Impulsive Self-Injurious Behaviors

Behavioral Health Update
BHSI Newsletter Vol. 2, No. 1
Impulsive Self-Injurious Behaviors
Paul Hill, Ph.D., L.P.

Health care providers and educators find few behaviors more alarming than self-injurious behavior (SIB). SIB is commonly defined as deliberate infliction of physical injury to one’s body without intent to die. While there may be no intent to die, it is precisely the potential lethality of this behavior that creates alarm. As many as sixty percent of individuals who engage in nonsuicidal SIB also engage in suicidal behavior. Further alarm stems from the association between SIB and other serious emotional or behavioral problems (e.g., obsessive-compulsive disorder, borderline personality disorder, psychosis, eating disorder).

Types of Self-Injurious Behavior?

People who engage in SIB are a largely heterogeneous group. However, based on similar patterns, four major categories of SIB can be designated. (a) Stereotypic SIB involves repetitive, monotonous, driven acts that seem to be devoid of thought, affect, or meaning. Common behaviors include head banging, self-hitting, or self-biting. This type of SIB is commonly associated with mental retardation, autism, or some types of congenital disorders (e.g., Lesch-Nyhan, Prader-Willi, or Cornelia de Lange Syndromes). (b) Major SIB involves isolated acts of severe and often life threatening self-injury. The acts can be impulsive or planned and typically occur in the context of psychosis or intoxication. This type of SIB most frequently includes castration, eye enucleation, and rarely, limb amputation. (c) Compulsive SIB refers to repetitive and often ritualized behaviors that occur multiple times a day. These behaviors seem to be obsessive-compulsive in nature in that they are frequently in response to an irresistible urge and result in gratification or relief. The most common forms of compulsive SIB include trichotillomania (hair pulling), onychophagia (nail biting), and skin picking (neurotic excoriation). (d) Impulsive SIB includes spontaneous and often symbolic acts that are most typically skin cutting, skin burning, or self-hitting. These acts often start out as isolated incidents but can become habitual. This type of SIB is frequently associated with borderline personality disorder, eating disorders, posttraumatic stress disorder, or some form of trauma or abuse. The remainder of this paper will focus on impulsive SIB.

Why Do People Deliberately Injure Themselves?

Several factors help make sense of this seemingly baffling behavior. (a) Affect Regulation: Many people who engage in SIB react abnormally to negative feelings. Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to settle. In theory, these people have learned to reduce their negative emotions through SIB. One-half to three-fourths of SIB patients report anesthesia or relief during the SIB. On a biological level, the anesthesia might be explained by an addiction hypothesis. This hypothesis suggests that the endogenous opioid system has been chronically overstimulated for the purpose of alleviating negative feelings. The individual develops a tolerance to the influx of endogenous opioids, cyclically suffers a withdrawal reaction, and is driven to release more endogenous opioids through SIB. (b) Dissociation: For some people, stress leads them to disconnect from reality or dissociate. The pain associated with SIB may help them to break through their detachment, reconnect with reality, and feel again. Many people who engage in SIB report that the behavior helps them feel or that the pain.

On a biological level, the pain hypothesis suggests that stress or emotional pain triggers overproduction of opioids or a failed negative feedback loop does not “shut off” release of opioids. The increased levels of endogenous opioids leads to numbness and dissociation, a state that only SIB can break through. (c) Limited Problem-solving skills: While maladaptive, impulsive SIB tends to serve as a coping response for people with limited problem-solving skills. Like more adaptive coping responses, SIB influences others in ways that alleviate difficult circumstances or demands. SIB can also elicit assistance and support. The SIB is reinforced by a responsive environment. (d) Shame: More than other emotions, shame appears to be associated with SIB. Many people who engage in SIB learn to devalue and blame themselves through experiences of childhood trauma, including sexual and physical abuse, or an unempathic or invalidating environment. For some, SIB is described as concrete atonement for being bad, and an aggressive, impulsive response to self-directed hate. The relief they experience is akin to relief that follows completion of penance. On a biological level, a strong correlation exists between decreased serotonin function and increased impulsivity, aggression, and suicidality.
What Can Providers and Educators Do?

èProvide supportive communication. Maintain an accepting, open attitude about the person who self-mutilates. Don’t make judgmental statements, browbeat, or avoid the subject due to your own discomfort. Blame and attack only induce shame and continue the cycle of self-hatred and frustration that leads to SIB. Pay more attention to healthier things the individual does than to SIB. Inquire about any efforts to delay or avoid the act of SIB and praise and encourage any successes. No medications have received U.S. Food and Drug Administration approval for treatment of impulsive SIB, nor have any double-blind placebo-controlled medication trials been performed. Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to decrease impulsive-aggressive behaviors and have received mixed support for reducing SIB. Because these medications are well-tolerated and pose a low risk for deliberate overdose, they are usually a good first choice in pharmacologic treatment. Sedative/hypnotic class drugs often are not helpful (i.e.,disinhibit in a negative way) and carry a high risk of abuse. Beyond this, medication strategies tend to focus on targeting symptoms that may be specifically associated with SIB (e.g., ß-blockers for dissociation). Help your patient or student learn strategies to exert more control over their SIB. Have them develop a list of things they can do to distract or delay SIB (e.g., call a friend, write in a journal, go somewhere especially around people, watch a movie or listen to music, exercise). Help them set limits to the amount of time they spend focused on SIB. Help your patient or student learn strategies to cope with intense emotions. Sometimes the first step can be to replace lethal forms of SIB with behaviors that do not produce lasting results. The strategies that are most commonly suggested include squeezing an ice cube or snapping oneself with a rubber band.?èThe most effective treatment of impulsive SIB involves a combination of psychotherapy and psychopharmacology. A therapeutic alliance is a critical element of treatment given the problems commonly reported by patients who engage in SIB (e.g., problems with trust, mood regulation, self-soothing, and suicidal behavior).