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Self-injurious Behavior in College Students

2006; American Academy of Pediatrics; Volume: 117; Issue: 6 Linguagem: Inglês

10.1542/peds.2006-0840

1098-4275

Armando R. Favazza,

Poisoning and overdose treatments

As an introduction to my comments on the Whitlock et al study1 (in this issue of Pediatrics), I would like to present some of my understandings about self-injurious behavior (SIB, the politically correct term for self-mutilation [SM]) based on 25 years of studying and treating self-injurers. Up until the late 1980s most psychiatrists and psychologists (the pediatric literature was conspicuously silent) regarded SM as a singular, horrific, and senseless behavior that was somehow linked with suicidality either symbolically or in fact. Only a few researchers attempted to truly understand this phenomenon.In 1987, my book Bodies Under Siege,2 which was broadly and favorably reviewed, brought a measure of order to SM by dividing it into 2 major categories that I labeled “culturally sanctioned” and “pathologic.” By examining deep-seated mutilative rituals, some going back to the stone age, I determined that they primarily served 3 purposes: (1) to attain grace and improve relationships with God; (2) to maintain social stability; and (3) to achieve physical healing. This finding led me to consider self-injury as a morbid form of self-help. By examining patients I devised a phenomenological classification of deviant SM that I refined in the 1996 second edition of my book and in collaborative publications. Deviant SM may be divided into 4 types: (1) major (eg, eye enucleation and amputations), which is rare and is associated with psychosis, transexualism, and intoxications; (2) stereotypic (eg, head-banging and self-biting), which is not uncommon in mental retardation and Tourette's syndrome; (3) compulsive (eg, severe excoriation of the skin and nail biting); and (4) impulsive (eg, skin cutting, burning, and carving), which is common and associated with a variety of mental disorders such as depression, anxiety, posttraumatic stress disorder, and personality disorders, especially borderline, histrionic, and antisocial. Impulsive self-mutilators may injure themselves episodically, whereas repetitive self-mutilators may develop deliberate self-harm syndrome (DSH), characterized by brooding about self-harm, self-identification as a “cutter” or “burner,” and rapid, temporary relief after an act of self-harm from numerous symptoms, especially escalating anxiety, episodes of depersonalization, and depression. Persons with the syndrome, which typically starts in early adolescence and lasts for 10 to 20 years, may develop eating disorders, kleptomania, and/or alcohol and substance abuse. They are at high risk for suicidal overdoses because of demoralization over their inability to control their self-harm behavior as well as disgust over their scarred bodies and self-isolation. I consider between 15 and 20 acts of self-harm to constitute a repetitive self-mutilator, whereas persons who develop the syndrome have self-injured themselves at least 50 times (some have cut themselves hundreds and even thousands of times). All 4 types of SM are encountered in all social classes and in all nations in the world. Compulsive and impulsive SM is more common in females by approximately a 6:4 ratio.Whitlock et al gathered such a great amount of data that their presentation becomes problematic. An important missing element is the role, if any, of alcohol and drug use in SIB. The authors chose to lump subjects into 3 groups: (1) persons with no SIB; (2) persons with 1 incident; and (3) persons with ≥2 incidents (“repeat SIB incidents”), although their Table 2 shows that 33.2% of those who self-injured engaged in 2 to 5 acts, 15.5% in 6 to 10 acts, 9.7% in 11 to 21 acts, and 15.2% in >21 acts. Although I am not sophisticated when it comes to statistics, it turns out that the odds ratios for single and repeat self-injurers in the study rise astronomically if the subjects also report suicidality, moderate psychological distress, characteristics of eating disorders, and emotional abuse.Although 70% of “repeat” subjects used multiple methods of SIB, the type of SIB in subjects with single incidents is not reported. The most common type, by far, of reported SIB was severe scratching or pinching skin (51.6%), and the second most common was banging or punching objects to the point of bruising or bleeding. It is difficult for me to believe that one such SIB incident would have any predictive potential. The authors, in fact, do not claim that one incident of SIB is predictive of clinical psychopathology but rather imply that it may be a manifestation of subclinical emotional distress, although “emotional distress” is not a diagnosis, and what it implies is anybody's guess. A favorable analogy could be made, perhaps, to the finding that subclinical depressive symptoms in adolescence may be predictive of major depression in adulthood. The question of the type of SIB is significant. Skin-cutting, for example, seems to me to be more salient than skin-scratching or punching a wall. In nonclinical populations, it is fairly common for male adolescents to punch a wall when they are frustrated or for young girls to scratch their skin. Even with cutting, I pay little attention to persons who report one impulsive or compulsive SIB act performed in past years. I would be concerned, however, if a patient had recently engaged in SIB. My biggest worry would be that the behavior was the beginning of a pattern that must be stopped to avoid progression to repetitive self-injury and development of DSH. The importance of the Whitlock et al study will be determined only by follow-up studies, and it will be quite a task to keep track of students who graduate or leave school.Clinically, I would advise that every physician or mental health professional inquire about SIB during the first contact with a patient as part of the mental status examination. During every physical examination, the physician should look for scars, bruises, and other signs of SIB. Once identified, patients should be warned about the “addictive” nature of SIB and the possibility of developing DSH. Psychological treatment, especially dialectic behavior therapy (which is often not available in many locales and demands highly motivated patients) is somewhat helpful. Medications to decrease impulsivity (such as selective serotonin-reuptake inhibitors) and regulate affect (such as mood stabilizers [lamotrigine, atypical antipsychotic agents, etc]) may be helpful also. SIB itself is a morbid form of self-help and is usually effective in decreasing severe anxiety, depersonalization, and other symptoms. The problems are that its effects are short-lived and the scarring can result in a life of self-isolation and demoralization. Early intervention to prevent the escalation and frequency of SIB is the best treatment.