Self-Injurious Behavior and How to Stop It

Fugen Neziroglu, PhD, ABBP, ADAA Member
Estee Acobas, MA
Bio-Behavioral Institute
Great Neck, New York

Maya, 19, has been struggling with an anxiety disorder since she was a young child. She has also been suffering from depression. She lives in a very dysfunctional home with an extremely critical and volatile father, a submissive mother, and a drug-addicted brother. Although she sometimes feels that her anxiety and depression alone are enough to make her want to die, she says that her home life is harder for her than anything else she has to deal with. Her mother recently discovered a fresh scar on Maya’s thigh.

Maya has been cutting herself. Her behavior falls in the category of impulsive self-injury, which is direct, intentional, and repetitive behavior that can result in mild to moderate physical harm. Other similarly harmful behaviors are hitting, burning, biting, pinching, puncturing, head-banging, scratching, and skin- or wound-picking with the purpose of harming one’s body. People typically injure themselves on the arms, legs, chest, hip, scalp, abdomen, genitals, and ankles. And they use a wide variety of objects: razor blades, knives, scissors, broken glass, paper clips, nail clippers, and even pen caps.  

Why do people injure themselves?
During an episode of self-injury, the brain releases chemicals that induce a sense of calmness and well-being. Sometimes people engage in self-injury to communicate, perhaps to demonstrate suffering or to elicit help or attention. It can also set or alter interpersonal boundaries, telling others to come closer or stay away, to test their devotion, or punish them.

Signs that may indicate self-injurious behavior are a change in mood, avoiding clothing and activities that might expose certain areas of the body, carrying sharp implements, making excuses for bruises or scratches, socially withdrawing, and an increasing number of conflicts with friends.

Coping Mechanism
People injure themselves intentionally to attract attention. Or they may relieve painful, intolerable, or complicated emotions, including anger, anxiety, self-loathing, guilt, depression, frustration, loneliness, and feeling empty, among others. People may lack the skills to deal with challenging emotions, or they may have the skills but lack the confidence to use them. They may be punishing themselves, too, using extreme behavior that is not unlike overeating, smoking, drinking, and other unhealthy ways people regulate their emotions.

Who is at risk?
Women are more likely than men to engage in self-injury, which usually begins between ages 14 and 16. Left untreated, the behavior can continue into adulthood.

Psychological and biological predispositions, along with some environmental factors, play the most crucial role in determining whether someone will self-injure. Those engaging in self-injury have been found to have low levels of serotonin and endorphins, and possibly the stress hormone cortisol, as well as increased levels of norepinephrine.

Although it may occur by itself, self-injurious behavior is often associated with eating disorders, posttraumatic stress disorder (PTSD), bipolar disorder, major depression, and dissociative disorders. Self-injury is a criterion of borderline personality disorder.

Victims of sexual abuse and those with a very poor body image are significantly more likely to engage in self-injury, as are people who display perfectionism and rigid thinking. The likelihood also increases in families experiencing divorce and dysfunction, as well as those promoting perfectionism to unreasonable levels. Peer influences, but not peers themselves, are also a factor; there exists the phenomenon of “copycat cutting” and the tendency of those who self-injure to cluster together. 

Consequences of self-injury
It might seem easier to ignore than to acknowledge, but using self-injury can become very dangerous and highly addictive. And the longer it is ignored, the harder it becomes to change.

Many people also engage in suicidal behavior; some experience suicidal thoughts during episodes of self-injury. Even without such behavior, cutting in certain bodily locations can be life-threatening. It is most risky when done while intoxicated or using substances or when a person is feeling highly impulsive, emotionally distressed, or empty. The behavior can be physically harmful after the fact, too: Wounds that are not properly treated may become infected.

Furthermore, interpersonal, social, and emotional consequences exist. Although people can control to some degree whether their injurious behavior is discovered, they cannot control the reactions of others, such as attention, recognition, repulsion, or guilt. Scars can cause significant social stigma, even long after the behavior has ceased, and they may be a constant reminder of a behavior that can cause emotional distress or even trigger further episodes. Other consequences include coming to terms with such behavior and having to break the escalating cycle of dealing with emotional difficulties by engaging in self-injury.

Treatment
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy, or CBT, is used to address self-injury and the underlying issues that may be contributing to emotional distress. The goal of CBT is to work on changing and replacing unhealthy and problematic behaviors such as self-injury. A mental health professional gradually exposes a person to thoughts, feelings, behaviors, and situations that have previously served as triggers while helping resist the performance of self-injurious behavior.

Dialectical Behavior Therapy
Dialectical-behavior therapy, or DBT, is a specific type of CBT. It focuses on helping people regulate their emotions and gain interpersonal skills that can help them reduce conflicts and have their needs met. Like CBT, DBT focuses on adapting healthier thinking styles and behaviors, but it emphasizes mood instability, intolerance of negative emotions, interpersonal deficits, chronic thoughts or actions related to suicide, and self-injurious behavior.
These are some of the key skills taught:

• Regulating emotions by using self-soothing techniques
• Learning how to cope with distress or negative emotions
• Focusing on the here and now
• Learning how to handle conflict

Name It, Tame It, and Break It Down
This strategy addresses self-injurious behavior in children and adolescents, specifically designed for use while having an urge to self-injure.
It has three specific steps:

1. Name it: Identify the specific emotion being experienced while having the self-injurious urge. The goal of this step is not to have a lengthy discussion, but to find a specific and accurate label for the emotion, which is defined by category (agitated, subdued, or shameful).
2. Tame it: Use a strategy to cope with the emotion and the urge. Emotions can be regulated by substituting an intense activity, such as holding ice or sucking on a lemon, or by a self-soothing activity such as taking a bath or a walk or playing with a pet.

It can also be helpful to engage in a healthy but distracting activity, such as riding a bike until anger begins to dissipate. It’s also worthwhile to focus on the positives in a given situation, such as signs of improvement.

3. Break it down: Once an urge has passed, it’s important to review the episode to learn from it. This involves identifying the trigger—the event, person, situation, certain feeling, or even a memory—that occurred immediately before the urge developed.

Then review the emotion that was labeled in the first step to establish the link between that emotion and the trigger. Identify the vulnerabilities both physiological (hunger, fatigue, and pain) and psychological (anger, anxiety, depression, stressors) that may have contributed to negative emotions or low urge-resistance.
Identify any negative or extreme thinking that may have led to the negative emotional experience. Finally, it is helpful to review the overall effectiveness of the strategy in the present situation, which may involve reviewing what has worked and what has not, as well as looking at what might have been done differently.

Hospitalization
In general hospitalization is an option only when absolutely necessary. It’s crucial that people learn how to cope within their environment, rather than rely on hospitalization as a way out. But it may be a short-term solution when people cannot successfully commit to keeping themselves safe, when they injure themselves daily, or when they exhibit suicidal and other harmful behaviors. 
           
Medication
A psychiatric consultation may be warranted if therapy alone is not achieving the maximum desired benefit; if certain symptoms may be better addressed by medication; or if symptoms are severe.
Cutting is usually a behavioral expression of underlying issues, so it has no specific medication. Three categories of medications are most frequently prescribed:

• Antidepressants are often prescribed for both anxiety and depression. This category includes SSRIs (selective serotonin reuptake inhibitors) and other medications.

• Anxiolytics, or antianxiety drugs, are generally mild sedatives known as benzodiazepines. They are fast-acting and wear off after a few hours, but they are habit- performing if taken consistently.

• Mood stabilizers help reduce the severity of mood swings, reduce manic symptoms, and to decrease impulsivity, irritability, and agitation. They may be prescribed to address mood instability present in people who self-injure, or to decrease manic-type side effects from SSRI medications. 

For more information about medications, click here, or visit the U.S. Food and Drug Administration website.

Resources
When Your Child Is Cutting: A Parent’s Guide to Helping Children Overcome Self-Injury (McVey, Khemlani-Patel and Neziroglu, New Harbinger Press, 2006).

The Bio-Behavioral Institute, Great Neck, New York; 516–487–7116; visit the website at www.Bio-Behavioral.com.