SELF-INJURIOUS BEHAVIORS

							   SELF-INJURIOUS
    BEHAVIORS IN
   ADOLESCENTS
    Pamela Campbell, M.D.
Associate Professor of Psychiatry
    SIU School of Medicine
                 Terminology
• Called by many different names:
  1.   Self-injurious behaviors (SIB)
  2.   Cutting
  3.   Self mutilation
  4.   Nonsuicidal, deliberate self injury
  WHAT ARE SELF-INJURIOUS
        BEHAVIORS?


• Self-injurious behaviors (SIBs) are defined
  as all behaviors involving the deliberate
  infliction of direct physical harm to one’s
  own body, internally or externally, with no
  intention to die as a result.
• Behaviors not sanctioned by the culture
        WHAT IS NOT SIB?

• Culturally Accepted Behaviors, including
1.  Body Piercing
2.  Tattoos
3.  Culturally ritualized self-injury
     CLASSIFICATION OF SIBS

•   Compulsive
•   Stereotypic
•   Major
•   Impulsive
           COMPULSIVE SIB
• Defined as repetitive, often ritualistic behaviors,
  usually occurring several times per day
• Includes trichotillomania (hair pulling),
  onychophagia (nail biting) and skin picking or
  scratching
• Most frequently seen in Tourette’s Syndrome
  and OCD
• More anxiety based symptom
• More easily defined as a habit, often
  unconscious
• Injury is not the goal
            Interventions
• Cognitive Behavioral Therapies
• Pharmacological
         STEREOTYPIC SIB
• Occurs Primarily in the Autistic Spectrum and
  Mental Retardation Groups
• Usually highly repetitive, rhythmic
• Usually not a conscious process with no specific
  meaning
• Not intended to cause pain
• Appears to be more biologically driven than
  other SIBs
• Significant overlap with compulsive SIB
    SYNDROMES WITH SIB
• Lesch-Nyhan: X-linked recessive
  disorder-will chew on self
• Cornelia de Lange Syndrome: rare
  congenital syndrome with excessive
  grooming and SIB, etiology unknown
• Prader-Willi: congenital disorder with
  abnormalities of chromosome 15-picking
  behaviors
         INTERVENTIONS
• SSRIs and antipsychotics have primary
  role
• Naltrexone and Fenfluramine have mixed
  to negative results
• Behavioral approaches
              MAJOR SIB
• Involves serious mutilation-cutting off
  genitalia or extremities, enucleating the
  eyes
• Usually associated with psychotic states,
  intoxication, and dissociative states
• Genital mutilation is most common
• Frequently associated with increased
  threshold for pain
        PHENOMENOLOGY
• Occurs primarily in psychotic individuals,
  usually schizophrenia, occasionally
  affective psychosis
• Frequently associated with religious
  delusions, sin and/or guilt
• Usually little or no pain reported
            INTERVENTIONS

•   Focus on the underlying pathology
•   Antipsychotics
•   Mood stabilizers
•   Antidepressants
•   ECT
             IMPULSIVE SIB
• A type of impulsive aggression with the goal of
  rapidly relieving intolerable states
• Includes skin cutting, burning, sticking pins or
  other sharp objects into the skin and self-hitting
  using one’s own body parts or other objects
• Heterogeneous phenomenon
• Typically begins in adolescence
• The usual intent is to cause pain and relieve
  tension
             WHO DOES IT
• Encompasses a wide range of diagnoses,
  including personality disorders, dissociative,
  depressive and anxiety disorders, including
  PTSD and eating disorders
• Predominantly female, but does occur in males
• Frequency is unclear, estimates include 1 per
  1000 individuals, however, it is a secretive
  disorder
• Usually starts in adolescence and continues into
  adulthood
        HISTORICAL NOTE
• SIB has been described for many years-first
  reports in literature in 1877
• Frequently associated with eating disorders
• Increased incidents beginning in the 1960s
• Previously, found predominately in borderline
  personality disorder
• Usually adult women
• Generally an impulsive and angry action
• Occurs during high levels of stress or intense
  emotional states
                ADOLESCENT SIB
                The New Epidemic
•   One study of a community
    sample of teenagers found
    13-23% reporting SIB
    (Jacobson CM, Gould M. Arch Suicide Res.
    2007)

•   Another study found 46%
    had engaged in some form
    of SIB and 28% were
    engaging in repetitive SIB
    (Lloyd-Richardson EE, etal. Psychol Med 2007)
                  Functions of SIB
•    D. Klonsky (Clinical Psychology Rev.
     2007) identified 7 hypothesized
     functions for SIB in the adult
     literature:
1.   Affect-regulation: to alleviate acute
     negative affect or arousal
2.   Anti-dissociation: alleviate
     depersonalization
3.   Anti-suicide: to avert suicidal wishes
4.   Interpersonal Boundaries: to assert
     autonomy or distinction from others
      Functions of SIB(cont.)
5. Interpersonal-influence: to
   manipulate others
6. Self-punishment: to
   express anger toward
   onself
7. Sensation-seeking: to
   generate excitement
       Functions of SIB(cont.)
• Messer and Fremouw (Clinical
  Psychology Review; In Press)
  reviewed available literature for
  Adolescent SIB
• Findings were very similar, with
  affect regulation, interpersonal
  influence and preventing
  depersonalization as being the
  most common goals of the
  behavior.
              Review Data
• Strongest support for
  affect regulation and self-
  punishment
• Modest support for others
            Trauma and SIB
•   SIB is a frequent symptom in those with abuse
    history
•   Frequently associated with neglect and
    abandonment in addition to abuse
•   Dissociated memories struggling to become
    conscious and resolved are maintained
    through the SIB
•   Traumatized children have difficulties
    expressing internal emotional states
    (alexithymia) resulting in development of
    alternative means for expressing ones needs
            Addictive Quality
• SIB can serve to reduce dysphoria or induce
  euphoria
• It also serve to distract from troubling thoughts
  and conflicts
• Patterns of extreme reactions to relative minor
  stressors and stress responses that do not
  extinguish over time, similar to addiction
• SIB serves as a quick and powerful method of
  self regulation
        CLINICAL CONCERNS

•   SIB can be highly addicting
•   SIB can spread rapidly among teenagers
•   SIB can continue for decades
•   By definition suicide is not the intent,
    however, 60% of individuals with impulsive
    SIB will have suicide attempts as well
  SEQUENCE OF EVENTS
• 1. A precipitating event-usually involves
  real or perceived loss, rejection, or
  abandonment
• 2. Escalation of intolerable affect
• 3. Attempts to resist
• 4. Self injury
• 5. Short lived affective relief
                Thirteen
• Graphic representation of impulsive self-
  injury
   EVALUATION AND
 TREATMENT OF SELF-
INJURY AND SUICIDE IN
    ADOLESCENTS
           ASSESSMENT
• A thorough evaluation by a mental health
  provider
• Psychiatric assessment for possible
  medication intervention
           ASSESSMENT
•  Newly identified Impulsive SIB does not
   require a visit to the emergency room,
   unless:
1. The injuries require stitches or other
   medical intervention
2. Serious suicidal ideation is present
    ASSESSMENT OF SUICIDAL
          IDEATION
• Determination of active intent to die, not passive
  wish to escape pain
• Feelings of hopelessness and/or helplessness
• Withdrawal from social/family activities
• Change in school performance
• Substance abuse, weapons in home, history of
  violence or previous attempts
• Current, specific plan to kill self
• Inability to contract for safety
• Parents or guardians feel unable to monitor for
  safety
        The Choking Game
• Form of impulsive behavior
• Goal of inducing a “high” by choking
  oneself or another
• Estimates of 500 deaths and injuries per
  year
• Activity performed in groups and alone
• Most dangerous when attempted alone
    The Choking Game cont.
• Involves having a peer squeeze neck or
  chest to cause loss of oxygen
• When performed alone, requires use of
  ligature
• Also used in enhance sexual experience,
  either alone or with partner
              Warning Signs
•   Frequent headaches
•   Bruising or marks on neck
•   Bloodshot eyes or petechiae
•   Changes in attitude
•   Confusion or grogginess after being alone
•   Increased need for privacy
•   Questions about asphyxiation
        Warning Signs cont.
• Locked or secured bedrooms/bathrooms
• Ligatures tied in strange knots or in
  unusual places
• May use bed sheets, belts, t-shirts, ties or
  ropes
• Wear marks on furniture
                 Treatment
•   Pharmacologic interventions
•   Behavioral interventions
•   Individual and group interventions
•   Family therapy
PHARMACOLOGIC TREATMENT

• No medications are approved or
  particularly studied for impulsive SIB
• Medications cannot address the dynamics
  leading to impulsive SIB
• Medications can lessen the intensity of
  affect and experiences and help create a
  more favorable climate for treatment
PHARMACOLOGIC TREATMENT

• Most studies involve small numbers and
  open label
• SSRIs helpful in Borderline Disorders
• Mood stabilizers most helpful in mood
  disorders, not Borderline
• Very limited data on opioid antagonists,
  Beta blockers, neuroleptics, and MAOIs
FOUNDATION OF THERAPEUTIC
     INTERVENTIONS
• SIB can be viewed as the result of limited
  problem solving skills and emotional
  dysregulation.
• Patients report experiencing intolerable
  anxiety and tension, depersonalization and
  experience relief after SIB.
• Both anger and shame are majoring
  driving emotions.
        EARLY INTERVENTIONS
• Initial approach is to try and substitute another behavior
  for the SIB
• Examples include using a rubber band or ice to cause
  pain but no injury, tear paper, bounce or squeeze an
  object, write, things to keep hands busy
• Each case needs to identify the best option
• One designated person to monitor for SIB
• Most SIB occurs in isolation, discourage social
  withdrawal
• Remove items used for SIB-this will not eliminate the
  behavior but emphasize the concern
      DIALECTIC BEHAVIORAL
            THERAPY
• Has been shown to be effective in controlled
  trials with Borderline Patients
• Involves weekly individual psychotherapy and
  skills training groups
• Skills training focusing on 4 main areas:
  emotion regulation, distress tolerance,
  interpersonal effectiveness and reduction of
  identity confusion and maladaptive cognitions.
• Usual duration of treatment is one year.
       VARIOUS THEORIES
• SIB serves to establish a clear sense of
  boundary
• Provides a sense of control and power
• Method of breaking through intolerable
  dissociation to feel alive again
• Also can be a method to induce dissociation
  from intolerable affect
            THEORIES cont.
• SIB is viewed as an attempt to communicate
  desperate needs or intense anger
• Behavior is triggered by perceived rejection or
  abandonment
• Subjects have a lack of connection between
  their actions and the environment
• Serves to engage others in nurturing and
  absolves the client from responsibility
       TREATMENT GOALS
•   Increase tolerance and capacity to
    regulate affect
•   Learn to identify feeling states
•   Develop more adaptive ways of coping
    with the intense affect
•   Adjustments in the approach to
    interacting with the environment
           Family Therapy
• Self-injurious behavior does not occur in
  isolation
• Behavior is profoundly disturbing to the
  family
• Denial is major
• Exploration of family dynamics
• Support and education for family
                Summary
• Self-injurious behaviors are serious and
  very destructive and can last for decades
• Many different forms and manifestations
• Impulsive SIBs are secretive disorders that
  are easily missed
• Suicide is a serious risk in this population
• Early detection and intervention is
  essential
              BIBLIOGRAPHY
• Bodies Under Siege, Self-mutilation and Body
  Modification in Culture and Psychiatry, Second Edition;
  A. Favazza, M.D., Johns Hopkins Univ. Press, 1996.
• Self-Injurious Behaviors, Assessment and Treatment.
  Edited by D. Simeon and E. Hollander, M.D. American
  Psychiatric Press. 2001.
• Cutting: Understanding and Overcoming Self-mutilation.
  Steven Levenkron, W.W.Norton and Co. 1998.
• Leibenluft,E, etal: The inner experience of the borderline
  self-mutilator. J Personal Disorder 1:317-324, 1987.