Non-suicidal self-injury

Alexander Chapman, Ph.D., R.Psych. (biography, no disclosures)

What frequently asked questions I have noticed

It can be puzzling that people seem to go against their instinct for self-preservation and survival by purposely harming their own bodies. Non-suicidal self-injury is the deliberate destruction of body tissue without the intent to cause death. Some of the common questions I hear about self-injury include the following:

1. Why do people self-injure?
2. Do all people who self-injure have borderline personality disorder (BPD)?
3. How can we best understand and treat self-injury?

Data that answers these questions

Why do people self-injure?

Well, as for the question of why people self-injure, there has been a fair amount of research attacking this question from different angles, from studies on peoples’ reasons or motivations for self-injury to research on the neurobiology of impulsive aggression (directed toward the self and others), and to actual laboratory studies examining the effects of self-injury on emotional states.

In terms of motivations, by far, the most common reason that people report for engaging in self-injury is to escape, manage, or regulate emotions (Brown et al., 2002; Chapman et al., 2006; Kleindienst et al., 2008). People do, however, report other reasons, such as to punish themselves for some perceived inadequacy or wrongdoing, or to communicate their emotional pain to other people. These data suggest that people who self-injure need to learn alternative ways to manage their emotions or to communicate to others, and also to work on reducing self-hatred and shame.

There also is evidence that lower levels of serotonin among people who self-harm (Herpertz et al. 1995; Simeon et al. 1992) may predispose them to experience stronger negative emotions, and particularly irritability and anger, making them more likely to act on urges to harm themselves (Cocarro et al. 1997).

Do all people who self-injure have borderline personality disorder (BPD)?

Oftentimes, self-injury has been considered the behavioural hallmark feature of BPD. It is not uncommon for people to assume that, if someone self-injures, she or he must be likely to have BPD. Self-injury and/or suicide attempts comprise one criterion for BPD, and accordingly, approximately 75% of people with BPD self-injure. On the flip side, however, only approximately 25-30% of people who self-injure are diagnosable with BPD (Andover et al., 2005; Herpertz et al., 1995). Therefore, care must be taken in the diagnosing of people who self-injure, and clinicians must recognize the possible bias toward assuming that the diagnosis must be BPD.

How can we best understand and treat self-injury?

I should say that, as a psychologist, I am focusing here primarily on psychosocial assessment and treatment, rather than medication-based interventions, although there is evidence that some medications can be helpful for self-injury. The best evidence is for selective serotonin reuptake inhibitors (SSRIs) in the treatment of more compulsive forms of self-injury, such as repetitive skin picking. Some evidence exists for tricyclic antidepressants and second generation antipsychotic medications, although the majority of the studies of these medications have been conducted with psychotic patients or those with developmental disabilities.

What I recommend (practice tip)

Often, self-injury is managed and treated in the context of therapy work with a psychologist or psychiatrist. Family physicians, however, are in an excellent position to be first responders, to offer helpful suggestions, and to help refer the patient to appropriate care.

In the context of a short, 15-minute meeting, it will not be possible to accomplish all of the suggestions below, but the clinician, upon noticing that self-injury has occurred, might at least be able to provide concrete, specific advice (see tip 4) regarding coping strategies, encourage the patient to seek further help or psychological treatment, and talk about self-injury in a direct, non-judgmental manner. When there is more time, or an ongoing treatment relationship with someone who self-injures, the following considerations are important.

1. Assess the patient’s experience and history with self-injury. Determine how long the patient has been engaging in self-injury, when and how it started, and what he or she does to self-injure (e.g., cutting, burning, and self-hitting are most common). Also, determine how often self-injury occurs and how medically serious the behaviour is.
2. Assess the contexts or situations in which the patient self-injures, the motivations or goals she or he has (e.g., to reduce emotional pain, to get back at someone else, to punish him or herself, to communicate), and what types of consequences occur when the patient self-injures. For example, it is important to know whether the patient feels emotional relief, or whether others provide more emotional support or withdraw demands when self-injury occurs.
3. Enhance the patient’s motivation to reduce self-injury without pushing her or him to stop right away. People who self-injure often rely on this as one of their only and most reliable coping strategies; it is hard for them to stop harming themselves, particularly if they do not yet have a coping strategy with which to replace it.
4. Provide concrete, specific advice and suggestions regarding alternative coping strategies. Examples might include intense exercise, progressive muscle relaxation, the application of ice packs or a cold bowl of ice water to the face, diaphragmatic breathing, self-soothing activities (e.g., a warm bath, aromatherapy, listening to music), or distracting activities (getting out of the immediate environment, spending time with others, doing crossword puzzles, etc.).

Fifth, an additional tip has to do with how the clinician speaks to the patient about self-injury. I recommend that clinicians be matter of fact, non-judgmental, and supportive in their interactions with patients around self-injury. Find ways to validate and empathize with the emotional pain they are experiencing, while also indicating that the clinician is there to help her or him change the behaviour and learn new coping strategies.

Resource

Dialectical Behaviour Therapy (DBT) Centre of Vancouver www.dbtvancouver.com: ongoing blog on self-injury and related topics that patients might find helpful.

References

1. Andover, M. S., C. M. Pepper, K. A. Ryabchenko, E. G. Orrico, and B. E. Gibb. (2005). Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide and Life-Threatening Behavior, 35, 581-591. (View with UBC or request from CPSBC)
2. Chapman, A.L., & Gratz, K.L. (2007). The borderline personality disorder survival guide: Everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications. (Book)
3. Chapman, A. L., K. L. Gratz, and M. Z. Brown. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research & Therapy, 44, 371-394. (View with UBC and CPSBC)
4. Coccaro, E. F., R. J. Kavoussi, Y. I. Sheline, M. E. Berman, and J. G. Csernansky. (1997). Impulsive aggression in personality disorder correlates with platelet 5-HT2A receptor binding. Neuropsychopharmacology, 16, 211-216. (View)
5. Farmer, R.F., & Chapman, A.L. (2007). Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action. APA Books: Washington, D.C. (Available from UBC’s online books)
6. Gratz, K.L., & Chapman, A.L. (2009). Freedom from self‐harm: Overcoming self‐injury with skills from DBT and other treatments. Oakland, CA: New Harbinger Publications. (Book)
7. Herpertz, S., S. M. Steinmeyer, D. Marx, A. Oidtmann, and H. Sass. (1995). The significance of aggression and impulsivity for self-mutilative behavior. Pharmacopsychiatry, 28, 64-72. (View with UBC or request from CPSBC)
8. Kleindienst, N., M. Bohus, P. Ludaescher, M. F. Limberger, K. Kuenkele, A. L. Chapman, Reicherzer, R. D. Stieglitz, and C. Schmahl. (2008). Motives for nonsuicidal self-injury among women with borderline personality disorder. Journal of Nervous and Mental Disease, 196, 230-236. (View with UBC and CPSBC)
9. Linehan, M.M. (1993a). Cognitive behavioral treatment of borderline personality disorder. New York: The Guilford Press. (Available to borrow from UBC’s collection or request from CPSBC)
10. Linehan, M.M. (1993b). Skills training manual for treating borderline personality disorder. New York: The Guilford Press. (Book)

Note:

Past article: Non-suicidal self-injury: reducing future risk by Dr. Shirley Sze on November 7, 2011

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