Freud stated, “The ego is above all a bodily ego.” (The Ego and the Id, 1923). He took this idea a step further and observed that a meaningful part of the ego is unconscious. Freud always explained psychological development through the bodily organism. He also considered the entire body as an erogenous zone and argued that all sensory organs and deep erogenous zones play a complementary role in arousal and the formation of desire (S. Freud, 1905 Three Essays on the Theory of Sexuality). Thus, the various organs of the body are seen both as erogenous zones and as organs that respond to needs; for example, the mouth is a site of oral pleasure but also the organ used for eating and swallowing.
The ego invests in bodily affective experiences. These affects, meaning motor and sensory images, constitute the source of drives. If the individual’s protective shields are not adequately developed, bodily perception is rejected. In Freud’s article “Beyond the Pleasure Principle” (1920), he stated that for the living organism, protecting itself from excitations is a more important task than understanding them. Generally, when people come to clinics, they present complaints related to their ego—sexual dissatisfaction, sleep problems, eating issues, fatigue, etc. (Penot, Bernard). These patients later describe their complaints as if their bodies did not belong to them. They cannot claim ownership of their bodies enough to see pleasure as legitimate. Their bodies seem to serve someone else, as if the body is centered around another’s pleasure rather than their own.
The opposite is also observed: many patients are dominated by an economy of bodily denial. Here, dangerous and unpleasant realities are denied, and such patterns can be seen in behavior disorders, self-harmers, and pathologies like anorexia. Narcissistic regression onto the body allows the subjective suffering linked to existential experience to be soothed (Debray, Rosine).
The infant’s body and the mother’s body can be considered the only concrete tools through which the first communications are formed. In the first months of life, the infant gradually learns to distinguish between their own body and the mother’s body. From what Melanie Klein called the “depressive position,” the mother begins to be perceived as the other. Freud described the famous experience of satisfaction as the foundation of subjective development, emerging only when reciprocity is present. Maternal satisfaction makes the infant’s satisfaction possible. In anorexia, the opposite dynamic is observed. Ultimately, the infant’s satisfaction encompasses the mother’s satisfaction. How then do we describe satisfaction for the self-injurious individual?
The meaningfulness of the newborn subject will gradually take shape through bodily contact with the mother, made possible by the mother’s responses.
For adolescents, body image acts as a protective boundary. In adolescence—a personal exploration—unintegrated aggressive and libidinal drives create difficulties. Drive energy shifts toward the bodily pole.
Anorexia nervosa and bulimia nervosa present a high risk for self-harm behavior. Self-harm is also frequently seen in individuals with impulse control problems. Obsessive-compulsive behaviors and impulsivity share overlapping psychopathological roots. The coexistence of obsessive-compulsive behaviors and self-harm has been emphasized (Paul et al., 2002). Anorexia nervosa is more related to obsessive-compulsive traits, whereas bulimia nervosa is more often associated with impulse control problems (Thornton & Russell, 1995). In these cases, distinguishing compulsive self-harm from impulsive self-harm is difficult.
Paul and colleagues (2002) examined the phenomenology and prevalence of self-harm in eating disorders. Lifetime prevalence of self-harm was: 35.8% in unspecified eating disorders, 34.3% in bulimia nervosa, and an overall rate of 34.6%. Self-harm was associated with traumatic life events, excessive expression of obsessive-compulsive thoughts and behaviors, dissociation, and high impulsivity—particularly in bulimic patients. Impulsive behaviors are more common in individuals with bulimia nervosa than in those with anorexia.
Yaryura–Tobias and Neziroglu (1978) proposed a relationship between eating disorders and self-mutilation. Favazza and colleagues (1986), based on a survey of 254 individuals, suggested an association between self-injury and eating disorders. Walsh (1988) reported that among 81 randomly selected bulimic patients completing a survey, 27 (33%) had a history of self-injury. Jacobs & Issacs (1986) compared 30 anorexia patients with 20 healthy controls and found that 35% of anorexia patients had a history of self-injury, while none of the controls did. Although methodological limitations exist—such as lack of random sampling, loose inclusion criteria for self-harm, and reliance on single questions—the trend suggests meaningful overlap. In a follow-up study, Winchel (year missing) found self-injury in 39% of hospitalized bulimic patients.
Across eating disorder subgroups, rates of self-harm vary. Garfinkel and colleagues observed that self-harm is more common in bulimic patients than anorexic ones.
Mitchell and colleagues found that among bulimic patients, those who abused laxatives had a 41% self-harm rate, compared to 26% among bulimics without laxative abuse. Some within this subgroup had attempted suicide. Although methodological issues exist, several studies suggest an overlap rate of 25%–40% between eating disorders and self-harm. In clinical settings, these conditions may be underreported because they are often hidden.
Conterio and Lader (1998) described self-injury as the “new anorexia” of our time. They argued that self-injury and eating disorders share similar psychodynamics.
According to them, cutting represents a powerful form of communication, much like self-starvation. Cutting is the “private language” of pain—expressing past and present trauma. It is the body’s scream, the reenactment of violation upon the self (Conterio & Lader 1998; Farber 2000; Nasser 2004; Strong 1998).
Acting-out behaviors are frequently seen in anorexic patients during treatment. Self-harm often appears after narcissistic injuries. These injuries push individuals into regression, leading to intense acting out, treatment refusal, and weight loss below dangerous limits. Behaviors include wrist-cutting, pouring acid on the hand, hitting the head against a wall, or pulling out hair. In self-harm, the archaic, sadistic superego is active. The patient attempts to form a symbiotic relationship with the idealized object (or therapist). In this relationship, the sadistic superego is projected onto the therapist—who is then perceived as rejecting or humiliating. These patients, like borderline or narcissistic patients, often use splitting and projective identification. Bulimic patients also frequently have histories of cutting, especially on their arms.
