PHOTO: Adrien King
Text: Nicoleta Casangiu and Alejandra Misiolek
People often hear self injury and they equate it with borderline personality disorder (BDP), since one of the criteria to diagnose borderline personality disorder is “non suicidal self-injury behaviors”. However studies have revealed that only 40% of people with BDP engage in self-injury behaviors.
Specifically, the rest of 60% of non-suicidal self injury behaviors occur in the context of numerous other psychiatric disorders, including posttraumatic stress disorder, depression, eating disorders, and substance use disorders.
In the the DSM-5 Diagnostic Manual, the non-suicidal self injury has been included in “conditions for further study, disorders that are not diagnosed” since there hasn’t been sufficient research or empirical studies to support it as a diagnostic.
Defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, includes behaviors such as cutting, burning, biting and scratching skin. Non suicidal self-injury is especially prevalent during adolescence with rates of 17–18% in recent reviews of community samples.
Recent studies have found that the average adolescent self-harmer is a female aged 14-16 years who cuts her wrists and forearms.
These adolescents show greater impulsivity than their non-self-harming peers, high emotional dysregulation, lower self-esteem and a more negative cognitive style than non-self-harming subjects, especially in the case of females. Low self-esteem has been revealed as a predisposing and maintaining variable for self-injurious behavior.
Studies have also found that the consumption of toxic substances is more prevalent in these adolescents and a greater and more lasting depressive symptomatology, with this variable acting as a predisposing and maintaining factor for self-harming behavior. Specifically, suicidal ideation is postulated as one of the triggering variables of self-harming acts. On the other hand, they have greater eating psychopathology, mainly of a bulimic nature.
But why would someone want to hurt himself/herself on purpose if they do not want to end their life?
Given that all behavior is purposeful whether adaptive, maladaptive, inappropriate, we only repeat behaviors if they have value and are reinforced by our dopaminergic system. Therefore, although it might be difficult to conceive by some, as it seems like that does not make any sense, to the individual that is engaged in this behavior, it makes perfect sense.
How can we understand why people engage in this kind of behavior?
There are some reasons for why they do engage in the absence of suicidal intent (either stated by the individual or inferred).
- On the one hand, it’s a behavior that gives the individual some kind of relief or the expectation to obtain relief from a negative feeling or a cognitive state. They forget about the psychic pain and they focus, they transfer the emotional pain that they cannot control to a physical pain that they can control.
- On the other hand, self-harm can induce a positive feeling state. The psychological pain of the individual is too much to bear so the physical pain becomes the focal point. It’s almost like a divergent tactic.
Therefore, there normally are interpersonal difficulties, anxiety, depression, tension, anger, self-criticism occurring prior to the self-injury that are troubling the individual before the self-injury act.
Psychological studies have proposed as an explanation the role of self-injurious behavior as a coping strategy to self-regulate aversive emotional states. Models supporting this idea suggest that these adolescents tend to reduce interpersonal distress through the commission of self-injurious behavior. The process by which self-harm alleviates emotional distress remains highly speculative, with the action of endogenous opioids being proposed. In relation to this hypothesis, there are also laboratory findings of reduced sensitivity to pain in adolescents who self-injure.
It has been found that self-injurious behavior can be explained by four factors:
- intrapersonal reinforcement (positive and negative)
- social reinforcement (positive and negative).
The first of these factors (“intrapersonal positive”), explains self-injurious behavior as generating pleasurable emotional states.
The second (“intrapersonal negative”) illustrates its already mentioned role in relieving aversive emotions. Regarding the third factor (“positive social”), it includes seeking support or attention from reference persons; finally, the fourth factor (“negative social”) encompasses exemption from social responsibilities.
Taken together, all these findings suggest that self-injurious behavior is more than an “emotional” or “avoidant” coping strategy in the face of stress (emotional self-regulation). It is an additional mechanism of interpersonal communication and control.
Studies have revealed that it’s a learned behavior. There is a remarkable consensus from studies that adolescents who self-harm tend to have family and friends who also self-harm. However, this fact alone does not indicate the mechanisms of transmission of self-harming behavior. Many of these adolescents interact through chat rooms and forums with other people who self-harm, using new technologies to share experiences and/or self-harming procedures. With respect to adolescents admitted to long-stay psychiatric units, these findings have not been confirmed. Among those subjects without a history of self-harm, exposure to and prolonged cohabitation with self-harming patients does not imply the emergence of such psychopathology.
As far as psychological intervention is concerned, taking into account that half of the adolescents who self-harm, mainly boys, do not seek any kind of help for fear of being stigmatized, the treatment of self-injurious behavior is currently at an experimental stage.
Most of these interventions have been carried out in the field of secondary prevention. This means interventions aimed at adolescents who self-harm and those focused on significant people (parents and teachers) in the subject’s environment, figures who are considered relevant as maintaining and/or auxiliary factors in the face of self-harming behavior.
There is also a growing interest in the implementation of primary prevention programs at school level.
For young children and adolescents, as a caregiver you want to prevent the child from engaging in these behaviors and make sure the home is safeguarded, to make sure the child does not have access to anything that could cause him injury.
As clinicians we need to understand self-injurious behavior to be framed in the stage of adolescence and as an expression of the difficulties of identity consolidation and emotional management typical of this period.
Thus, we conceive the self-injurious symptom as an implicit message that must be taken from a general perspective of the life cycle. By giving it meaning within the personal history and family context of the patient, we can contribute to a therapeutic approach that advocates the non-chronic nature of the symptom and promotes a positive prognosis.
Frias, A. at all: Conducta autolesiva en adolescentes: prevalencia, factores de riesgo y tratamiento, C. Med. Psicosom, No 103 – 2012.
American Psychological Association [APA]. (2014). Manual de diagnóstico y estadístico de los trastornos mentales (DSM-5). Editorial Médica Panamericana.