SELF-MUTILATION

Introduction to Self Injury

DEFINITION OF SELF-MUTILATION
Several definitions of this phenomenon exist. In fact, researchers and mental health
professionals have not agreed upon one term to identify the behavior. Self-harm,
self-injury, and self-mutilation are often used interchangeably.

Some researchers have categorized self-mutilation as a form of self-injury. Self-injury is
characterized as any sort of self-harm that involves inflicting injury or pain on one’s own
body. In addition to self-mutilation, examples of self-injury include: hair pulling, picking
the skin, excessive or dangerous use of mind-altering substances such as alcohol, and
eating disorders. Favazza and Rosenthal (1993) identify pathological self-mutilation as the deliberate alteration or destruction of body tissue without conscious suicidal intent.
Self-mutilating behavior does exist within a variety of populations. For the purpose of
accurate identification, three different types of self-mutilation have been identified:
1) superficial or moderate; 2) stereotypic; and 3) major. Superficial or moderate
self-mutilation is seen in individuals diagnosed with personality disorders (i.e. borderline
personality disorder).
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 nurturing 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. This child experiences
rage, but cannot express that rage toward anyone but him or herself. Consequently,
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.” In this case, self-mutilative behavior serves to center the person
(Levenkron, 1998, p. 48).

REASONS FOR SELF-MUTILATING BEHAVIOR
Individuals who self-injure often have suffered sexual, emotional, or physical abuse from
someone with whom a significant connection has been established such as a parent or
sibling. This often results in the literal or symbolic loss or disruption of the relationship.
The behavior of superficial self-mutilation has been described as an attempt to escape
from intolerable or painful feelings relating to the trauma of abuse.
The person who self-harms often has difficulty experiencing feelings of anxiety, anger,
or sadness. Consequently, cutting or disfiguring the skin serves as a coping
mechanism. The injury is intended to assist the individual in dissociating from immediate
tension (Stanley, Gameroff, Michaelson & Mann, 2001).

CHARACTERISTICS OF INDIVIDUALS WHO SELF-MUTILATE
Self-mutilating behavior has been studied in a variety of racial, chronological, ethnic,
gender, and socioeconomic populations. However, the phenomenon appears most
commonly associated with middle to upper class adolescent girls or young women.
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 unexpressable rage, and a sense of powerlessness. An additional
characteristic identified by researchers and therapists is the inability to verbally express
feelings.

COMMON MISCONCEPTIONS OF
SELF-MUTILATION

Suicide
Stanley et al., (2001) report that approximately 55%-85% of self-mutilators have made
at least one attempt at suicide. Although suicide and self-mutilation appear to possess
the same intended goal of pain relief, the respective desired outcomes of each of these
behaviors is not entirely similar.
Attention-seeking behavior
Levenkron (1998) reports that individuals who self-mutilate are often accused of “trying
to gain attention.” Although self-mutilation may be considered a means of
communicating feelings, cutting and other self-harming behavior tends to be committed
in privacy.
Dangerousness to others
Another reported misconception is that those individuals who commit self-harm are a
danger to others. Although self-mutilation has been identified as a characteristic of
individuals suffering from a variety of diagnosed pathology, most of these individuals are
functional and pose no threat to the safety of other persons.
TREATMENT OF THE INDIVIDUAL WHO SELF-MUTILATES
Methods employed to treat those persons who self-mutilate range on a continuum from
successful to ineffective. Those treatment methods that have shown effectiveness in
working with this population include: art therapy, activity therapy, individual counseling,
and support groups. An important skill of the professional working with a self-harming
individual is the ability to look at wounds without grimacing or passing judgment
(Levenkron, 1998). A setting that promotes the healthy expression of emotions, and
counselor patience and willingness to examine wounds is the common bond among
these progressive interventions (Levenkron, 1998; Zila & Kiselica, 2001).

CONCLUSION
Research shows that self-mutilation has been in existence far longer than the
understanding and accurate conceptualization of the phenomenon. Therapeutic
interventions have improved substantially over the past two decades. However, further
study is imperative to insure that those who practice the behavior continue to receive
effective care.

Article Summary
Self-mutilation is common in borderline personality disorder, but this pattern of behavior does not usually carry suicidal intent. Instead, it serves other functions, including regulation of dysphoric affect, communication of distress, expression of emotions, and coping with dissociative states. Multiple causal factors, including biological, psychological, and social risks, influence thresholds for self-mutilation. Management of this behavior can be informed by understanding its psychological functions. This review made use of both MEDLINE and PsycINFO databases, identifying all English articles between 1980 and 2004. This review will focus on the pattern seen in BPD: repetitive, nonlethal self-injury without intent to die.
Self-mutilation began to be discussed in the psychiatric literature only several decades ago, in a series of clinical reports and reviews 8–13 that described patients who repeatedly, but superficially, cut their wrists.it occurs in serious psychopathology, most particularly mental retardation, schizophrenia, and personality disorders,14–16 and it is especially common in BPD.1
Although self-injury often lacks suicidal intent, it can perform other psychological functions, several of which have been suggested in the BPD literature. The first (and most often discussed) is that self-injury can provide relief  from negative mood states. Since self-mutilation tends to reduce dysphoria resulting from stressful life events, it can become a habitual method of dealing with psychological distress, reduce distress , communicate distress and obtain care . express emotions in a symbolic fashion. derives from its connection with dissociative phenomena.

FUNCTIONS OF SELF-MUTILATION IN BPD
Descriptor  for self-mutilation. Provides psychological functions provide relief from negative mood states. Since self-mutilation tends to reduce dysphoria resulting from stressful life events, it can become a habitual method of dealing with psychological distress in such cases the behavior comes to function like an addiction; distraction is another mechanism by which self mutilation can reduce distress in BPD physical injury tends to refocus the patient’s attention away from mental pain to physical pain. used to communicate distress and obtain care from other people—significant others as well as therapists, express emotions in a symbolic fashion, describe cutting as a self-punishment related to guilty feelings or as a way of expressing anger that cannot be communicate, it derives from its connectionwith dissociative phenomena. BPD patients may experience dissociation as dysphoric or may be in a dissociated state when they cut. BPD has been shown to have a strong associationwith multiple comorbidities, affective instability and impulsivity
Self-mutilation in BPD is associated with a history of abuse in childhood, could be due to social environment—in particular, from learning (through imitation) of behaviors observed in other patients or in the media
If one of the primary functions of self-injury is to reduce dysphoria, then therapy needs to identify the causes of that dysphoria and to help patients find better ways of dealing with emotions
TREATMENT :
Linehan’s dialectical behavior therapy (DBT), which is specifically designed to target parasuicidal behaviors by improving emotion regulation, Controlled trials in several settings have shown that self-mutilation in BPD can be reduced by DBT within a year of treatment, yielding results significantly better than treatment as usual. While other forms of cognitive-behavioral therapy (CBT) have been proposed for BPD, they have not yet been subjected to empirical testing. In a randomized controlled trial psychodynamically oriented outpatient therapy other methods used are “mentalization-based treatment” (MBT), designed to reduce impulsive behaviors in BPD by increasing self-observation, have been encouraging.selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, and naltrexone

Abstracts

Title: Reported childhood onset of self-mutilation among borderline patients.
Authors: Zanarini MC; Frankenburg FR; Ridolfi ME; Jager-Hyman S; Hennen J; Gunderson JG
Abstract: The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.

Title: Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder.
Author(s): Chengappa KN; Ebeling T; Kang JS; Levine J; Parepally HAbstract:
Abstract:  The  seven subjects, all white women with a mean age of 37 years were selected for careful chart audits. All subjects carried DSM-III-R or DSM-IV borderline personality disorder diagnoses and an Axis I disorder diagnosis. These subjects had been admitted to 2 state psychiatric hospitals owing to severe self-mutilation and/or violence and subsequently treated with clozapine. After clozapine treatment, there were statistically significant reductions in incidents of self-mutilation (restraint), seclusion, the use of p.r.n. antianxiety medications, and injuries to staff and peers. It is thus concluded that clozapine deserves careful consideration for a controlled study in patients with borderline personality disorder and psychoses, especially if the clinical issues include severe self-mutilation, aggression, and violence.

Title: Clinical correlates of self-mutilation in borderline personality disorder.
Author(s): Dulit RA; Fyer MR; Leon AC; Brodsky BS; Frances AJ
Abstract: Among 124 consecutively admitted inpatients with borderline personality disorder, there were 62 who did not mutilate themselves, 23 who mutilated themselves infrequently (fewer than five lifetime events), and 39 who mutilated themselves frequently (five or more lifetime events); each received ratings on numerous measures of psychopathology.
The results found that compared to nonmutilators, frequent mutilators were significantly more likely to be in outpatient treatment at the time of admission and had more weeks of prior outpatient and inpatient treatment; they were also more likely to receive comorbid diagnoses of current major depression, anorexia nervosa, and bulimia nervosa. Frequent mutilators had significantly higher group means on the Beck Scale for Suicidal Ideation, were more likely to have attempted suicide, and were more likely to have attempted suicide more often than both infrequent mutilators and nonmutilators. The adjusted odds ratios from logistic regression analyses demonstrated that major depression, bulimia nervosa, number of prior suicide attempts, and acute suicidal ideation were each associated with greater risk of frequent mutilation. CONCLUSIONS: Borderline patients who frequently mutilate themselves may represent a subgroup of especially high utilizers of psychiatric treatment who are at particularly high risk for suicidal behavior and for comorbid major depression and eating disorders. Clinicians should consider aggressive treatment of comorbid axis I disorders and careful assessment of suicide risk in these patients.

Title: Professional attitudes towards deliberate self-harm in patients with borderline personality disorder.
Author(s): Commons Treloar AJ; Lewis AJ
Abstract: The aim of the present study was to assess the attitudes of mental health and emergency medicine clinicians towards patients diagnosed with borderline personality disorder. A purpose-designed questionnaire and an assessment tool to quantify attitudinal levels were used to collect demographic information and assess the attitudes of 140 mental health and emergency medicine practitioners across two Australian health services and a New Zealand health service. Statistically and clinically significant differences were found between emergency medical staff and mental health clinicians in their attitudes towards working with borderline personality disorder. The strongest predictor of attitudes was whether the clinician worked in emergency medicine or mental health. This was followed by years of experience and specific training in personality disorders as significant predictors of attitudes to self-harm. The implications of these findings for the professional training of clinicians in the management and treatment of borderline personality disorder patients are discussed.

References

Introduction
Simpson, Chris  (2001-12-00). Self-Mutilation. ERIC/CASS Digest. 1-4, ERIC Digests, http://www.eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/1a/26/aa.pdf ERIC

Articles
Paris J (2005). Understanding self-mutilation in borderline personality disorder. Harvard Review Of Psychiatry [Harv Rev Psychiatry] 2005 May-Jun; Vol. 13 (3), pp. 179-85. 16020029, http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=16020029&site=ehost-live                                                                                                                 MEDLINE

Abstracts
[Zanarini MC; Frankenburg FR; Ridolfi ME; Jager-Hyman S; Hennen J; Gunderson JG (2006) Reported childhood onset of self-mutilation among borderline patients. [Journal of Personality Disorders (J PERS DISORD), 2006 Feb; 20(1): 9-15 (26 ref) 2009285665. http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2009285665&site=ehost-live, CINAHL with Full Text
Chengappa KN; Ebeling T; Kang JS; Levine J; Parepally H (1999), Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. The Journal Of Clinical Psychiatry [J Clin Psychiatry] 1999 Jul; Vol. 60 (7), pp. 477-84. 10453803Database: http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=10453803&site=ehost-live, MEDLINE

Dulit RA; Fyer MR; Leon AC; Brodsky BS; Frances (1994) Clinical correlates of self-mutilation in borderline personality disorder.The American Journal Of Psychiatry [Am J Psychiatry] 1994 Sep; Vol. 151 (9), pp. 1305-11.8067485 http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=8067485&site=ehost-live, MEDLINE

Commons Treloar AJ; Lewis AJ (2008) Professional attitudes towards deliberate self-harm in patients with borderline personality disorder. The Australian And New Zealand Journal Of Psychiatry [Aust N Z J Psychiatry] 2008 Jul; Vol. 42 (7), pp. 578-84. 18612861 http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=18612861&site=ehost-live, MEDLINE