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Self-Injurious Behaviors
Gender And
Cultural
Issues
Abid Nazeer M.D.
PGY2
LSUHSC
Psychiatry
Objectives
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Define and categorize Self-Injurious
Behaviors (SIB)
Discuss etiology, epidemiology, and
treatment options of SIB
Describe and distinguish specific sub-type
of SIB, Self-Mutilation
Discuss the gender and cultural aspects of
Self- Injurious Behaviors
Self-Injurious Behavior
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Definition – Self directed acts which result
in tissue damage.
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No suicidal intention in SIB
Many methods to self-injure:
-Cutting
-Skin picking
-Biting
-Toxic Ingestion
-Burning
-Hair pulling
-Head banging
-Auto castration
-Scratching
-Branding
-Hitting
Self-Injurious Behaviors
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The DSM-IV only mentions self-injury as a
symptom or criterion for diagnosis in
borderline personality disorder, stereotypic
movement disorder (autism, MR), and
factitious disorder.
Extreme forms can be present in psychotic
and delusional disorders.
Impulse Control Disorders
Types of Self-Mutilation
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Major – such as eye enucleation and castration, very rare,
associated with psychosis and acute intoxication
Stereotypic – repetitive behavior that has relatively fixed
pattern of expression, e.g. head banging, self-hitting, handbiting. Associated with MR, PDD, Autism, Down’s Syndrome,
Lesch-Nyhan Syndrome, and de Lange Syndrome, or
Stereotypic Movement Disorder (Axis I)
Superficial/Minor- cutting, burning, interfering with wound
healing, and scratching. Associated with borderline and
antisocial personality disorders, adolescents, incarcerated
men, and may be component of many psychiatric disorders.
Also called “parasuicide”, “deliberate self-harm”, “cutters”
Favassa A, Rosenthal, Repetitive Self Mutilation, Psychiatric Annals. 1992; 22:2,
S.I.B.
Culturally Sanctioned
Ritual
Practices
Pathological
Suicidality
Self-Mutilation
Major
Stereotypic
Superficial/Moderate
Compulsive
(OCD spectrum)
Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and
Body Modification in Culture and Psychiatry, 2nd ed. Baltimore:
The Johns Hopkins University Press.
Impulsive
(Impulse Control D/O)
Episodic
Repetitive
Impulse Control Disorders
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Failure to resist impulse, drive, or temptation to
perform act that is harmful to self/others.
Relief of mounting tension or arousal with act
Includes
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Intermittent Explosive Disorder
Kleptomania
Pyromania
Pathological Gambling
Trichotillomania
Impulse Control Disorder NOS
Repetitive Self-Mutilation?
Compulsive vs. Impulsive
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Compulsive self-harm part of
OCD ritual involving
obsessional thoughts; person
tries to relieve tension and
prevent bad things from
happening by engaging in selfharm behaviors
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Episodic self harm behavior is
engaged infrequently by
people who otherwise don’t
think about it and don’t
perceive themselves as “selfinjurers”. Usually a symptom
of some other disorder.
Repetitive self-harm is a
switch to ruminating about self
harm even when doing the act,
identify as “self-mutilators”.
Considered a “disease” itself.
Reflex response to any sort of
stress, positive or negative.
Etiology of S.I.B.
Biological Considerations and Neurochemistry
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Serotonin – Decreased levels correspond to
increased aggression and self injurious
behavior.
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Irritability is expressed as screaming or throwing
things when serotonin levels are normal.
Research correlates this by showing decreased
platelet imipramine binding sites in self-injurers (Simeon
et al. 1992) and linked to impulsivity and aggression
(Birmaher et al. 1990)
Etiology of S.I.B.
Biological Considerations and Neurochemistry
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Endorphin Model – Pain resulting from SIB may elicit release
of endogenous opioids (endorphins) which acts as an
analgesic on opiate receptors like morphine or heroin.
(Thompson et al. 1994). Little or no pain seen in many selfinjurers which is termed “blunted nociception”.
Dopamine supersensitivity or hypersecretion of endorphins
seen. Repetitive self-injurious actions my come under control
of addictive reinforcers and these receptor effects.
Thompson, T., Hackerberg, T., Cerulti, D., Baker, D., Axtell, S. (1994), Opioid Antagonist Effects on Self-Injury
in Adults with Mental Retardation. American Journal on Mental Retardation, 49: 85-102.
Etiology of S.I.B.
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Biological Considerations and
Neurochemistry
Middle Ear infection in Autistic/MR patients
may lead to head banging or ear hitting.
Sub-clinical seizures may cause sudden SI
episode.
Chronic medical conditions
Etiology of S.I.B.
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Social and Behavioral Considerations
Arousal – counteract overarousal or
underarousal (Edelson 1984)
Frustration due to poor communication
Social attention acts as positive reinforcer
(Lovas et. Al 1969)
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Avoidance or escape from social encounter
Etiology of Self-Mutilation
Social and Behavioral Considerations
2004 Study by Nock and Prinstein (89 adolescent inpatients surveyed)
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To stop bad feelings (immediate relief)
To feel something, even if it was pain
To punish yourself
To relieve feeling numb or empty
To feel relaxed
Social modeling – 82% of responders say at least
one friend self-injured in the last 12 months
Nock and Prinstein. A functional approach to the assessment of self-mutilative behavior. Journal of
Consulting and Clinical Psychology 2004; 72: 885-890.
Etiology of Self-Mutilation
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Way of coping with intense internal emotions, or
even preventing suicide.
“Physical pain is easier in dealing with than
emotional pain.”
Risk Factors
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History of physical or sexual abuse
Parental neglect or abandonment
Comorbid conditions such as depression, eating disorders, personality
disorders (BPD, antisocial, histrionic), PTSD, and anxiety disorders
Alcoholism and illicit drug use
Female sex
Epidemiology of S.I.B.
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The few studies which have been done on
community samples of young adults and
adolescents vary in prevalence rates of SIB
between 4% to 38%
Conterio and Favazza estimate that 750
per 100,000 population exhibit self-injurious
behavior
Favazza, A. R. & Conterio, K. (1988). The plight of chronic self-mutilators. Community Mental Health
Journal, 24, 22-30
Epidemiology of S.I.B.
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In M.R. and Autistic populations, SIB is
negatively correlated with I.Q.
SIB seen in as many as 15-20% of people
with MR, and much higher in profound MR
Estimate of up to 2/3 of people with MR
who reside in public residential facilities
show SIB (Baumeister and Forehand, 1973)
Treatment of S.I.B.
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Pharmacological
SSRI’s – High doses appear to be effective
in many cases. Fluoxetine was studied in
two double blind placebo studies and
shown to have benefit in reducing SIB.
First choice in OCD spectrum disorders.
Coccaro, E. F., Kavoussi, R. J., & Hauger, R. L. (1997b). Serotonin
function and antiaggressive response to fluoxetine: a pilot study.
Biological Psychiatry, 42(7), 546-552
Treatment of S.I.B.
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Pharmacological
Naltrexone (opiate antagonist) found to be
effective in about half the patients with stereotypic
type of self injury.
May have therapeutic window in dosing.
No one has yet done a placebo-controlled doubleblind crossover study that controls for type of
behavior as well as psychiatric diagnosis.
Buzan, R. D., Thomas, M., Dubovsky, S. L., & Treadway, J. (1995). The use of opiate antagonists for
recurrent self-injurious behavior. Journal of Neuropsychiatry and Clinical Neurosciences, 7(4), 437-444
Treatment of S.I.B.
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Pharmacological
Anti-psychotics – Clozapine, Risperidone, Olanzapine,
Fluphenazine
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Other medications studied
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Lithium
Carbamazepine
Beta Blockers
Baclofen
Stimulants
Clonidine
Amantadine
Treatment of S.I.B.
Non-Pharmacological
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ECT - has shown benefit in a few case reports for major or severe selfinjury
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Cognitive Behavioral Therapy – combat the cognitive
distortions and beliefs that SI is an acceptable form of managing feelings
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Behavior Modification – eliminate some behaviors and develop
others, operant conditioning
Jones, A.B. (2001). Self-injurious behavior in children and adolescents, Part II: Now what?
The treatment of SIB, KidsPeace Healing Magazine
Treatment of S.I.B.
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Non-pharmacological
Addiction Model – Used in more chronic cases to develop
a sense of regaining control over one’s life in realistic way.
Emphasizes techniques to build up time between having urges and
acting upon urges.
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Psychodynamic Therapy – help identify
attachments
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Aims of Therapy - tolerate greater intensities w/o
resorting to self harm, develop ability to articulate emotions and
needs, learn coping skills, problem solving, anger management,
conflict resolution, and assertiveness training
Gender Issues with S.I.B.
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Estimated that 67% of self-injurers are female
(Miller 1994).
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Many other studies link increased rates of suicide
attempts and SIB in female whereas males show
greater suicide mortality rates.
Males select more dangerous methods of self
harm and are therefore more likely to receive
medical attention. Same number of males and
females present to the hospital (Cantor 2000).
Gender Issues with S.I.B.
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Genital self-mutilation reported in higher
numbers in males than females. Reason
may be because castration is more
dramatic than cutting, so it’s reported more
frequently.
Alao, O Adekola: Female Genital Mutilation. Psychiatric Services 50:971 1999
Gender Issues with S.I.B.
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Sexual Orientation – A longitudinal study of
a cohort of 1037 individuals in New
Zealand showed a strong, statistically
significant link between same sex attraction
and SIB. Men, more so than women,
showed higher risks for self-harm with
greater degree of same-sex attraction.
Skegg, Karen: Sexual Orientation and Self Harm in Men and Women. Am J Psychiatry
160:541-546, March 2003
Cultural Issues with S.I.B
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Body Modification piercings and tattoos may
be rituals or practices.
Rituals reflect community
tradition, underlying
symbolism, healing,
expressions of spirituality,
social order marking
Practices may be fads, for
ornamentation, and
identification for a cultural
group
Cultural Issues with S.I.B.
Culturally sanctioned forms of SIB can be seen as
rituals for country festivals, as government
protests, and religious customs.
Cultural Issues with S.I.B.
There is a recent rise in SIB
in today’s society. Media
exposure through musicians
such Marilyn Manson,
movies such as Girl
Interrupted, and admissions
of SIB from celebrities such
as Johnny Depp and
Angelina Jolie has increased
social acceptance and
awareness. In addition, the
phenomenon of “Cutter
Clubs” has further
supported the concept of
social remodeling.