Self-injurious behavior: causes, patterns, and clinical interventions

Deliberate self-harm (DSH) or self-injurious behavior (SIB) involves intentional self-poisoning or injury, irrespective of the apparent purpose of the act. (Vela, Harris and Wright, 1983) Self-mutilation is also used interchangeably with self-mutilation, though self-mutilation is one aspect of DSH. Approximately 1% of the United States population uses physical self-injury as a way of dealing with overwhelming feelings or situations, often using it to speak when no words will come. There are different ways in which DSH is manifested: cutting, burning, and abusing drugs, alcohol or other substances. This occurs at times of extreme anger, distress and low self-esteem, in order to either create a physical manifestation of the negative feelings which can then be dealt with, or alternatively to punish yourself. Extremely emotional distress can also cause DSH -- this is sometimes linked with hearing voices, particularly as a way of stopping the voices.

DSH is also often called parasuicide, but it is important to distinguish it from suicide. DSH is not an attempt at suicide, though people who harm themselves have a greater propensity for suicide. DSH was not as widely recognized as an independent affliction. DSH "victims" were often overlooked for people who were in accidents or did not have self inflicted wounds.

The issue is becoming more widely recognized. But it's difficult to say whether the numbers of people self-harming are themselves increasing. It is much more common than could be seen from the only available statistics but it is very probable that it there have been high numbers for a long time - it's not something that's suddenly started happening. What's changing is the increasing willingness on the part of service users to talk about the issue and their dissatisfaction with services.

Self-harming is basically identified as a coping mechanism. This mechanism is similar to alcohol abuse or even (using a distant analogy) taking a vacation to deal with the stress of everyday life. This is not to say that there are no extreme cases. Self-harming as a coping or self-management strategy can (and should) be seen as similar to the control that people with anorexia feel over their bodies. Self-harming, similar to anorexia, can become habitual. It can manifest at particular points of a regular cycle of mental distress. Again, like anorexia, it is usually only a visible condition when extreme. Self-harm is often associated with depression, low self-esteem and a poor physical self- image. There is also a strong association with sexual abuse.

People who self-harm find a variety of personal strategies useful to minimize or manage their approach including: Having a better understanding of why and when one self-harm; and identifying those people who are supportive; in addition, it is important to build up a strong support network. People who are prone to DSH can be trained to make a small cut rather than a big one, using clean implements. This may mean cutting earlier rather than later when the distress has built up. People can also be counseled to do something else. Distraction can be important. Another method is to avoid putting oneself in a self-harming situation. A good idea is to remove sharp objects like razor blades in the house. On the other hand, deterrence may also be key. A self-injuring person may want to keep the object they use (may be at a comfortable distance) in order to serve as a reminder not to use it.

People who are in a position to help may not always understand. They might patronize or blame the self-harming person. This is one of the primary reasons why DSH victims do not actively seek help. Anybody who is concerned about somebody who is self-harming should be aware that they couldn't necessarily change their friend or relative's life or coping mechanisms. Instead they should simply try to be caring, respectful and willing to listen (if that is what is wanted) while allowing their friend or relative to retain their dignity. In emergency rooms, people with self-inflicted wounds are often told directly and indirectly, that they are not as deserving of care as someone who has an accidental injury. They are treated badly by the same doctors who would not hesitate to do everything possible to preserve the life of an overweight, sedentary heart-attack patient. Doctors in emergency rooms and urgent-care clinics should be sensitive to the needs of patients who come in to have self-inflicted wounds treated. If the patient is calm, denies suicidal intent, and has a history of self-inflicted violence, the doctor should treat the wounds as they would treat non-self-inflicted injuries. Refusing to give anesthesia for stitches, making disparaging remarks, and treating the patient as an inconvenient nuisance simply further the feelings of invalidation and unworthiness the self-injurer already feels.

The forms and severity of self-injury can vary, although the most commonly seen behavior is cutting, burning, and head banging. Other forms of self-injurious behavior include: carving, scratching, branding, marking burning/abrasions, biting, bruising, hitting, picking, and pulling skin and hair. Knowing that DSH people inflict self-injury for physical or emotional reasons is important. It is not per se, a voluntary act. Therefore it should be distinguished between other forms of body mutilation. These forms are body piercing, tattooing and scalding patterns in the body. These are voluntary acts. They are performed either for sexual gratification or for body decoration. Sometimes these acts make people one of a crowd or it enables others to fit in among their peers. Several cultures view body painting, piercing, tattooing and other forms of body mutilation as rites of passage. Other times, they are parts of cultural or religious rituals. These voluntary acts are not self-injurious behaviors.

As contradictory as it may sound, self-injury actually makes people feel better. It reduces physiological and psychological tension rapidly. Studies have suggested that when people who self-injure get emotionally overwhelmed, an act of self-harm brings their levels of psychological and physiological tension and arousal back to a bearable baseline level almost immediately. In other words, they feel a strong uncomfortable emotion, don't know how to handle it, and know that hurting themselves will reduce the emotional discomfort extremely quickly.

One factor common to most people who self-injure is invalidation. For example, in abusive homes, children may have been severely punished for expressing certain thoughts and feelings. At the same time, they had no good role models for coping. You can't learn to cope effectively with distress unless you grow up around people who are coping effectively with distress. Although a history of abuse is common about self-injurers, not everyone who self-injures was abused. Sometimes invalidation and lack of role models for coping are enough, especially if the person's brain chemistry has already primed them for choosing this sort of coping.

Self-injurers come from all walks of life and all economic brackets. People who harm themselves can be male or female; straight, gay, or bisexual; people with a doctoral level of education or high-school dropouts or high-school students; rich or poor; from any country in the world. Some people who self-injure manage to function effectively in demanding jobs; they are teachers, therapists, medical professionals, lawyers, professors and engineers. Some are on disability. Their ages range from early teens to early 60s.

Self-injury may be called parasuicide but it is a maladaptive coping mechanism, which a way to stay alive. People who inflict physical harm on themselves are often doing it in an attempt to maintain psychological integrity. They release unbearable feelings and pressures through self-harm. This eases their urge toward suicide. And, although some people who self-injure do later attempt suicide, they almost always use a method different from their preferred method of self-harm.

Many new therapeutic approaches have been and are being developed to help self-harmers learn new coping mechanisms and teach them how to start using those techniques instead of self-injury. These approaches reflect a growing belief among mental-health workers that once a client's patterns of self-inflicted violence stabilize, real work can be done on the problems and issues underlying the self-injury. Also, research into medications that stabilize mood, ease depression, and calm anxiety is being done; some of these drugs may help reduce the urge to self-harm.

It is important to note that individuals should not be coerced into stopping self-injury. Any attempts to reduce or control the amount of self-harm a person does should be based on the person's willingness to undertake the difficult work of controlling and/or stopping self-injury. Treatment should not be based on a practitioner's personal feelings about the practice of self-harm. People who self-injure do generally do so because of an internal dynamic, and not in order to anger or irritate others. Their self-injury is a behavioral response to an emotional state, and is usually not done in order to frustrate caretakers.

Although offering mental-health follow-up services is appropriate, psychological evaluations with an eye toward hospitalization should be avoided in the emergency room unless the person is clearly a danger to his/her own life or to others. In places where people know that self-inflicted injuries are liable to lead to mistreatment and lengthy psychological evaluations, they are much less likely to seek medical attention for their wounds and thus are at a higher risk for wound infections and other complications.

Types of Self-harm

Favazza (Favazza, 1989; Pies and Popli, 1995)

Favazza (Favazza, 1996) further breaks down superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury comprises hair-pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. Both episodic and repetitive self-harm are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-harm is self-injurious behavior engaged in every so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder.

What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners (Favazza, 1996).

Additionally, self-injurious behavior may be divided into two dimensions: nondissociative and dissociative. Self-mutilative behavior often stems from events that occur in the first six years of a child's development. Nondissociative self-mutilators usually experience a childhood in which they are required to provide nurturance and support for parents or caretakers. If a child experiences this reversal of dependence during formative years, that child perceives that she can only feel anger toward self, but never toward others. Self-mutilation will later be used as a means to express anger. Dissociative self-mutilation occurs when a child feels a lack of warmth or caring, or cruelty by parents or caretakers. A child in this situation feels disconnected in his/her relationships with parents and significant others. Disconnection leads to a sense of "mental disintegration." (Levenkron, 1998)

Physiological Manifestation

Favazza and Rosenthal (Vogel, Krajci and Anderson, "Adults with Pediatric-Onset Spinal Cord Injury: Part 2: Musculoskeletal and Neurological Complications," 2002; Vogel, Krajci and Anderson, "Adults with Pediatric-Onset Spinal Cord Injury: Part 1: Prevalence of Medical Complications," 2002)

Self-biting with multiple finger amputations was reported in two adult males with complete C4 (Arons et al., 1984; Altman, Haavik and Higgins, 1983)

The majority of literature on self-injurious behavior relates to individuals with developmental delays. (1) In particular, self-injurious behavior has been well described in children with Lesch-Nyhan syndrome (A sex-linked recessive inherited disease in humans that results from mutation in the gene for the purine salvage enzyme hypoxanthine phosphoribosyltransferase (HGPRT), located on the X chromosome). (Nyhan et al., 1980; Goldstein et al., 1985)

There are many possible genetic causes of SIB. When looking at brain functions and behavior, genetic origins are certainly important. The role of the environment cannot be overlooked either. The circumstances of life ultimately affect the expression of any chemical imbalance in the brain. Traumatic life events, eating, stress, even learning are all factors that can bring out - or control - a genetic condition like SIB. Many forms of mental retardation are genetic. In certain kinds, SIB is so predictable that it is considered part of the disorder. In fact, scientists learn about SIB just from studying the origins of mental retardation. Mental retardation and SIB are linked in these genetic conditions: Lesch-Nyhan, Prader-Willi (A condition in children with floppiness (hypotonia), obesity, small hands and feet and mental retardation. It is due to loss of part or all of chromosome 15), de Lange (A congenital anomaly characterized by impaired development, mental retardation, characteristic facies with snyophrys and hairline well down on forehead, depressed bridge of nose with uptilted tip of nose, small head with low-set ears, and flat spade like hands with simian crease and short tapering fingers), and Fragile X (Lubs, 1969) (X chromosome with a fragile site associated with a frequent form of mental retardation. The fragile X is also called FRAXA (the second A signifies it was the first fragile site found on the X chromosome). It is due a trinucleotide repeat (a recurring motif of 3 bases) in the DNA at that spot.)

Psychological Manifestation

Scientists think that problems in the serotonin system may predispose some people to self-injury by making them tend to be more aggressive and impulsive than most people. This tendency toward impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the self. Once this happens, the person harming himself learns that self-injury reduces his level of distress, and the cycle begins. Some researchers theorize that a desire to release endorphins, the body's natural painkillers, is involved.

The overall picture seems to be of people who: strongly dislike/invalidate themselves, are hypersensitive to rejection; they are chronically angry, usually at themselves tend to suppress their anger have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward are more impulsive and more lacking in impulse control tend to act in accordance with their mood of the moment tend not to plan for the future are depressed and suicidal/self-destructive suffer chronic anxiety tend toward irritability do not see themselves as skilled at coping do not have a flexible repertoire of coping skills do not think they have much control over how/whether they cope with life tend to be avoidant do not see themselves as empowered. People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (Linehan, 1993) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals.

Dulit (Haines et al., 1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping.

Demographics

Self-mutilating behavior has been studied in a variety of racial, chronological, ethnic, gender, and socioeconomic populations. DSH transcends most of these demographics. If a specific group were to be picked to have the largest number of cases, it would include middle to upper class adolescent girls or young women. Conterio and Favazza (Favazza and Conterio, 1988) estimated that 750 per 100,000 population exhibit self-injurious behavior. They found that 97% of respondents were female. Across the United Kingdom, the best estimate (from emergency room data) is 1 in 130 people - 446,000 or nearly half a million.

People who participate in self-injurious behavior are usually likeable, intelligent, and functional. At times of high stress, these individuals often report an inability to think, the presence of inexpressible rage, and a sense of powerlessness. An additional characteristic identified by researchers and therapists is the inability to verbally express feelings.

Suyemoto and MacDonald (American Psychiatric Association. And American Psychiatric Association. Task Force on DSM-IV., 2000).

Miller (Miller, 1994) suggests that many self-harmers suffer from Trauma Reenactment Syndrome. TRS sufferers have common characteristics: (1) They feel a sense of being at war with their bodies; (2) excessive secrecy as a guiding principle of life; (3) inability to self-protect for control. Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on the roles of the abuser, the victim and the bystander.

In patients with borderline personality disorder, self-mutilation typically begins in adolescence and may persist for decades (Coid, Allolio and Rees, 1983).

Psychiatric inpatients with personality disorders and schizophrenia seem to be particularly susceptible to parasuicide behavior as a contagion -- emulating the behavior of others. (B. Ross and McKay, 1976) reported that some self-mutilating acts in a training school for delinquent girls occurred in a context of an initiation rite. Rosen and Walsh came to the conclusion that contagious self-mutilation may be viewed as a concrete display of affinity between two people. Adolescents appeared to use self-mutilation to communicate feelings and to ensure a tight bond within a relationship.

Methods of Alleviating Self-Injurious Behavior

The primary step in alleviating the problems associated with self-injurious behavior is to avoid pre-cognitive notions and misconceptions (discussed in the next section). Two distinct approaches can be followed in the treatment of DHS:

Psychopharmacology

When self-injurious behavior connects to untreated depression or anxiety, medication can be extremely useful. Anti-depressants can dramatically reduce the negative feelings and cognitions associated with the cycle of self-harm. Anxiolytics prevent the escalation of panic and generalized anxiety, which decreases the need for dissociation and self-injury. Providing a pharmacological safety net also helps to process painful trauma memories without becoming flooded or overwhelmed.

Medications such as carbamazepine and gabapentin have been particularly useful. These had reduced DSH symptoms significantly. In several cases, especially for those children and adolescents whose DSH behavior came from spinal cord injuries, carbamazepine has been particularly useful. Significant relapses occurred after the medication was stopped. This has been shown to be especially effective in treating children and adolescents. When the carbamazepine treatment was resumed, the DSH stopped. (Vogel, Krajci and Anderson, "Adults with Pediatric-Onset Spinal Cord Injury: Part 2: Musculoskeletal and Neurological Complications," 2002; Vogel, Krajci and Anderson, "Adults with Pediatric-Onset Spinal Cord Injury: Part 1: Prevalence of Medical Complications," 2002)

Droperidol has been demonstrated to be effective in individuals with developmental delays. Droperidol however, has Parkinsonian. This has been alleviated with orphenadrine or benzhexol. (Arons et al., 1984)

Treatment with anticonvulsants, such as phenytoin, carbamazepine or gabapentin, may be beneficial for those individuals with self-injurious behavior accompanied by symptoms consistent with dysesthesia (An unpleasant abnormal sensation, whether spontaneous or evoked). Because antidepressants are useful in treating neuropathic pain, antidepressants may also be beneficial in those individuals with self-injurious behavior associated with dysesthesia. (McQuay et al., 1996)

Risperidone originally came on the market for persons with schizophrenia. A group of researchers at the University of Kansas obtained permission to run clinical trials on Risperidone for the treatment of DSH. Clinical studies showed that half of the persons who took Risperidone experienced a 50% reduction of DSH episodes. Risperidone acts as a modulator adjusting the amount of serotonin and dopamine in the brain. Serotonin and dopamine regulate learning, reward, and emotions. In this instance, medicine plays an especially important role in treatment. Schroeder's study is noteworthy because he restricted participation to those persons who experience repeated, severe bouts of SIB and have not found relief elsewhere. (Valdovinos et al., 2002)

Self-injurious behavior has been managed with physical and behavioral interventions, counseling and medications. Physical interventions have included orthotics, bandaging, gloves, or restraints that protect the body part from continued damage. (Altman, Haavik and Higgins, 1983) Behavioral and psychological interventions have also been utilized with variable success in children with and without developmental delays.

Psychotherapy

It is extremely important to work with a helping professional who has an expertise in self-injurious behavior or related disorders. Psychotherapy can provide a non-judgmental and supportive environment where self-injury can be processed openly and the meaning behind the injury can be explored. Trained therapists can provide safer, alternative ways to communicate, self-soothe and cope. The use of journaling, art therapy, relaxation techniques, visualizations, cognitive re-framing and affect management are all recommended and useful.