of EMA in this sample will also pave the way for future studies using this methodology.

2) Service users and families:
Ultimately, we hope that the research will contribute to better prevention and treatment strategies for people who self-harm and also those with eating disorders. In doing so, we hope that it will help to reduce the suffering and accelerate the recovery of people with these common and burdensome mental health conditions. Increasing understanding of the aetiology of these conditions will, we think, also help to reduce the stigma associated with them.

3) Clinical community:
Our findings could lead to the identification of early markers of self-harm and eating disorders risk. This would aid the early identification of young people who are at increased risk of self-harm and eating disorders and enable more efficient targeting of resources to those who are most in need, and most likely to benefit from early intervention. In addition, a better understanding of underlying mediators such as bullying, social cognition and emotion recognition will enable the development of successful novel treatment strategies.

4) Development of capacity and capability:
If funded, the project will support the career development of a talented new PI in the field of eating disorder research (HB), also enabling her to broaden her research experience into the area of self-harm. Our proposal brings together an outstanding multidisciplinary team of academic experts who will be supporting HB throughout the project. Such a partnership is extremely rare, and the infrastructural funding underpinning this partnership will potentially allow our team to develop further competitive proposals tackling the issue of self-harm and eating disorders.
In addition, the two researchers employed on the study will develop new skills through the analysis, write-up and presentation of study findings. These skills will be invaluable in terms of their future career development.