Background: Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.Methods: Four cases from different treatment centers in Israel were analyzed.Results: All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.Discussion: All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological Frontiers in Psychiatry | www.frontiersin.org

From a self-psychology perspective, the profound disruption of the will to exist physically and psychically in patients suffering from anorexia can be seen as a primary impairment of the selfobject's capacity to make space for them within itself. Kohut viewed the primary phase of the baby's existence in the mother's mind as its “virtual conception.” On this foundation, the author uses the notion of “virtual selfobject” to understand the impaired will to exist in patients with anorexia and describes how the therapist may embrace a standpoint that creates a space-for-being for the patient, facilitating the reactivation of self needs in the transference. The notion of virtuality thus entails a future perspective, which ostensibly foretells or creates the potential future emergence of the patient's self. This conceptualization and its application are illustrated through a life-restoring therapy with a patient hospitalized with a life-threatening eating disorder.