Self-Injury: Psychotherapy with People Who Engage in Self-Inflicted Violence

Self Injury : Psychotherapy with People Who Engage in Self-inflicted Violence
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Findings with regard to race and NSSI are mixed, with some studies suggesting that it may be more common among Caucasians [21] and others showing similarly high rates in minority samples [9] , [22].

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There is also evidence linking NSSI to sexual orientation such that incidence of NSSI is slightly elevated among those who report exclusive homosexual attraction and some same-sex attraction, and it is very elevated among individuals with bisexual and questioning sexual orientation status unpublished data [9]. The U. Although most widely investigated in industrialized regions such as Europe, North America, Australia, and New Zealand, NSSI also occurs with some regularity in other industrialized and non-industrialized countries as well [21] , [22] , [25].

In general, reasons for self-injuring break down into three general categories: psychological, social, and biological. Of these, psychological functions are most commonly cited and center around reducing psychological pain, expressing and alleviating psychological distress, and refocusing one's attention away from negative stimulus [12] , [17] , [26]. Social function models point to the importance of viewing NSSI as a behavior undertaken to fulfill multiple functions simultaneously, most of which are intrapersonal emotion regulation but some of which are fundamentally interpersonal in nature.

In addition to being identified as factors that predispose or place at-risk adolescents who ultimately adopt NSSI as a release for negative emotion [27] , [28] , research finds interpersonal factors also make significant contributions to NSSI maintenance [12] , [27] , [28]. Biological models of function tend to focus primarily on the role of NSSI in regulation of endogenous opioids. The homeostasis model of NSSI, for example, suggests that individuals who self-injure may have chronically lower than normal levels of endogenous opioids.

In this model, NSSI is fundamentally remedial—it represents an attempt to restore opioids to normal levels. Low levels of opioids may result from a history of abuse, trauma, or neglect or may be biologically endowed through other processes [29]. These models are very helpful in deepening understanding about how and why some individuals perceive that they are dependent on NSSI behavior for emotion regulation. Identifying unique antecedents to NSSI is more difficult since it shares with many adolescent risk behaviors predisposing factors such as emotion dysregulation, self-derogation, childhood adversity, and comorbid or antecedent psychiatric disorders [30].

In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse [27] , [31]. Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders [27]. While much of this research reflects comorbidity in clinical populations, more recent studies of these relationships in community populations of youth document similar patterns, though at significantly lower levels of association [7] , [9] , [32].

That NSSI and suicide behaviors are related is well documented [3] — [5] , but the nature of its relationship remains somewhat ambiguous. Most NSSI treatment specialists and scholars agree that in the vast majority of cases NSSI is utilized to temporarily alleviate distress rather than to signal the intention to end one's life [17] , [25] , [33]. Indeed, some see it as a means of avoiding suicide [34] , [35]. Thus, in its relation to suicide, NSSI possesses an ambiguous, seemingly paradoxical, status as both a temporarily functional means of sustaining life by reducing and regulating strong negative emotion while simultaneously serving as a potential harbinger for suicidal intent and attempts.

This dual status suggests that efforts to discern variations in motivation and intent may be the most productive means of generating information useful in tailoring treatment guidelines, materials, and services. While Walsh [17] has argued that NSSI and suicide are entirely distinct psychological and behavioral phenomenon, Joiner theorizes that some suicidal individuals acquire the capacity to engage in high lethality behavior i. Assuming that suicide behavior is a consequence of NSSI behavior assumes a temporal relationship that has yet to be documented.

If this assumption proves true, then the data would suggest that for some NSSI serves as a harbinger of distress that, if left unmitigated, may lead some individuals to consider or attempt suicide later. It is widely assumed that NSSI is contagious, although lack of empirical data necessarily limits our capacity to test this assumption. Nevertheless, studies of contagion among adolescents in clinical settings demonstrate the tendency for NSSI to spread in a population [37] — [39] and the presence of self-injury in media, such as in music, movies, and newspapers, has increased dramatically in the past several years [40].

The Internet, as well, has proven to be a popular avenue for the gathering of individuals who practice NSSI [41]. Studies of the social contexts of behavior consistently show that positive and negative behaviors are socially patterned and often clustered [42] and that the primary mechanism of spread tends to be through a the shaping of norms, b providing social reinforcement of behaviors, c providing or limiting opportunities to engage in the behavior, and d facilitating or inhibiting the antecedents for the behavior [42].

Considered together, these mechanisms provide a useful framework for understanding how self-injury might spread in community populations of youth and point to the need for prevention and intervention approaches that address each of these areas. Although NSSI treatment specialists can offer advice based on experience, few studies that actually test treatment strategies have been conducted. In a systematic review of 23 randomized controlled trials related to Deliberate Self Harm a U.

They caution, however, that current knowledge is insufficient and more trials are sorely needed [43]. Because of the time-limited and structured coping skill-building nature of the technique, she specifically identifies problem-solving therapy and dialectical behavioral therapy as the most promising CBT-based candidates but suggests that while both may be efficacious under the right treatment conditions, neither has emerged as efficacious in the limited study available.

Although dialectical behavior therapy has been used with significant success in borderline personality disordered patients with suicide and NSSI as well [46] , there is significant need for well-designed and rigorous trials of NSSI treatment strategies among community populations. Although common among adolescents, NSSI is often undetected.

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Medical providers are uniquely positioned to assess for NSSI behavior during intake assessments and during examination since wounds or scars may be visible. Arms, fists, and forearms opposite the dominant hand are common areas for injury. However, evidence of self-injurious acts can and do appear anywhere on the body.

It is important that questions about the marks be non-threatening and emotionally neutral. Immediate risk of infection: Open wounds should be assessed for likelihood of infection. Even in cases where wounds are healed, a discussion of how to care for wounds is warranted. This is particularly important since a significant number of those with NSSI experience indicate inflicting wounds of unintended severity [9] , [17]. NSSI severity: In general, lifetime frequency of NSSI in combination with the number of methods used and the likelihood that the methods used will cause severe tissue damage i.

Extent of informal and formal support system: Has the patient disclosed injury to anyone, and if so, how supportive are those who know? Does the patient currently receive therapy in which presence of NSSI has been disclosed? If not, referral is warranted—particularly for high-severity cases. Presence of comorbid mental health conditions, such as disordered eating, depression, anxiety, borderline personality disorder, and generalized psychological distress. Presence of one or more of these conditions in NSSI patients is common and may heighten risk of suicide [3] , [19] , [46].

Suicide assessment: Although NSSI is not a suicidal gesture, it can indicate the presence of suicidal thoughts and feelings and should trigger suicide assessment in individuals who have self-injured in the previous year. NSSI is a common practice among adolescents, and medical providers are uniquely positioned to detect its presence, to assess its lethality, and to assist patients in caring for wounds and in seeking psychological treatment. NSSI assessment should be standard practice in medical settings. Randomized control trials of effective treatment and prevention strategies are warranted.

Because NSSI research is nascent, unanswered research questions abound. Those most pressing for clinicians and allied medical health professionals include a discerning individuals with NSSI history at elevated risk for suicide from those not at elevated risk, b effective treatment regimes, c effective prevention strategies in school and community settings, and d assessment and referral protocols likely to result in effective treatment and abatement of NSSI behavior.

Ross S, Heath N A study of the frequency of self-mutilation in a community sample of adolescents.

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J Youth Adolesc 66— This is one of the first descriptive studies of NSSI in a high school sample of adolescents. It paved the way for study of NSSI in community populations by documenting a high prevalence rate and providing novel descriptive details [24]. J Consult Clin Psychol — This is the first study to document a functional model of NSSI that moved beyond the pejorative manipulation function and provided empirical support for a multi-functional conceptualization of NSSI in adolescents [12].

Pediatrics — This was the first large-scale epidemiological study to document the phenomena of NSSI in college students and to provide detailed epidemiological portraits of the phenomenon [9]. Muehlenkamp J, Gutierrez PM Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res 69— This was among the very first empirical papers to document the distinctions between NSSI and suicide beyond the intent of the behavior, and did so within a community sample of high school students, expanding research on NSSI to nonclinical settings [4].

Suicide Life Threat Behav — It also paved the way for looking at the relationship between NSSI and common adolescent risk behaviors such as alcohol use [25]. The author has declared that no competing interests exist. No specific funding was received for this piece. Provenance: Commissioned; externally peer reviewed. National Center for Biotechnology Information , U. Generating alternative behaviours that the person can engage in instead of self-harm is one successful behavioural method that is employed to avoid self-harm.

Any avoidance or coping strategy must be appropriate to the individual's motivation and reason for harming. It is difficult to gain an accurate picture of incidence and prevalence of self-harm. The World Health Organization estimates that, as of , , deaths occur as a result of self-harm. Many adolescents who present to general hospitals with deliberate self-harm report previous episodes for which they did not receive medical attention.

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Current research suggests that the rates of self-harm are much higher among young people [8] with the average age of onset between 14 and In general, the latest aggregated research has found no difference in the prevalence of self-harm between men and women.

However, this discrepancy has been known to vary significantly depending upon population and methodological criteria, consistent with wide-ranging uncertainties in gathering and interpreting data regarding rates of self-harm in general. For example, feminist author Barbara Brickman has speculated that reported gender differences in rates of self-harm are due to deliberate socially biased methodological and sampling errors, directly blaming medical discourse for pathologising the female. This gender discrepancy is often distorted in specific populations where rates of self-harm are inordinately high, which may have implications on the significance and interpretation of psychosocial factors other than gender.

There does not appear to be a difference in motivation for self-harm in adolescent males and females. For example, for both genders there is an incremental increase in deliberate self-harm associated with an increase in consumption of cigarettes, drugs and alcohol. Triggering factors such as low self-esteem and having friends and family members who self-harm are also common between both males and females. In New Zealand, more females are hospitalised for intentional self-harm than males.

Females more commonly choose methods such as self-poisoning that generally are not fatal, but still serious enough to require hospitalisation.

In a study of a district general hospital in the UK, 5. The male to female ratio was although the self-harm rates for males and females over 65 in the local population were identical. Only recently have attempts to improve health in the developing world concentrated on not only physical illness but also mental health. Research into self-harm in the developing world is however still very limited although an important case study is that of Sri Lanka, which is a country exhibiting a high incidence of suicide [91] and self-poisoning with agricultural pesticides or natural poisons.

The improvement of medical management of acute poisoning in the developing world is poor and improvements are required in order to reduce mortality. Some of the causes of deliberate self-poisoning in Sri Lankan adolescents included bereavement and harsh discipline by parents. The coping mechanisms are being spread in local communities as people are surrounded by others who have previously deliberately harmed themselves or attempted suicide.

Self-Injurious Behavior in Adolescents

Great potential for the reduction of self-harm lies in education and prevention, but limited resources in the developing world make these methods challenging. Deliberate self-harm is especially prevalent in prison populations. A proposed explanation for this is that prisons are often violent places, and prisoners who wish to avoid physical confrontations may resort to self-harm as a ruse, either to convince other prisoners that they are dangerously insane and resilient to pain or to obtain protection from the prison authorities.

Self-harm was, and in some cases continues to be, a ritual practice in many cultures and religions. The Maya priesthood performed auto- sacrifice by cutting and piercing their bodies in order to draw blood. Self-harm is practised in Hinduism by the ascetics known as sadhu s. In Catholicism it is known as mortification of the flesh. Some branches of Islam mark the Day of Ashura , the commemoration of the martyrdom of Imam Hussein, with a ritual of self-flagellation , using chains and swords. Dueling scars such as those acquired through academic fencing at certain traditional German universities are an early example of scarification in European society.

Constance Lytton , a prominent suffragette , used a stint in Holloway Prison during March to mutilate her body. Her plan was to carve 'Votes for Women' from her breast to her cheek, so that it would always be visible. But after completing the "V" on her breast and ribs she requested sterile dressings to avoid blood poisoning , and her plan was aborted by the authorities. Kikuyu girls cut each other's vulvas in the s as a symbol of defiance, in the context of the campaign against female genital mutilation in colonial Kenya.

The movement came to be known as Ngaitana "I will circumcise myself" , because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas described the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators. The term "self-mutilation" occurred in a study by L. Emerson in [] where he considered self-cutting a symbolic substitution for masturbation. The term reappeared in an article in and a book in when Karl Menninger refined his conceptual definitions of self-mutilation.

His study on self-destructiveness differentiated between suicidal behaviours and self-mutilation. For Menninger, self-mutilation was a non-fatal expression of an attenuated death wish and thus coined the term partial suicide. He began a classification system of six types:. Pao differentiated between delicate low lethality and coarse high lethality self-mutilators who cut.

The "delicate" cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. The "coarse" cutters were older and generally psychotic. After the s the focus of self-harm shifted from Freudian psycho-sexual drives of the patients. Favazza and Rosenthal reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation. The rituals are mutilations repeated generationally and "reflect the traditions, symbolism, and beliefs of a society" p.

Practices are historically transient and cosmetic such as piercing of earlobes, nose, eyebrows as well as male circumcision for non-Jews while Deviant self-mutilation is equivalent to self-harm. There are many movements among the general self-harm community to make self-harm itself and treatment better known to mental health professionals, as well as the general public. Some people wear an orange awareness ribbon or wristband to encourage awareness of self-harm.

Self-harm in non-human mammals is a well-established but not widely known phenomenon. Its study under zoo or laboratory conditions could lead to a better understanding of self-harm in human patients. Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self-harm in higher mammals, e.

Self Inflicted

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