Clinical and theoretical issues in self-injurious behavior

Questões teórico-clínicas do comportamento de automutilação

revisão

Clinical and theoretical issues in self-injurious behavior

Questões teórico-clínicas do comportamento de automutilação

Jose A. Yaryura-Tobias¹, Maria C. Mancebo¹, and Fugen A. Neziroglu¹

ABSTRACT

This article presents an overview of pathological self-injurious behavior (SIB). Historical and cultural aspects, epidemiology, classification and clinical aspects and pathogenesis are described. The importance of comprehensive assessment of symptomatology and functions of SIB for treatment planning are discussed.

KEYWORDS

Self-injurious behavior, self-mutilation, psychological treatment, drug therapies, related disorders.

RESUMO

O presente artigo apresenta um panorama do comportamento de automutilação patológica. São descritos aspectos históricos e culturais, epidemiologia, classificação e aspectos clínicos e patogênese. É discutida ainda a importância de uma avaliação compreensiva da sintomatologia e das funções do comportamento para fins de tratamento.

DESCRITORES

Automutilação; tratamento psicológico; terapias medicamentosas;transtornos associados.

Historical and cultural aspects

Human destruction is an ancient developed behavior leading to the loss of hope and eventually death. Human destruction may be identified with the red color, symbolizing danger, blood, and death. Accordingly, those who self-harm may identify themselves with the loss of blood. Society and individuals adopt destructive behavior as a way to meet emotionally and physically driven needs, manifested by injurious acts connoting biopsychosocial pathology. These acts, grouped under the heading of self-injurious behavior (SIB) emerge from heterogeneous causes.

Most social mutilations involve skin and other soft anatomical structures. Several examples may be seen across cultures: perforation of nasal cartilage in certain African and American Indian tribes; perforation of earlobes in Western and Eastern cultures; male circumcision or female clitorectomy as initiation rites, scarification and neck or lip-stretching customs in some African cultures. Tattooing in Middle East countries and body tattooing by soldiers and members of drug subcultures are also common. More recently, fashion trends among adolescents in Western cultures involve body piercing (nose, tongue, eyebrow, naval) and body tattooing.

The semantics of SIB expresses social and biological roles that modify and change clinical concepts related to values, moral codes, or anatomic-chemical and psychological variables pertaining to self-harm. Literally, self-mutilation involves amputation of an essential body part or limb and is usually connected to cultural phenomena or mental disturbances. For our purposes, self-injurious behavior (SIB) describes intentional infliction of bodily injuries to oneself without intent to die¹ or with intent to die.²

Pathological SIB is a direct, socially unacceptable, repetitive behavior that causes minor to moderate physical injury. When self-mutilating, the individual is in a psychologically disturbed state but is not attempting suicide. Nowadays, on an individual basis, the terms "physical injury" and "mutilation" are interchangeable and not necessarily mutually exclusive.

Epidemiology

It jis difficult to estimate lifetime prevalence rates of SIB because patients may not volunteer to provide this information.³ Archival studies are problematic because it is hard to differentiate between suicidal acts and SIB. Many individuals treat their own injuries and thus, data sources such as police or hospital records may underestimate the prevalence of self-injurious behavior.

Favazza and Conterio⁴ estimate the prevalence rate of self-mutilation in the general population of the United States to be between 1% and 2%. Adolescents present the highest risk with reported rates as high as 40%⁵ and 61%.⁶ In a sample of college students, the rate of SIB was 12%.⁷ Hospital emergency room studies indicate a rate of 2.4% of patients presenting SIB.⁸ The rates are higher in psychiatric settings, ranging from 3% to 5%^9,10 and 4% to 20% of psychiatric inpatients.^5,11 Although the literature reports higher rates in women, sex differences do not always exist¹² and there is a paucity of studies that include men in their samples.¹³

Classification

Is SIB a symptom rather than a syndrome? This is a basic question that needs to be addressed in treatment planning. We believe SIB is a symptom that should be treated within the context of the psychiatric disorder in which it is manifested.

SIB has been reported as part of the vast array of symptoms found in individuals suffering from psychiatric disturbances as well as apparently normal infants, children and adults. In the 1960s, researchers began to propose that cutting behaviors be classified as a separate syndrome¹⁴ referred to as the Wrist-Cutting syndrome¹⁵ and Repetitive Self-Mutilation syndrome.¹³

We believe several factors mediate against an independent disorder. One is the inability to observe patient's subjectivity; the other one is the exclusion of SIB in the diagnostic labyrinth of psychiatric taxonomy.¹⁶ SIB has mostly been rejected as a syndrome and accepted as a symptom present in many psychiatric conditions.

Heterogeneous disorders, notably OCD, may insert into each other as a pathological blend¹⁷ known as a continuum or comorbidity. Heterogeneous disorders may share the presence of self-harm as a major symptom. Consequently, clinicians confront the following disorders presenting SIB: mental retardation, Prader-Willi syndrome, Cornelia de Lange syndrome, Lesch-Nyhan syndrome, Gilles de la Tourette syndrome, aggressive disorders, trichotillomania, nail-biting, head banging, anti-social behavior in prison inmates, psychosis, borderline personality disorder, eating disorders, Compulsive-Orectic-Mutilative syndrome, Body Dysmorphic disorder, Post traumatic stress, and substance abuse disorders.^18-23

The classification of pathological SIB considers several variables including: directness of the act, social acceptability, number of episodes, degree of damage, and intent or psychological state of the patient.²⁴ Researchers have examined SIB in the context of eating disorders^22,25 obsessive-compulsive, and impulse disorders.^26,27

Clinical aspects

Patients who self-injure may be secretive about mentioning SIB when they present for a psychiatric examination. Therefore, a physical examination is endorsed. The preferred area of injury is usually the dorsal side of the limbs to avoid large blood vessels. Patients choose either soft or hard tissues to be harmed, or decide for complete excision of a given anatomical part. The most commonly affected area is the skin, by scratching, picking, digging, bruising, burning, and mostly by cutting. Hair pulling is practiced on the scalp, axilla, pubis, eyelashes, and eyebrows. Another type of lesion is self-inflicted dermatoses, namely dermatitis artefacta and neurotic excoriations. The amputation of body parts, such as penectomy or ocular enucleation indicates an underlying psychotic process. In mental retardation the lesions are very deep and patients may even use their teeth to amputate a body part (e.g. in Lesch-Nyhan syndrome).

These SIB symptoms are observed in outpatient and inpatient settings.^1,12 All these symptoms may be found in the presence of concomitant disorders and may often be overlooked if not specifically assessed. Patients often isolate themselves to engage in a ritualized pattern of self-injury. For example, one of our patients had a special box where she kept her tools, and performed a set of ritualistic steps prior to cutting herself. Similar to behaviors observed in patients with OCD, tension increases when patients resist urges to self harm. Conversely, they may experience a sense of relief after they commit the act.

The onset of SIB is of gradual insertion in the concomitant pathology, and follows a chronic course, which is difficult to arrest. The emotional impact of SIB sometimes causes the psychiatric staff to overlook other symptoms and associated disorders may go unrecognized. The Compulsive-Orectic-Mutilative syndrome^22,28 consisting of aggressive behavior, obsessive-compulsive symptoms, self-mutilation, dysmenorrhea, and an eating disorder presents a history of high pain thresholds, and a higher incidence of sexual or physical abuse. Finally, the recognition of underlying disorders facilitates a better treatment outcome.

Pathogenesis

Animal research

Biological factors have been observed in aviary and animal species.²⁹ Some of these behaviors seems to be a pathological off shoot of displacement activity, also known as grooming behavior.³⁰ Experimental research results show that the administration of amphetamines results in self-mutilation in mice,³¹ rats,^32,33 horses³⁴ and dogs.³⁵

Human research

Three major biochemical systems: catecholaminergic, serotoninergic, and opiate, together with purine metabolism derivatives and genetic defects seem to be involved in SIB. Research results linking lack of pain during self-harm to depersonalization, borderline personality or transient analgesic state^36,37 led to theoretical explanations emerging from studies performed in the opioid system. Current literature indicates that the opioid neuropeptide regulatory system may be faulty in SIB. For example, painful stimulation causes an increased release of endorphins in humans,³⁸ and in mice.³⁹ Furthermore, elevated levels of B-endorphin in the Cerebral Spinal Fluid in patients with SIB symptoms⁴⁰ suggest that victims of childhood physical abuse may develop elevated levels of endorphins because of repeated exposure to pain and injury, or because of being prohibited from reacting physically to the infliction of pain. Kirkmayer and Carrol⁴¹ cite animal studies in which the receiver of pain developed higher levels of endorphins than the animals that inflicted pain. When the victim was able to retaliate the difference disappeared. The authors use this evidence to support their hypothesis that prohibition of physical responses to pain leads to an accumulation of tension and increase in endorphins. Self-injury stimulates the release of endorphins and results in a reduction of tension. This reduction in built-up tension is reinforcing to the individual and leads to maintenance of the self-injurious behavior.

Other authors suggest that chronic self-injurious behavior may function to maintain high levels of endorphins and prevent withdrawal symptoms similar to those experienced by patients with opiate drug addictions. Richardson and Zaleski,⁴² following the use of an opiate antagonist to treat a chronic self-mutilating patient, hypothesized that individuals may become addicted to their own opiate system and resort to SIB to produce increased levels of B-endorphin. As tolerance builds up, more SIB is needed to release B-endorphin and to prevent withdrawal and so forth. Furthermore, extremely high endorphin levels cause a down-regulation of endorphinergic pathways with the consequent build-up of dysphoria⁴³ a common mood of patients with SIB. These mechanisms not only actively maintain analgesia-pain-pleasure, but also may induce "an addiction to pain" and to the chronic course of this behavior.

Animal and human research indicates serotonin (5-HT) dysregulation is associated to SIB. In humans, 5-HT is associated with obsessive-compulsive⁴⁴ impulsive,^45,46 aggressive and self-injurious behaviors.⁴⁷ Furthermore, 5-HT is associated to its precursor L-tryptophan,⁴⁸ and 5-hydroxytryptophan.⁴⁹ Some evidence to support these findings is the effectiveness of serotonin reuptake blockers to treat these disorders.

A faulty mechanism of dopamine (DA) in Gilles de la Tourette syndrome with 50% of patients with SIB has been reported.⁵⁰ Amphetamine-DA mediated self-harm has also been recorded.⁵¹ One should consider a 5-HT and DA interaction playing a primordial role in the relationship of anger and self-harm.⁵²

Central and peripheral mechanisms suggest beta-blockers as agents for aggression and self-injury. Central mechanisms include specific blockade of adrenergic receptors in the central nervous system, membrane stabilization, and nonspecific effects on DA and 5-HT systems.

The presence of aggression as a contributing factor of self-harm suggests a cerebral circuit to explicate this pathology. One may postulate the presence of a loop involving the amygdala, the basal ganglia, the thalamus, the hypothalamus, and the frontal lobe. This loop considers the interaction among rage regulated by the amygdala,⁵³ appetite regulated by the hypothalamus, and fear regulated by the hypothalamus, while the frontal loop establishes the higher cortical activity connection.

Of note, OCD syndromes presenting SIB are mostly associated with rage, fear, appetite, compulsivity, and motor activity.⁵⁴ These functions seem to pertain mostly to the primitive brain.

Psychological research

What is the personal profile of the individual that assumes this behavior in due time and what is its purpose? Psychological theories are applied to answer these questions.

Psychodynamic theories include several models linking SIB to coping mechanisms, sexuality, early parental relationships, and environmental factors. Suyemoto³ reviews theories on the ambivalence of the patient's desire for life and death, an "antisuicide model," that is an active coping mechanism. The acts are intended to alleviate feelings of guilt by sacrificing a body part while allowing the patient to live.⁵⁵ SIB as a coping mechanism may also be manifested by the isolationist quality of detachment and/or dissociation. For others, SIB adopts depersonalization as a relief outlet to end dissociation or even to cause dissociation, depending on which condition is more reinforcing for the patient.^56-58

SIB seems to manage various mental states (e.g. death, depression) that respond favorably to the harmful act.⁵⁹ Our experience also indicates that SIB is an addiction to moral pain emerging during childhood as a learning process. Accordingly, SIB is a coping mechanism for dealing with emotional pain because the physical pain distracts the individual.⁶⁰ However, this theory does not hold for patients reporting analgesia during the act of SIB.³

Freud's theory of infantile sexuality suggests that pain may be a source of sexual excitement in the child. Thus, some researchers view SIB as an attempt to control sexuality or sexual maturation. ⁶¹ Of note, is the absence of self-mutilation before menarche,¹⁵ a correlation between sexual abuse and self-mutilation, and increased sexual dysfunction particularly in cases of genital self-mutilation.⁶²

Childhood abuse may result in feelings of self-hatred or self-directed anger, as a consequence of a neglectful or abusive parent⁶³ or lack of maternal handling¹⁴. The individual learns that SIB is reinforcing usually through family modeling of abuse, where pain is linked to caring or to control. Then, SIB is maintained because it is reinforced by the environment⁶⁴. Further, researchers have described "contagion effects" on inpatient wards that stem from observations that SIB is rewarded which causes other patients to imitate it.⁶⁵

Treatment

Several key issues dominate the treatment procedure. Firstly, are patients with SIB motivated for treatment? Some patients report a pleasurable response following the act and may be more resistant to relinquish SIB. Secondly, is there an inwardly directed anger? Self-harm is a self-directed expression of anger. Therefore, motivation and anger are two modifiers of treatment outcome. Finally, the impact of SIB affects the therapist who experiences frustration when treating individuals with SIB.

The pharmacology of SIB can be divided according to drug biochemical action on the patient's symptoms. These clinical aspects pertain to the nuclear psychiatric disorders. Succinctly, one treats the major condition assuming that improvement will indirectly benefit SIB severity. Thus, one needs to remember that self-harm is an expression of several pathologies.

Partial and selective serotonin re-uptake inhibitors (SSRIs)

SSRIs are used extensively in the treatment of SIB, based on their action upon aggression, depression, and compulsivity. These characteristics may be observed in many patients suffering from SIB. SSRIs appear effective in reducing SIB alone or in combination with the following disorders: Clomipramine with OCD,⁶⁶ Compulsive-Orectic-Mutilave syndrome,⁴⁴ severe onicophagia,²⁰ and trichotillomania⁶⁷ and in children;⁶⁸ Fluoxetine with borderline personality,⁶⁹ schizotypal,⁷⁰ developmental disabilities,^71,72 and compulsive facial picking;⁷³ Benzodiazepines, amitriptylene, and pimozide for dermatosis artefacta;⁷⁴ Trazadone, Sertraline, Paroxetine and Fluvoxamine with mental retardation and autism.^75-79

Antipsychotics

Antipsychotics have been used to treat SIB associated with mental retardation. Efficacy is reported with Fluphenazine in Lesch-Nyhan syndrome⁸⁰ and in borderline personality,⁸¹ with Haloperidol and Thiroidazine in Prader-Willi syndrome;⁴⁴ with Haloperidol and Phenelzine in borderline personality;⁸² Resperidone in mental retardation⁸³ and in borderline personality.⁸⁴

Other pharmacological agents

Buspirone has also been used to treat SIB in individuals with mental retardation,⁸⁵ autism,⁸⁶ Lesch-Nyhan syndrome with 5-hydroxytryptophan.⁴⁹ Naltrexone, an opiate antagonist that appears to prevent the reinforcing consequences of pain-induced behavior and allow extinction to occur, has been administered to patients with SIB,^87,42 with OCD⁸⁸ with Prader-Willi syndrome,⁸⁹ with placebo,⁹⁰ and in a five year retrospective study of individuals with profound mental retardation.⁹¹

Lithium has been reviewed in ten individual case reports with SIB, aggressive behavior, and mental retardation⁹² in aggressive behavior and SIB in two patients with brain injury.⁹³ Carbamazepine has also been used for Lesch Nyhan syndrome⁹⁴ and in Prader-Willi syndrome.⁸⁹

Two double blind, placebo-controlled studies with Nadolol were conducted with a sample of adults with moderate and severe mental retardation. A 41% decrease in SIB was obtained after Pindolol, and a 33% decrease after Nadolol administration.⁸⁵

Comments

Our review failed to find sufficient articles reporting pharmacological treatment in conditions other than the mentally retarded and autism with SIB. Perhaps because these patients are usually housed in residences or hospitals, providing easy access for treatment. Most related papers are open studies without placebo or control, and samples are generally small or anecdotal. The tolerability and safety of the above mentioned agents is acceptable, and their efficacy is moderate or equivocal.

Psychological treatments

Various models of psychotherapeutic interventions are reported to be effective in decreasing self-injurious behavior. The function of SIB varies across patients and selection of psychological techniques should focus on its effectiveness in patients with similar motivations for self-harming.

A wide body of literature exists on behavior modification techniques such as aversive conditioning using electric shock,⁹⁵ relaxation training, exposure and response prevention^64,96 substitution of adaptive behaviors,⁹⁷ and stress inoculation training.⁹⁸ In inpatient and residential settings, it is important to train staff to deal with SIB in a non-rewarding manner. If attention is a desirable consequence of the behavior then it could not only increase SIB in that patient but result in a ward epidemic.⁹⁹

Outcome studies of psychodynamic treatment mostly consist of case reports with little follow-up. The majority of the literature indicates that it is used with patients who have difficulty verbalizing their emotions and needs and with those patients that dissociate.³

Marsha Linehan¹⁰⁰ has developed a multidimensional cognitive-behavioral therapy program combining standard techniques such as problem solving, exposure, contingency management and cognitive modification with Eastern theories of acceptance and validation. SIB is viewed as a learned coping skill and patients are trained to use other more adaptive coping skills. Controlled clinical trials indicate that DBT is more effective than usual treatment in reducing SIB¹⁰¹ and six months following the end of treatment.¹⁰² Intense DBT involves one year of participation in a skills training group as well as individual psychotherapy focusing on implementation of learned skills.

Conclusion

Pathological SIB is a direct, socially unacceptable, repetitive behavior that causes minor to moderate physical injury. Individuals are typically in a psychologically disturbed state when they engage in SIB but are not attempting suicide. It is estimated that SIB occurs in 1-2% of the general population and in men as well as women. Although many patterns of symptomatology occur, SIB is a symptom that should be treated within the context of the psychiatric disorder in which it is manifested. Clinicians should assess SIB by questioning patients directly regarding self-harm as many patients may not voluntarily report SIB. The preferred areas of injury appear to be the dorsal side of the limbs, avoiding large blood vessels. Patients may choose certain tissues to be harmed or complete excision of an anatomical part. The most commonly affected area is the skin, including hair pulling.

The onset of SIB is a gradual insertion in the concomitant pathology, and follows a chronic course, which is difficult to arrest. Catecholaminergic, serotoninergic, and opiate systems, together with purine metabolism derivatives and genetic defects seem to be involved in SIB. Research results linking lack of pain during self-harm led to theoretical explanations emerging from studies performed in the opioid system. Psychological theories focus on the purpose of the behavior and its environmental causes. Psychodynamic theories include models linking SIB to childhood experiences and coping mechanisms. Cognitive theories focus on SIB as a learned pattern of coping skills and a way to regulate emotions.

Key issues in treatment include motivation for SIB and the underlying emotional states that it serves to express. Treatment of patients with SIB can lead to frustration on the part of the therapist when patients are resistant to treatment. Drug therapies most commonly used are SSRIs and antipsychotics. Psychological treatments commonly used include behavior modification technique, psychodynamic therapies, and cognitive-behavioral therapy. Dialectical Behavior Therapy in particular has demonstrated efficacy in reducing SIB in individuals with borderline personality disorder.

Correspondence

Jose A. Yaryura-Tobias, M.D.

935 Northern Boulevard, Suite #102

Great Neck, New York 11021 USA

Telephone: [phone], Fax: [phone]

Email: [e-mail]

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¹

. Institute for Bio-behavioral Therapy and Research - New York, EUA

Publication Dates

• Publication in this collection
  21 Mar 2000
• Date of issue
  Sept 1999