Deliberate SelfHarm: Definition

1
Deliberate Self-Harm Definition
The direct, deliberate destruction or alteration
of body tissue without conscious suicidal intent
but resulting in injury severe enough for tissue
damage to occur. (Pattison Kahan, 1983 Gratz,
2001).

• This includes
• Cutting
• Burning
• Carving skin
• Sticking with pins, needles
• Biting
• Punching self
• Banging head
• Severe scratching
• Wound interference

• It does not include
• Piercing or tattooing
• Overdosing/self-poisoning
• Substance abuse
• Eating disordered behaviors
• Self-injurious behavior
• associated with MR/DD
• Self-harm behaviors with
• suicidal intent

2
Terminology

• Deliberate self-harm is sometimes called
• Self-injurious behavior
• Non-suicidal self-injury
• Parasuicide
• Suicide gesture
• Self-mutilation
• We use deliberate self-harm because it is the
  least pejorative and least stigmatizing of these
  terms. It is also the term suggested in one of
  the seminal papers in the field.

3
Favazzas Typology of Self-Mutilation (1988)

• Major Self-Mutilation
• Rare and typically seen in people with psychotic
  disorders, mania or severe drug intoxication.
• Includes severe self-mutilating behaviors such as
  eye enucleation or amputation of limbs,or
  self-castration.
• Explanations given are usually based in religious
  or sexual delusions, or delusions of sinfulness.
• Identification with Christ
• Biblical or demonic influence
• Commands from God
• Desire to be female
• Control of sexuality

Favazza, 1988 Favazza, 1989, Favazza, 1998
4
Favazzas Typology of Self-Mutilation (1988)

• Stereotypic Self-Mutilation
• Common among individuals with mental retardation
  and developmental disabilities (autism,
  Lesch-Nyhan disease, Tourettes syndrom)
• Includes behaviors such as scratching, biting,
  head-banging, oral injuries (biting/picking of
  lips, gums)
• Hypotheses for this type of behavior
• Social reinforcement (behavior decreases in the
  absence of adults)
• Negative reinforcement (the behavior is used to
  end an aversive situation, such as classroom
  time)
• Self-stimulation in the absence of adequate
  neurosensory stimulation, an individual will
  engage in self-harming behavior to stimulate
  himself (also found in normal-intelligence
  infants and animals).

5
Favazzas Typology of Self-Mutilation (1988)

• Moderate/Superficial Self-Mutilation
• Most commonly seen in women, with onset in
  adolescence
• Most common form is skin cutting, though 75 use
  multiple methods
• Numerous, wide-ranging explanations for the
  behavior
• Tension release
• Anti-dissociation
• Interpersonal control/influence
• Social functions (identity formation, group
  membership)

6
Prevalence

• Community Samples
• Adolescents 13-16 (Ross Heath, 2002
  Muehlenkamp Gutierrez, 2004)
• College Students 17-36 (Gratz, 2001 Whitlock
  et al. 2006 Brown et al. 2007)
• Adults 4 (Klonsky, et al., 2003 Briere
  Gil, 1998)
• Clinical Samples
• Inpatient adolescent 24-82 (Taimenin et al.
  1998 Rosen Walsh, 1989 Nock Prinstein,
  2004)
• Inpatient adult 21-35 (Briere Gil, 1998
  Paul et al. 2002)
• Inpatient BPD 75-80 (Soloff, 1994 Shearer et
  al., 1988)

7
Who Self-Harms?

• Men and women engage in the practice equally,
  though women are more likely to seek treatment.
• Most people begin in adolescence or in their
  early twenties, and the behavior tends to
  decrease in the 40s and 50s.
• Those who start earlier are somewhat more severe
  and DSH may be more persistent
• No association with race or SES
• LGBT have a higher rates of DSH

8
Risk Factors

• The most consistent risk factor for DSH is
  childhood abuse-- physical, sexual, emotional
  abuse and neglect.
• For men only, childhood separation from the
  father is a risk-factor
• Familial alcohol abuse
• Dissociation

9
Deliberate Self-Harm and Suicide

• Although some clinicians and researchers put DSH
  on a continuum with suicide
• both acts embrace a self-destructive drive
  towards death (Suyemoto, 1998)
• DSH is a compromise to avoid suicide (Walsh
  Rosen, 1988)
• DSH differs from suicide only in clarity,
  intensity and expectation (Brown et al. 2002
  Linehan, 1993).
• Most self-harmers describe DSH as distinct from
  suicide both in intent and the emotional
  processes involved.
• However, many individuals who self-harm also
  report suicide ideation or suicide attempts.
• In clinical and community samples of adolescents
  and young adults, 28-39 of those with
  moderate-severe or repeated DSH reported suicidal
  ideation, plans, or attempts. (Lloyd-Richardson
  et al. 2007 Walsh Rosen, 1988 Whitlock et al.
  2006)

10
Deliberate Self-Harm and Suicide

• Different Reasons for Suicide Attempts and DSH
  (Brown et al. 2002)
• DSH Feeling generation, self-punishment, anger
  expression, distraction (among other reasons)
• Suicide attempt to make others better off (among
  other reasons)
• Evidence of different emotional processes
  (Chapman Dixon-Gordon, 2007)
• DSH relief was the most common emotional
  consequence
• DSH associated with a positive shift in emotions
  69 of the time
• Suicide attempt Anger and guilt were the most
  common emotional antecedents and the most common
  emotional consequences.
• Other researchers have suggested that the
  difference between suicide and DSH is that those
  who commit suicide experience before the suicidal
  act, and those who self-harm experience relief
  afterward (Walsh Rosen, 1988)
• DSH could be anti-suicide
• DSH alleviates dissociated, depersonalized,
  deadened states and therefore moves the
  self-harmer toward feeling more alive.

11
Functions of Deliberate Self-Harm

• One of the most difficult tasks in attempting to
  understand any pathological behavior is
  discerning why this particular behavior at this
  particular time to serve this particular function
  for this particular patient (Suyemoto, 1998,
  537).
• In understanding deliberate self-harm, the task
  is to understand the functional aspects of the
  behavior.

12
Related Diagnoses

• In the DSM-IV, DSH is only listed as criteria for
  BPD but it is commonly seen in several other
  clinical populations.
• Borderline Personality Disorder 75-80
  (Herpertz, 1995)
• Eating disorders 40-85 of ED patients (Claes,
  Vandereycken Vertommen, 2001, 2003 Paul et al.
  2004 Linehan et al. 2006 Herpertz, 1995)
• Depression 35-96 (Kumar et al. 2004 Briere
  Gil Matsumoto, 2004, Soloff, 1994 Linehan et
  al. 2006)
• Substance abuse 25-30 (Briere Gil, Matsumoto,
  2004 Linehan et al. 2006)
• Posttraumatic Stress Disorder 50 (Matsumoto,
  2004 Linehan, 2006)
• Any psychiatric comorbidity 41-87 (McAuliffe et
  al. 2001 Lloyd-Richardson et al. 2007 Kumar et
  al. 2004)

13
DSH in BPD

• DSH has been called the behavioral specialty of
  BPD occurs in 75-80 of those with BPD (Gratz
  Gunderson, 2006)
• Emotion regulation function The hallmark of BPD
  is emotional distress (chronic feelings of
  hopelessness, depression, anger, anxiety),
  coupled with ineffective attempts to regulate
  emotions.
• Interpersonal influence?

14
Nock and Prinsteins Function Subscales

• Automatic-Negative Reinforcement
• Relief from aversive internal states makes the
  behavior more likely
• To stop bad feelings to relieve dissociated
  states
• Automatic-Positive Reinforcement
• A desirable internal consequence makes the
  behavior more likely
• To feel something, even pain to punish yourself
  to feel relaxed
• Social-Negative Reinforcement
• Relief from a negative external experience makes
  the behavior more likely
• To get out of something you dont want to do to
  avoid punishment to avoid other people
• Social-Positive Reinforcement
• A desirable social/external consequence makes the
  behavior more likely
• To get control of a situation to get a reaction
  from others to give yourself something to do
  when youre alone to get attention
• 
  
• (Nock Prinstein, 2004)

15
Emotion Regulation Model of DSH(automatic-negativ
e reinforcement)

• 96 of self-harmers (with BPD) reported that
  emotion release was the reason for the behavior.
  (Brown et al. 2002)
• Emotional dysregulation develops through a
  combination of individual risk factors (emotional
  reactivity and intensity) and environmental risk
  factors (invalidating environments that fail to
  teach strategies for emotion regulation.
• DSH may develop as a way to manage intense or
  out-of-control emotions. It may serve to
• Reduce anxiety - Release tension
• Release anger - Provide a sense of control
• Relieve guilt, loneliness - Concretize
  emotional pain
• Terminate dissociation - Stop racing thoughts
• Gratz, 2003 Briere Gil, 1998 Connors,
  1996 Linehan, 1993

16
Chapman, Gratz Browns Experiential Avoidance
Model

• Experiential avoidance any effort to avoid or
  escape internal experiences or the situations
  that produce them
• Experiences thoughts, feelings or physical
  sensations
• Avoidance strategies thought suppression,
  avoidance substance abuse, DSH.
• Avoidance is negatively reinforced since, when
  you avoid, immediate discomfort is reduced. This
  relationship becomes very strong after repeated
  experiences.

17
Chapman, Gratz Browns Experiential Avoidance
Model

• In the long term, thought suppression tends to
  increase distress, increase the frequency of
  distressing thoughts and increase the likelihood
  of a rebound effect from the suppressed emotional
  experience (ie temporary relief leads to greater
  anxiety)
• Avoidance decreases the likelihood of extinction
  of unwanted emotions and prevents the individual
  from learning that aversive emotional states,
  while unpleasant, are not threatening.

18
Interpersonal Functions?

• Often clinicians, family members and friends of
  self-harmers are influenced by the behavior so
  they assume that the self-harmers intent is
  manipulation or control. (Linehan, 1993 Favazza,
  1989 Gratz, 2003).
• There is some evidence of interpersonal an
  expressive functions of self-harm (Nock
  Prinstein, 2004 Favazza, 1989), and also that
  the interpersonal functions might be an
  unintended consequence or secondary to the
  emotion regulation functions.
• In studies of DSH, interpersonal influence is
  never given as the primary reason for the
  behavior.
• However, there seems to be another subset of
  self-harmers who never disclose that they engage
  in the behavior.
• 35 of self-harmers reported that they never
  told anyone about it (Whitlock, 2006)

19
Empirically Supported Treatment

• Emotion-Regulation Group Treatment Gratz
• 14-week emotion-regulation group therapy (added
  to other therapies).
• Draws on DBT and Acceptance and Commitment
  Therapy, with emphasis on
• Identification of functions of DSH
• Emotional clarity and awareness, functions of
  emotions
• Benefits and consequences of emotional acceptance
  (ie that non-acceptance may amplify negative
  emotions) pain vs suffering
• Identifies valued directions and commitment to
  valued actions
• Treatment participants showed significant
  decreases in DSH, depression, emotional
  dysregulation, stress and anxiety.