1. Self-Injurious Behaviors Gender And Cultural Issues Abid Nazeer M.D. PGY2 LSUHSC Psychiatry

2. Objectives 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

3. Self-Injurious Behavior Definition – Self directed acts which result in tissue damage. No suicidal intention in SIB Many methods to self-injure: -Cutting-Burning-Scratching -Skin picking-Hair pulling-Branding -Biting-Head banging-Hitting -Toxic Ingestion-Auto castration

4. Self-Injurious Behaviors 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

5. Types of Self-Mutilation 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, hand- biting. 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,

6. S.I.B. Culturally Sanctioned RitualPractices Pathological SuicidalitySelf-Mutilation MajorStereotypicSuperficial/Moderate Compulsive (OCD spectrum) Impulsive (Impulse Control D/O) EpisodicRepetitive Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns Hopkins University Press.

7. Impulse Control Disorders 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 Intermittent Explosive Disorder Kleptomania Pyromania Pathological Gambling Trichotillomania Impulse Control Disorder NOS Repetitive Self-Mutilation?

8. Compulsive vs. Impulsive Compulsive self-harm part of OCD ritual involving obsessional thoughts; person tries to relieve tension and prevent bad things from happening by engaging in self- harm behaviors Episodic self harm behavior is engaged infrequently by people who otherwise don’t think about it and don’t perceive themselves as “self- injurers”. 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.

9. Etiology of S.I.B. Biological Considerations and Neurochemistry Serotonin – Decreased levels correspond to increased aggression and self injurious behavior. 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)

10. Etiology of S.I.B. Biological Considerations and Neurochemistry 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 self- injurers 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.

11. Etiology of S.I.B. 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

12. Etiology of S.I.B. 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) Avoidance or escape from social encounter

13. Etiology of Self-Mutilation Social and Behavioral Considerations 2004 Study by Nock and Prinstein (89 adolescent inpatients surveyed) 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.

14. Etiology of Self-Mutilation Way of coping with intense internal emotions, or even preventing suicide. “Physical pain is easier in dealing with than emotional pain.” Risk Factors 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

15. Epidemiology of S.I.B. 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

16. Epidemiology of S.I.B. 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)

17. Treatment of S.I.B. 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

18. Treatment of S.I.B. 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 double- blind 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

19. Treatment of S.I.B. Pharmacological Anti-psychotics – Clozapine, Risperidone, Olanzapine, Fluphenazine Other medications studied Lithium Carbamazepine Beta Blockers Baclofen Stimulants Clonidine Amantadine

20. Treatment of S.I.B. Non-Pharmacological ECT - has shown benefit in a few case reports for major or severe self- injury Cognitive Behavioral Therapy – combat the cognitive distortions and beliefs that SI is an acceptable form of managing feelings 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

21. Treatment of S.I.B. 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. Psychodynamic Therapy – help identify attachments 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

22. Gender Issues with S.I.B. Estimated that 67% of self-injurers are female (Miller 1994). 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).

23. Gender Issues with S.I.B. 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

24. Gender Issues with S.I.B. 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

25. Cultural Issues with S.I.B 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

26. 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.

27. 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.