SELF-INJURY AND EATING PATHOLOGY
You must be 18 years or older to participate in this research.
Yes, I am 18 years or older.

What is your age? Years

What is your gender?
 Male
Female

What country do you currently reside in?

What ethnic background do you identify with?

Do you want the results of this research sent to you?
 Yes
No 

If yes, please provide a contact name and address so these can be sent to you:
Name:
Postal address:       
or
E-mail address:


SECTION 1
Below are a number of statements that describe ways in which people act and think. For each statement, please indicate how much you agree or disagree with the statement. If you Agree Strongly select 1, if you Agree Somewhat select 2, if you Disagree somewhat select 3, and if you Disagree Strongly select 4.  Be sure to indicate your agreement or disagreement for every statement below.

Item Description
Agree
Strongly
Agree
Somewhat
Disagree
Somewhat
Disagree
Strongly
 
1
2
3
4
1. I have a reserved and cautious attitude toward life.
2. I have trouble controlling my impulses.
3. I generally seek new and exciting experiences and sensations.
4. I generally like to see things through to the end.
5. My thinking is usually careful and purposeful.
6. I have trouble resisting my cravings (for food, cigarettes, etc.).
7. I'll try anything once.
8. I tend to give up easily.
9. I am not one of those people who blurt out things without thinking.
10. I often get involved in things I later wish I could get out of.
11. I like sports and games in which you have to choose your next move very quickly.
12. Unfinished tasks really bother me.
13. I like to stop and think things over before I do them.
14. When I feel bad, I will often do things I later regret in order to make myself feel better now. 
15. I would enjoy water skiing.
16. Once I get going on something I hate to stop.
17. I don't like to start a project until I know exactly how to proceed.
18. Sometimes when I feel bad, I can’t seem to stop what I am doing even though it is making me feel worse.
19. I quite enjoy taking risks.
20. I concentrate easily.
21. I would enjoy parachute jumping.
22. I finish what I start.
23. I tend to value and follow a rational, "sensible" approach to things.
24. When I am upset I often act without thinking.
25. I welcome new and exciting experiences and sensations, even if they are a little frightening and unconventional.
26. I am able to pace myself so as to get things done on time.
27. I usually make up my mind through careful reasoning.
28. When I feel rejected, I will often say things that I later regret.
29. I would like to learn to fly an airplane.
30. I am a person who always gets the job done.
31. I am a cautious person.
32. It is hard for me to resist acting on my feelings.
33. I sometimes like doing things that are a bit frightening.
34. I almost always finish projects that I start.
35. Before I get into a new situation I like to find out what to expect from it.
36. I often make matters worse because I act without thinking when I am upset.
37. I would enjoy the sensation of skiing very fast down a high mountain slope.
38. Sometimes there are so many little things to be done that I just ignore them all.
39. I usually think carefully before doing anything.
40. Before making up my mind, I consider all the advantages and disadvantages.
41. In the heat of an argument, I will often say things that I later regret.
42. I would like to go scuba diving.
43. I always keep my feelings under control.
44. I would enjoy fast driving.
45. Sometimes I do impulsive things that I later regret.


SECTION 2
This questionnaire contains a number of statements describing the way people behave and feel. You are asked to rate yourself on these statements by selecting the number that best describes how characteristic or uncharacteristic each statement is of you.

For example:

1.   At parties, I like to talk to everyone ....................................................................... 1  2  3  4  5
2.   I like to spend most of my time alone...................................................................... 1  2  3  4  5

In the above examples, you would select the number “5” for the first statement, if you think the item is very like you.  If the second statement is moderately unlike you, you would select the number “2”.

For each statement in the questionnaire, select the number that best describes you.  Answer every statement, even if you are not completely sure of your response.

NOTE:  Some of the questions may describe situations and circumstances that are not familiar to you.  Please try to imagine how you would react and answer accordingly.  If you are a student, please consider school as employment in the questions referring to employment.


Item Description
Very
Unlike Me
Moderately
Unlike Me
Somewhat Like And Unlike Me
Moderately Like Me
Very
Like Me
 
1
2
3
4
5
1. I usually do jobs systematically step by step.
2. I do jobs thoroughly even if no one else will ever see them.
3. When I see things out of place, I have an almost uncontrollable urge to put them back.
4. I do everything to the best of my ability.
5. I try to keep everything in its proper place.
6. I do everything thoroughly.
7. I put all of my efforts into every task I do.
8. I am happiest when my time is carefully organized.
9. I spend a lot of time making sure that everything is exactly the way it should be.
10. I spend hours trying to make everything as exact as possible.
11. I measure everything precisely, never relying on estimates.
12. I do my best even if others do not expect it.
13. When things are a mess I have to tidy them up straight away.
14. I like to do things very methodically.
15. I like attending to small details.
16. I cannot tolerate a mess.


SECTION 3
This questionnaire asks about a number of different things that people sometimes do to hurt themselves. Please be sure to read each question carefully and respond honestly. Often, people who do these kinds of things to themselves keep it a secret, for a variety of reasons. However, honest responses to these questions will provide us with greater understanding and knowledge about these behaviours and the best way to help people. Please answer yes to a question only if you did the behaviour intentionally, or on purpose, to hurt yourself. Do not respond yes if you did something accidentally (e.g., you tripped and banged you head on accident).

1. Have you ever intentionally (i.e., on purpose) cut your wrist, arms, or other area(s) of your body (without intending to kill yourself)?         
 No (go to Question 2)
Yes 

If yes,
1a. How old were you when you first did this? Years     
1b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
1c. When was the last time you did this?
1d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
1e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


2. Have you ever intentionally (i.e., on purpose) burned yourself with a cigarette?         
 No (go to Question 3)
Yes 

If yes,
2a. How old were you when you first did this? Years     
2b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
2c. When was the last time you did this?
2d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
2e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


3. Have you ever intentionally (i.e., on purpose) burned yourself with a lighter or a match?         
 No (go to Question 4)
Yes 

If yes,
3a. How old were you when you first did this? Years     
3b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
3c. When was the last time you did this?
3d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
3e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


4. Have you ever intentionally (i.e., on purpose) carved words into your skin?         
 No (go to Question 5)
Yes 

If yes,
4a. How old were you when you first did this? Years     
4b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
4c. When was the last time you did this?
4d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
4e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


5. Have you ever intentionally (i.e., on purpose) carved pictures, designs, or other marks into your skin?         
 No (go to Question 6)
Yes 

If yes,
5a. How old were you when you first did this? Years     
5b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
5c. When was the last time you did this?
5d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
5e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


6. Have you ever intentionally (i.e., on purpose) severely scratched yourself, to the point that scarring or bleeding occurred?         
 No (go to Question 7)
Yes 

If yes,
6a. How old were you when you first did this? Years     
6b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
6c. When was the last time you did this?
6d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
6e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


7. Have you ever intentionally (i.e., on purpose) bit yourself, to the extent that you broke the skin?         
 No (go to Question 8)
Yes 

If yes,
7a. How old were you when you first did this? Years     
7b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
7c. When was the last time you did this?
7d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
7e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


8. Have you ever intentionally (i.e., on purpose) rubbed sandpaper on your body?         
 No (go to Question 9)
Yes 

If yes,
8a. How old were you when you first did this? Years     
8b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
8c. When was the last time you did this?
8d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
8e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


9. Have you ever intentionally (i.e., on purpose) dripped acid onto your skin?         
 No (go to Question 10)
Yes 

If yes,
9a. How old were you when you first did this? Years     
9b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
9c. When was the last time you did this?
9d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
9e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


10. Have you ever intentionally (i.e., on purpose) used bleach, comet, or oven cleaner to scrub your skin?         
 No (go to Question 11)
Yes 

If yes,
10a. How old were you when you first did this? Years     
10b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
10c. When was the last time you did this?
10d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
10e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


11. Have you ever intentionally (i.e., on purpose) stuck sharp objects such as needles, pins, staples, etc. into your skin, not including tattoos, ear piercing, needles used for drug use, or body piercing?         
 No (go to Question 12)
Yes 

If yes,
11a. How old were you when you first did this? Years     
11b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
11c. When was the last time you did this?
11d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
11e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


12. Have you ever intentionally (i.e., on purpose) rubbed glass into your skin?         
 No (go to Question 13)
Yes 

If yes,
12a. How old were you when you first did this? Years     
12b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
12c. When was the last time you did this?
12d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
12e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


13. Have you ever intentionally (i.e., on purpose) broken your own bones?         
 No (go to Question 14)
Yes 

If yes,
13a. How old were you when you first did this? Years     
13b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
13c. When was the last time you did this?
13d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
13e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


14. Have you ever intentionally (i.e., on purpose) banged your head against something, to the extent that you caused a bruise to appear?         
 No (go to Question 15)
Yes 

If yes,
14a. How old were you when you first did this? Years     
14b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
14c. When was the last time you did this?
14d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
14e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No


15. Have you ever intentionally (i.e., on purpose) punched yourself, to the extent that you caused a bruise to appear?
 No (go to Question 16)
Yes 

If yes,
15a. How old were you when you first did this? Years     
15b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
15c. When was the last time you did this?
15d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
15e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


16. Have you ever intentionally (i.e., on purpose) prevented wounds from healing?
 No (go to Question 17)
Yes 

If yes,
16a. How old were you when you first did this? Years     
16b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
16c. When was the last time you did this?
16d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
16e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


17. Have you ever intentionally (i.e., on purpose) picked your skin to the point that bleeding or scarring resulted?
 No (go to Question 18)
Yes 

If yes,
17a. How old were you when you first did this? Years     
17b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
17c. When was the last time you did this?
17d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
17e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


18. Have you ever intentionally (i.e., on purpose) pulled out hair from your head, face or body?
 No (go to Question 19)
Yes 

If yes,
18a. How old were you when you first did this? Years     
18b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
18c. When was the last time you did this?
18d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
18e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


19. Have you ever intentionally (i.e., on purpose) bitten your nails to the point where they became inflamed, bled, or caused scarring?
 No (go to Question 20)
Yes 

If yes,
19a. How old were you when you first did this? Years     
19b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
19c. When was the last time you did this?
19d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
19e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


20. Have you ever intentionally (i.e., on purpose) ground your teeth together?
 No (go to Question 21)
Yes 

If yes,
20a. How old were you when you first did this? Years     
20b. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
20c. When was the last time you did this?
20d. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
20e. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


21. Have you ever intentionally (i.e., on purpose) done anything else to hurt yourself that was not asked about in this questionnaire?
 No (go to next section)
Yes 

If yes,
21a. What did you do to hurt yourself?
21b. How old were you when you first did this? Years     
21c. How many times have you done this? (please write an actual number (e.g., 1, 5, or 15 NOT some, many, or few)
21d. When was the last time you did this?
21e. How many years have you been doing this? If you are no longer doing this, how many years did you do this before you stopped? (please write the actual number of years you engaged in this behaviour). Years  
21f. Has this behaviour ever resulted in hospitalisation or injury severe enough to require medical treatment?
 Yes  No 


SECTION 4
Answer each question by selecting the appropriate number. Please respond to each question as honestly as possible.

1. I am satisfied with my eating patterns.
Agree
Neutral
Disagree a little
Disagree
Disagree strongly

2. Would you presently call yourself a "binge eater"?
Yes, absolutely
Yes
Yes, probably
Yes, possibly
No, probably not

3. Do you feel you have control over the amount of food you consume?
Most or all of the time
A lot of the time
Occasionally
Rarely
Never

4. I am satisfied with the size and shape of my body.
Frequently or always
Sometimes
Occasionally
Rarely
Never

5. When I feel that my eating behaviour is out of control, I try to take rather extreme measures (strict dieting, fasting, laxatives, diuretics, self-induced vomiting, vigorous exercise) to get back on course.
Always
Almost always
Frequently
Sometimes
Never or my eating behaviour is never out of control

5.a. Please indicate which measure/s you use:
 strict dieting fasting laxatives diuretics self-induced vomiting vigorous exercise

6. I use laxatives or suppositories to help control my weight.
Once a day or more
3-6 times a week
Once or twice a week
2-3 times a month
Once a month or less (or never)              

7. I am obsessed about the size and shape of my body.
Always
Almost always
Frequently
Sometimes
Seldom or never

8. There are times when I rapidly eat a very large amount of food.
More than twice a week
Twice a week
Once a week
2-3 times a month
Once a month or less (or never)

9. How long have you been binge eating (eating uncontrollably to the point of stuffing yourself)?
Not applicable; I don't binge eat
Less than 3 months
3 months to 1 year
1-3 years
3 or more years
        
10. Most people I know would be amazed if they knew how much food I can consume at one sitting.
Without a doubt
Very probably
Probably
Possibly
No

11. I exercise in order to burn calories.
More than 2 hours a day
About 2 hours a day
More than 1 but less than 2 hours per day
One hour or less per day
I exercise but not to burn calories or I don't exercise

12. Compared with women your age, how preoccupied are you about your weight and body shape?
A great deal more than average
Much more than average
More than average
A little more than average
Average or less than average

13. I am afraid to eat anything for fear that I won't be able to stop.
Always
Almost always
Frequently
Sometimes
Seldom or never

14. I feel tormented by the idea that I am fat or might gain weight.
Always
Almost always
Frequently
Sometimes
Seldom or never

15. How often do you intentionally vomit after eating?
2 or more times a week
Once a week
2-3 times per month
Once a month
Less than once a month or never

16. I eat a lot of food when I'm not even hungry.
Very frequently
Frequently
Occasionally
Sometimes
Seldom or never

17. My eating patterns are different from the eating patterns of most people.
Always
Almost always
Frequently
Sometimes
Seldom or never

18. After I binge eat I turn to one of several strict methods (vigorous exercise, strict dieting, fasting, self-induced vomiting, laxatives or diuretics) to try to keep from gaining weight.
Never or I don't binge eat
Rarely
Occasionally
A lot of the time
Most or all of the time

18.a. Please indicate which method/s you use:
 strict dieting fasting laxatives diuretics self-induced vomiting vigorous exercise
        
19. I have tried to lose weight by going on strict diets.
Not in the past year
Once in the past year
2-3 times in the past year
4-5 times in the past year
        
20. I exercise vigorously and for long periods of time in order to burn calories.
Average or less than average
A little more than average
More than average
Much more than average
A great deal more than average

21. When engaged in an eating binge, I tend to eat foods that are high in carbohydrates (sweets and starches).
Always
Almost always
Frequently
Sometimes
Seldom or I don't binge

22. Compared to most people, my ability to control my eating behaviour seems to be:
Greater than others' ability
About the same
Less
Much less
I have absolutely no control

23. I would presently label myself a "compulsive eater" (one who engages in episodes of uncontrolled eating).
Absolutely
Yes
Yes, probably
Yes, possibly
No, probably not

24. I hate the way my body looks after I eat too much.
Seldom or never
Sometimes
Frequently
Almost always
Always

25. When I am trying to keep from gaining weight, I