Psychiatric Nursing and Behavior

Self-Injury

Biopsychosocial Approach to Treating Self-Injurious Child and Adolescent Psychiatric Nursing

My initial thoughts/feelings on the topics were: (This section contains your general feelings on the topic and NOT what the readings have informed you.

Initially, I did not have much knowledge about self-injurious behavior (SIB). Though I had from time to time heard about the behavior, it never actually crossed my mind that it is a behavior that could warrant significant medical attention. In my life, I have actually not encountered an individual with the behavior. I have not even heard many people mention or talk about it. I thought that people who would perhaps contemplate harming themselves are suicidal people, substance abusers, or insane people. In fact, I thought the behavior was more relatable with non-human animals as opposed to humans. I did not even think the behavior was evident in children. I also viewed it as some form of deviant behavior.

Input from the readings have altered my perceptions in the following ways: (use assigned scholarly sources) (60 points)

Literature has extensively changed my perception and understanding of SIB. It is now clear to me that SIB is a serious psychiatric condition stemming from multiple factors and requiring significant medical attention. SIB is a behavior characterized by intentional, self-infliction of harm or injury on one's body in an effort to cope with psychological stress (Askew & Byrne, 2009). Victims resort to self-harm to get relief from anxiety, stress, depression, and other overwhelming and confusing emotions (Wilkinson, 2011). The harm often involves scratching, hitting, banging, cutting, piercing, and burning body parts, interfering with healing wounds, as well as ingesting toxic substances (Juhnke, Granello & Granello, 2010). For victims, such behaviors are often profound ways of reinstating psychological equilibrium (Askew & Byrne, 2009).

SIB has an approximated lifetime incidence of 17%, with hospitalized patients being one of the most affected populations (Askew & Byrne, 2009). This is without a doubt a significant prevalence, underscoring the need for greater attention to the disorder. In addition to cutting, stabbing, or scratching body parts with sharp objects, banging the body against hard objects, and self-poisoning, the behavior may also be characterized by hair pulling, obsessive thoughts, suicidal tendencies, and an overwhelming desire to harm oneself (Juhnke, Granello & Granello, 2010).

SIB may often be confused with suicidal behavior or borderline personality disorder. It is, however, important to note that SIB, suicidal, and borderline personality disorder are different. Nonetheless, individuals with suicidal tendencies and borderline personality disorder are at a greater risk for SIB compared to the rest of the population (Wilkinson, 2011). Other risk factors include anxiety disorders, depression, autism, attention deficit disorder, bipolar disorder, phobias, substance abuse disorders, posttraumatic stress disorder (PTSD), schizophrenia, eating disorders, and other psychiatric and behavioral disorders (Juhnke, Granello & Granello, 2010). SIB may further be predicted by a history of abuse, troubled family relationships, auditory hallucinations, nightmares, sleeping difficulties, arthritis, dissatisfaction with one's body, perfectionism, physical illness during infancy or childhood, as well as genetic factors ((Askew & Byrne, 2009; Jefic, 2010; Wilkinson, 2011). In essence, several factors may contribute to SIB -- from individual to psychological, biological, and social factors.

While psychological, biological, and social factors have been associated with SIB, its exact etiology remains largely unknown. It has, however, been suggested that the behavior stems from increased opioid activity in the brain (Askew & Byrne, 2009). According to this theory, the brain discharges innately occurring endorphins and other opiate-like chemicals whenever an individual harms their body. The chemicals provide pleasure and relief from psychological distress. Studies involving primates have theorized that social deprivation results in SIB via neurobiological changes (Askew & Byrne, 2009).

The notion of social deprivation is particularly useful in explaining SIB in children and adolescents. Children brought up by parents or guardians with psychiatric disorders tend to experience social isolation as their parent's mental condition hampers their capacity to provide an environment that supports healthy child development (Askew & Byrne, 2009). This knowledge is crucial for treating children with SIB. Mental health practitioners dealing with children must understand the child's emotional experience to get to the bottom of the behavior, and thereby prescribe effective interventions.

As SIB emanates from multiple factors, its treatment should as well be characterized by a multi-dimensional approach. Indeed, Askew & Byrne (2009) advocate for a biopsychosocial approach. In other words, the treatment of SIB should focus on not only individual, but also social, biological, molecular cognitive, and psychological dimensions. From a biological and molecular perspective, pharmacological interventions can be fairly effective in treating SIB. These mainly include naltrexone, clonidine, and sertraline (Askew & Byrne, 2009). Medications work by reducing opioid addiction, which is consistent with the opiate mechanisms theoretically involved in creating SIB. Medication, however, may not be effective in the long-term as SIB may present with other underlying factors of a cognitive, psychological, and behavioral nature. This underscores the need for cognitive behavioral therapy.

Cognitive behavioral therapy focuses on correcting beliefs, thoughts, and attitudes that support self-harm (Askew & Byrne, 2009). Through therapy, which may involve individual, group, or family therapy, the patient gets an opportunity to talk about their experiences in the presence of a mental health practitioner as well as family members and peers. The individual is then familiarized with activities they may engage in instead of their self-destructive behaviors, such as journaling, exercise, and relaxation (Jefic, 2010).

Social support may also be important for ceasing SIB (Askew & Byrne, 2009). The usefulness of social support particularly stems from the possible connection between social deprivation or isolation and SIB. When an individual at risk for SIB gets opportunities for healthy, meaningful social interactions, they may be less likely to engage in SIB. The interactions may keep the individual's mind occupied with more positive thoughts, eventually reducing the urge for self-harm (Juhnke, Granello & Granello, 2010). Social interactions may be particularly useful for children and adolescents, who may be at a greater risk for self-harm. With technological advancements, providing social support has become easier. Internet forums can now be used as a venue for children and adolescents affected by SIB to share their experiences with others experiencing the same (Askew & Byrne, 2009). Social support may be provided by not only peers, but also family members. Indeed, the importance of the involvement of the family in the treatment of SIB cannot be overemphasized.

In Askew & Byrne's (2009) case study, a biopsychosocial approach completely eliminated SIB in six months. The patient was a 14-year-old girl with a history of parental neglect, parental depression, PTSD, and other psychiatric and behavioral complications. She reported that cutting and scratching her body gave her immense relief from the emotional distress she was undergoing. The intervention involved medication (sertraline and naltrexone) as well as individual, group, and family therapy. Jefic's (2010) case study also reported similar outcomes. While a biopsychosocial approach can be successful in ceasing SIB, it is important to note that evidence for effectiveness of the intervention remains scarce in large part due to little understanding of the etiology of the behavior. More studies, especially randomized controlled studies, are needed to validate the effectiveness of pharmacological and cognitive behavioral interventions, both as single-dimensional interventions and multidimensional interventions.

Three implications for my nurse practitioner practice that are unique to that role and distinct from my current role as a Registered Nurse. (20 points)

On the whole, SIB, especially in children and adolescents, is a serious psychiatric condition requiring greater attention. It is not a deviant behavior contrary to popular belief. The importance of greater attention to child and adolescent SIB particularly stems from the ever more widespread incidence of child neglect and abandonment due to, among other factors, depression, mental illness, and substance abuse disorders on the part of parents. These factors can predispose children and adolescents to SIB, with those with underlying psychiatric complications such autism being at a greater risk. Early prevention is, therefore, important. This has important implications for practice in the field of psychiatric nursing.