Tuesday, February 02, 2010

Self-Harm in the News


Two different articles in the last couple of days have come up on the topic of self-harm, one at a Psychology Today blog and one at CNN Online. Crucially, people who self-harm are 75% more likely to suicide, so it's very important to take this behavior seriously.

Both articles make another crucial point - self-harm is not really about manipulation or attention seeking, although both might be secondary motives. The real motivation is that emotional pain is too much to handle, so physical pain is preferable. By intentionally cutting or burning (or some other form of self-harm), the person uses physical pain to dissociate from their emotional pain (often sourced in trauma).

An Introduction to Self-Injury

Why on Earth would someone purposely want to cut his or her self? As odd as this might seem to many of us, non-suicidal self-injury (NSSI) such as cutting, burning or intensely scratching oneself without suicidal intent, is a major problem that most people don't know much about. We may not hear much about NSSI in the news because it is sort of a taboo subject. Yet, despite how taboo it may seem, it is actually quite common - especially for girls in high school and college. Current estimates suggest that approximately 4% or more of the population self-injures, and as high as 14% of adolescents may do so. NSSI can often lead to emergency room visits due to severe injuries, and these injuries can cause permanent nerve damage for some. Given all of this, you would think that more people would pay attention to the growing public health concerns of NSSI!

So why would someone ever want to purposely inflict pain or injury on his or her self? Studies conducted by Nock and Prinstein (2004, 2005) suggest that there are four primary reason for engaging in NSSI: 1) to reduce negative emotions, 2) to feel "something" besides numbness or emptiness, 3) to avoid certain social situations, and 4) to receive social support. Although instances of all of these reasons for NSSI occur, a common misconception is that NSSI is primarily a form of social manipulation. In reality a number of studies have found that the primary reason for NSSI is reason number one: to reduce negative emotion. This seems like such a bizarre reason! How is it that inflicting physical pain or injury could be used to deal with emotional pain? Despite how paradoxical this may seem, people most often report the following reasons for NSSI: to stop bad feelings, to relieve feelings of aloneness, emptiness, or isolation, to distract from other problems, to decrease feelings of rage, to release tension, and to control racing thoughts.

I bring up the topic of NSSI on Overcoming Self-Sabotage because self-injury can be used as a maladaptive approach to stress, similar to the way many people use alcohol or drugs to help them "forget" about their problems for a little while. Similarly, many people who self-injure do so to cope with stressful situations or upsetting problems with other people. However, this usually backfires and thus causes more problems. Many come to view self-injury as their only way of dealing with problems, and become dependent on it. The effects of NSSI can start to wear off over time, resulting in the need for more frequent and more severe injuries to get the same effect. Those who self-injure often have trouble with other areas of their lives, such as school, work, and relationships. The worst thing of all about NSSI is that it is strongly connected to later suicide attempts and death by suicide. This outcome alone is great reason for concern! Given all of the problems that can arise from self-injury, and the fact that it is often used as a way of coping with emotional pain, it is without a doubt "self-sabotage."

So how is it that self-injury works as a coping tool? Currently, we do have some understanding about why it can help people deal with negative emotion. As one way of understanding it I will discuss a model suggested by Chapman and colleagues (2006), who have proposed the Experiential Avoidance Model of self-injury. This model suggests that, because of things like distraction, self-punishment, and release of endorphins, self-injury may help people avoid feeling negative emotion. These individuals may find upsetting emotions to be too difficult to handle, or they may be generally opposed to experiencing any negative emotion at all, and thus NSSI may be a way for helping them avoid emotional experience. Because NSSI helps individuals avoid and escape negative emotion, it may then become rewarding and more "addictive" in a repetitive cycle. Thus, when upset, the natural instinct may become to self-injure.

In this post I have only touched the tip of the iceberg on NSSI research. Fortunately new and exciting findings on this topic are being generated on a regular basis. Although I will write about treatment of NSSI in future posts, this current post is just meant to provide a general understanding of NSSI. I will leave you with this final note, however. Many who self-injure are reluctant to give up doing so because it is such a powerful way to relieve negative emotion. For them it is a primary tool for dealing with stress and upsetting situations, and they feel like they will be helpless without it. Yet, study after study shows that NSSI causes more problems than it solves over time, and it can potentially lead to a tragic end: suicide. Thus, if you self-injure, I encourage you to seek professional help and strive to find a new tool for coping, because this one will only lead to more suffering. NSSI truly is a "false-friend."
This article from CNN looks at self-harm in teens.

Some kids hurt themselves to feel better

By Theodore Beauchaine, Special to CNN
February 1, 2010 10:27 a.m. EST


Editor's note: Theodore Beauchaine is the Robert Bolles and Yasuko Endo Associate Professor of Psychology at the University of Washington, where he is also director of the Child and Adolescent Adjustment Project. He is editor of "Child and Adolescent Psychopathology," associate editor of the journal "Psychophysiology" and a contributing author to the upcoming "Oxford Handbook of Suicide and Self-injury."

Seattle, Washington (CNN) -- They come from all walks of life. One teenage girl cuts her thighs after piano lessons to avoid the crushing pressure for perfection. She sees a therapist twice a week, but she never gets better.

Another young woman makes dangerous cuts to her arms and wrists when she is anxious. She is on her fourth foster placement because no one can handle her behavior. Another burns her fingers with a cigarette lighter when she hears her parents fight. She's been hospitalized twice in the past year.

Stories such as these are heard daily by those of us who study and treat self-injury -- that is, any activity resulting in intentional bodily damage to oneself. It is a syndrome found across cultures and socioeconomic classes (although it tends to be a bit more common among the more well-off), and it appears to be on the rise.

Though cutting the skin with sharp objects is the most common method used, especially by girls, other means of self-injury including head banging, overdosing, burning, hanging, drowning and shooting.

Given its potential for death and serious injury, this phenomenon has received increasing media attention, with a number of movies, such as "Secretary" in 2002, portraying the phenomenon.

From my perspective, this is an urgent public health issue, yet funding for research and treatment lags well behind funding for other behavioral disorders, such as autism.

Self-injury is troubling for several reasons.

First of all, almost 400,000 adolescents and young adults were treated medically for self-inflicted injuries in 2006, the most recent year for which these injuries were counted.

One recent study revealed that the number of children and adolescents in the U.S. who were hospitalized for depression, which is sometimes accompanied by self-injury among youth, increased by 27 percent between 1997 and 2007.

Second, self-injury is associated with crippling psychiatric distress. Girls who engage in such behaviors score lower than their peers on almost all measures of positive psychological adjustment, such as sociability, and higher than their peers on almost all measures of negative psychological adjustment, such as depression and delinquency.

Third, adolescent self-injury is linked to adult borderline personality disorder -- a chronic and difficult to treat mental health condition characterized by impulsive behaviors, difficulties self-regulating emotions, mood instability and high rates of suicide.

Finally, self-injury is the single best predictor of suicide. Intentional self-injurers are about 75 times more likely to kill themselves than others in the population, an especially alarming statistic.

Scientists are not sure why rates of self-injury appear to be on the rise, or how to stop the trend.

When teens who self-injure are asked why they do it, most say the behaviors help them regulate overwhelming negative emotions, including anger, sadness and rejection. This emotion-regulating function may occur because injuries trigger the release of endogenous opioids, chemicals produced by the body that relieve pain. Over repeated episodes of self-harm, the endogenous opioid system may become more efficient at reducing physical and psychological pain.

Recent studies conducted at high schools and universities reveal that almost 20 percent of individuals self-injure at least once, and about 11 percent self-injure repeatedly.

Given how common the behavior is -- and the alarmingly high risk of eventual suicide -- one might expect self-injury to be a major public health priority. One might also expect considerable investment into basic science aimed at understanding the brain mechanisms involved and treatment-outcome research aimed at developing effective interventions.

Unfortunately, this has not been the case. Little is known about the brain mechanisms of self-injury, particularly in adolescence, and traditional approaches to treatment usually involve inpatient hospitalization, which is more cost-effective than individual care.

However, when treated in groups, as is often the case in hospitalization, self-injuring girls often become worse, not better, an effect known as contagion. (Note that this can also occur through access to Web sites and Web postings in which self-injurers share strategies.)

Nevertheless, there has been some progress toward understanding and treating adolescent self-injury.

On the basic research side, Christina Derbidge, a graduate student in my lab, is conducting a study in which the brains of adolescent girls who engage in self-injury are imaged as they cope with negative emotions.

On the treatment side, Dr. Marsha Linehan's Dialectical Behavior Therapy at the University of Washington is signs of hope. The therapy is a variant of cognitive therapy and an effective treatment for adults with borderline personality disorder. It has been adapted to adolescent patients with encouraging results.

Despite these positive developments, a much greater investment is needed. For fiscal year 2010, the National Institutes of Health --far and away the primary source of funding for health research in the world -- projects spending $41 million on suicide and suicide prevention (NIH does not report specific funding figures for self-injury).

In contrast, NIH expenditures for autism are expected to be $141 million in 2010. Corrected for the higher prevalence rate of suicide, this translates into a six-fold greater investment per person with autism.

Indeed, across the past five years, NIH has spent more than $700 million on autism research, with impressive results in terms of treatment effectiveness and our understanding of the genetic and neural underpinnings of the disorder. Given the urgency of preventing suicide among our youth, a similar investment is needed in self-injury research.

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