SelfInjurious Behaviors

1
Self-Injurious Behaviors

• Gender And Cultural Issues
• Abid Nazeer M.D.
• PGY2
• LSUHSC
• Psychiatry

2
Objectives

• Define and categorize Self-Injurious Behaviors
  (SIB)
• Discuss etiology, epidemiology, and treatment
  options of SIB
• Describe and distinguish specific sub-type of
  SIB, Self-Mutilation
• Discuss the gender and cultural aspects of Self-
  Injurious Behaviors

3
Self-Injurious Behavior

• Definition Self directed acts which result in
  tissue damage.
• No suicidal intention in SIB
• Many methods to self-injure
• -Cutting -Burning -Scratching
• -Skin picking -Hair pulling -Branding
• -Biting -Head banging -Hitting
• -Toxic Ingestion -Auto castration

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Self-Injurious Behaviors

• The DSM-IV only mentions self-injury as a symptom
  or criterion for diagnosis in borderline
  personality disorder, stereotypic movement
  disorder (autism, MR), and factitious disorder.
• Extreme forms can be present in psychotic and
  delusional disorders.
• Impulse Control Disorders

5
Types of Self-Mutilation

• Major such as eye enucleation and castration,
  very rare, associated with psychosis and acute
  intoxication
• Stereotypic repetitive behavior that has
  relatively fixed pattern of expression, e.g. head
  banging, self-hitting, hand-biting. Associated
  with MR, PDD, Autism, Downs Syndrome,
  Lesch-Nyhan Syndrome, and de Lange Syndrome, or
  Stereotypic Movement Disorder (Axis I)
• Superficial/Minor- cutting, burning, interfering
  with wound healing, and scratching. Associated
  with borderline and antisocial personality
  disorders, adolescents, incarcerated men, and may
  be component of many psychiatric disorders. Also
  called parasuicide, deliberate self-harm,
  cutters

Favassa A, Rosenthal, Repetitive Self Mutilation,
Psychiatric Annals. 1992 222,
6
Favazza, A. R. (1996). Bodies Under Siege
Self-Mutilation and Body Modification in Culture
and Psychiatry, 2nd ed. Baltimore The Johns
Hopkins University Press.
7
Impulse Control Disorders

• Failure to resist impulse, drive, or temptation
  to perform act that is harmful to self/others.
• Relief of mounting tension or arousal with act
• Includes
• Intermittent Explosive Disorder
• Kleptomania
• Pyromania
• Pathological Gambling
• Trichotillomania
• Impulse Control Disorder NOS
• Repetitive Self-Mutilation?

8
Compulsive vs. Impulsive

• Compulsive self-harm part of OCD ritual involving
  obsessional thoughts person tries to relieve
  tension and prevent bad things from happening by
  engaging in self-harm behaviors

• Episodic self harm behavior is engaged
  infrequently by people who otherwise dont think
  about it and dont perceive themselves as
  self-injurers. Usually a symptom of some other
  disorder.
• Repetitive self-harm is a switch to ruminating
  about self harm even when doing the act, identify
  as self-mutilators. Considered a disease
  itself. Reflex response to any sort of stress,
  positive or negative.

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Etiology of S.I.B.

• Biological Considerations and Neurochemistry
• Serotonin Decreased levels correspond to
  increased aggression and self injurious behavior.
  
• Irritability is expressed as screaming or
  throwing things when serotonin levels are normal.
• Research correlates this by showing decreased
  platelet imipramine binding sites in
  self-injurers (Simeon et al. 1992) and linked to
  impulsivity and aggression (Birmaher et al. 1990)

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Etiology of S.I.B.

• Biological Considerations and Neurochemistry
• Endorphin Model Pain resulting from SIB may
  elicit release of endogenous opioids (endorphins)
  which acts as an analgesic on opiate receptors
  like morphine or heroin. (Thompson et al. 1994).
  Little or no pain seen in many self-injurers
  which is termed blunted nociception.
• Dopamine supersensitivity or hypersecretion of
  endorphins seen. Repetitive self-injurious
  actions my come under control of addictive
  reinforcers and these receptor effects.

Thompson, T., Hackerberg, T., Cerulti, D., Baker,
D., Axtell, S. (1994), Opioid Antagonist Effects
on Self-Injury in Adults with Mental Retardation.
American Journal on Mental Retardation, 49
85-102.
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Etiology of S.I.B.

• Biological Considerations and Neurochemistry
• Middle Ear infection in Autistic/MR patients may
  lead to head banging or ear hitting.
• Sub-clinical seizures may cause sudden SI
  episode.
• Chronic medical conditions

12
Etiology of S.I.B.

• Social and Behavioral Considerations
• Arousal counteract overarousal or underarousal
  (Edelson 1984)
• Frustration due to poor communication
• Social attention acts as positive reinforcer
  (Lovas et. Al 1969)
• Avoidance or escape from social encounter

13
Etiology of Self-Mutilation

• Social and Behavioral Considerations
• 2004 Study by Nock and Prinstein (89 adolescent
  inpatients surveyed)
• To stop bad feelings (immediate relief)
• To feel something, even if it was pain
• To punish yourself
• To relieve feeling numb or empty
• To feel relaxed
• Social modeling 82 of responders say at least
  one friend self-injured in the last 12 months

Nock and Prinstein. A functional approach to the
assessment of self-mutilative behavior. Journal
of Consulting and Clinical Psychology 2004 72
885-890.
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Etiology of Self-Mutilation

• Way of coping with intense internal emotions, or
  even preventing suicide.
• Physical pain is easier in dealing with than
  emotional pain.
• Risk Factors
• History of physical or sexual abuse
• Parental neglect or abandonment
• Comorbid conditions such as depression, eating
  disorders, personality disorders (BPD,
  antisocial, histrionic), PTSD, and anxiety
  disorders
• Alcoholism and illicit drug use
• Female sex

15
Epidemiology of S.I.B.

• The few studies which have been done on community
  samples of young adults and adolescents vary in
  prevalence rates of SIB between 4 to 38
• Conterio and Favazza estimate that 750 per
  100,000 population exhibit self-injurious
  behavior

Favazza, A. R. Conterio, K. (1988). The plight
of chronic self-mutilators. Community Mental
Health Journal, 24, 22-30
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Epidemiology of S.I.B.

• In M.R. and Autistic populations, SIB is
  negatively correlated with I.Q.
• SIB seen in as many as 15-20 of people with MR,
  and much higher in profound MR
• Estimate of up to 2/3 of people with MR who
  reside in public residential facilities show SIB
  (Baumeister and Forehand, 1973)

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Treatment of S.I.B.

• Pharmacological
• SSRIs High doses appear to be effective in
  many cases. Fluoxetine was studied in two
  double blind placebo studies and shown to have
  benefit in reducing SIB. First choice in OCD
  spectrum disorders.

Coccaro, E. F., Kavoussi, R. J., Hauger, R. L.
(1997b). Serotonin function and antiaggressive
response to fluoxetine a pilot study. Biological
Psychiatry, 42(7), 546-552
18
Treatment of S.I.B.

• Pharmacological
• Naltrexone (opiate antagonist) found to be
  effective in about half the patients with
  stereotypic type of self injury.
• May have therapeutic window in dosing.
• No one has yet done a placebo-controlled
  double-blind crossover study that controls for
  type of behavior as well as psychiatric
  diagnosis.

Buzan, R. D., Thomas, M., Dubovsky, S. L.,
Treadway, J. (1995). The use of opiate
antagonists for recurrent self-injurious
behavior. Journal of Neuropsychiatry and Clinical
Neurosciences, 7(4), 437-444
19
Treatment of S.I.B.

• Pharmacological
• Anti-psychotics Clozapine, Risperidone,
  Olanzapine, Fluphenazine
• Other medications studied
• Lithium
• Carbamazepine
• Beta Blockers
• Baclofen
• Stimulants
• Clonidine
• Amantadine

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Treatment of S.I.B.

• Non-Pharmacological
• ECT - has shown benefit in a few case reports for
  major or severe self-injury
• Cognitive Behavioral Therapy combat the
  cognitive distortions and beliefs that SI is an
  acceptable form of managing feelings
• Behavior Modification eliminate some behaviors
  and develop others, operant conditioning

Jones, A.B. (2001). Self-injurious behavior in
children and adolescents, Part II Now what? The
treatment of SIB, KidsPeace Healing Magazine
21
Treatment of S.I.B.

• Non-pharmacological
• Addiction Model Used in more chronic cases to
  develop a sense of regaining control over ones
  life in realistic way. Emphasizes techniques to
  build up time between having urges and acting
  upon urges.
• Psychodynamic Therapy help identify attachments
  
• Aims of Therapy - tolerate greater intensities
  w/o resorting to self harm, develop ability to
  articulate emotions and needs, learn coping
  skills, problem solving, anger management,
  conflict resolution, and assertiveness training

22
Gender Issues with S.I.B.

• Estimated that 67 of self-injurers are female
  (Miller 1994).
• Many other studies link increased rates of
  suicide attempts and SIB in female whereas males
  show greater suicide mortality rates.
• Males select more dangerous methods of self harm
  and are therefore more likely to receive medical
  attention. Same number of males and females
  present to the hospital (Cantor 2000).

23
Gender Issues with S.I.B.

• Genital self-mutilation reported in higher
  numbers in males than females. Reason may be
  because castration is more dramatic than cutting,
  so its reported more frequently.

Alao, O Adekola Female Genital Mutilation.
Psychiatric Services 50971 1999
24
Gender Issues with S.I.B.

• Sexual Orientation A longitudinal study of a
  cohort of 1037 individuals in New Zealand showed
  a strong, statistically significant link between
  same sex attraction and SIB. Men, more so than
  women, showed higher risks for self-harm with
  greater degree of same-sex attraction.

Skegg, Karen Sexual Orientation and Self Harm in
Men and Women. Am J Psychiatry 160541-546, March
2003
25
Cultural Issues with S.I.B

• Body Modification -piercings and tattoos may be
  rituals or practices.
• Rituals reflect community tradition, underlying
  symbolism, healing, expressions of spirituality,
  social order marking
• Practices may be fads, for ornamentation, and
  identification for a cultural group

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Cultural Issues with S.I.B.
Culturally sanctioned forms of SIB can be seen as
rituals for country festivals, as government
protests, and religious customs.
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Cultural Issues with S.I.B.
There is a recent rise in SIB in todays society.
Media exposure through musicians such Marilyn
Manson, movies such as Girl Interrupted, and
admissions of SIB from celebrities such as Johnny
Depp and Angelina Jolie has increased social
acceptance and awareness. In addition, the
phenomenon of Cutter Clubs has further
supported the concept of social remodeling.