Research Article: Self-Injurious Behavior in Adolescents

Date Published: May 25, 2010

Publisher: Public Library of Science

Author(s): Janis Whitlock

Abstract: Janis Whitlock discusses the epidemiology and and care of adolescents undertaking nonsuicidal self-injury, also called “deliberate self-harm.”

Partial Text: What constitutes non-suicidal self-injury (NSSI) is a matter of some debate, but its growing presence in mainstream and popular media as well as the growing number of anecdotal reports by physicians, therapists, and junior and senior high school counselors suggest that it may be, as some have called it, “the next teen disorder” [1]. Referred to in the literature and media as “self-injurious behavior,” “self-injury,” “self-harm,” “self-mutilation,” or “cutting,” self-injury is typically defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned [2]. Although most often not a suicidal gesture, it is statistically associated with suicide and can result in unanticipated severe harm or fatality [3],[4],[5].

Although study of NSSI in adolescence is relatively new, empirical advances in NSSI research over the past several years have resulted in a solid foundation of knowledge about basic epidemiological parameters. Many normally developing youth practice what is typically referred to as common NSSI [6]. This form of self-injury includes NSSI that is (a) compulsive (ritualistic and rarely premeditated such as hair pulling or trichotillomania), (b) episodic (every so often and with no identification as someone who self-injures), and (c) repetitive (performed on a regular basis and with ego identification as someone who self-injures). Common NSSI can be mild, moderate, or severe depending on the lethality of the injuries. Although common NSSI can and does co-occur with other DSM classifiable mental illnesses, such as depression or anxiety, it is also increasingly evident that it presents independently of other mental illness [7].

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]. Much less common but sometimes cited are reasons such as “so someone would pay attention” and “to get a rush or surge of energy.” Both underscore the role of both social and biological roles in maintaining NSSI. 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.

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.e., suicide) by engaging in increasingly severe NSSI over time [36]. 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.K.-based term that includes NSSI and suicide-related behavior), reviewers concluded that the most promising approaches include problem-solving therapy, provision of emergency service contact information, long-term psychological therapy, and depot flupenthixol (for those with repeat self-harm experience). They caution, however, that current knowledge is insufficient and more trials are sorely needed [43]. In a systematic review of NSSI-specific treatment strategies, Muehlenkamp concludes that approaches utilizing largely cognitive-behavioral therapy (CBT) may prove most efficacious in NSSI treatment [44]. 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. 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. Other signs include inappropriate dress for season (consistently wearing long sleeves or pants in summer), constant use of wrist bands/coverings, unwillingness to participate in events/activities that require less body coverage (such as swimming or gym class), and frequent bandages and odd/unexplainable paraphernalia (e.g., razor blades or other implements that could be used to cut or pound). It is important that questions about the marks be non-threatening and emotionally neutral. Treatment veteran Barent Walsh indicates that he has the most success making patients comfortable and gleaning clinically useful information by demonstrating “respectful curiosity” toward individuals with NSSI history [17].

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.



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