PG
Psychology

Self-Mutilation

August 21, 2014.
Roberta R. Ball, DO,

Educational Objectives

The goal of this program is to improve management of self-mutilation. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize patterns and signs of self-mutilating behavior.

2. Ask appropriate open-ended questions when evaluating patients who self-mutilate.

3. Distinguish nonsuicidal self-injury (as defined in Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition) from other disorders in which self-mutilation occurs.

Summary

Background on self-mutilation: also known as self-injury or self-harm; act of deliberately harming oneself; not typically intended as suicide; unhealthy way of coping with emotional pain, intense anger, and frustration; offers momentary sense of calm and release of tension, usually followed by guilt, shame, and return of painful emotions; associated with risk for more serious or fatal outcomes; linked to impulse control problem (controversial); many patients have repetitive thoughts about self-injury before acting on them; often linked to depression, eating disorders, and borderline personality disorders

Forms of self-injury: cutting or severe scratching on parts of body (eg, hands, arms, legs, front of torso [usually body parts that can be hidden under clothing]) with sharp object (eg, razors, knives, surgical instruments); burning (with, eg, cigarettes); carving; piercing; head banging; biting; pulling out hair; picking at skin or wounds

Patterns: usually occurs after being upset; one or more methods may be used; can occur only few times, or can be long-term repetitive behavior; more frequent in girls and women, teenagers, and young adults; in geriatric population, skin picking and scratching most often associated with dementia; self-cutters often have friends who self-injure; often associated with neglect or abuse in early years; often linked to drugs and/or alcohol use

Signs of self-mutilation: scars; fresh cuts; scratches; bruises; wounds; broken bones; keeping sharp objects on hand (eg, in book bag); wearing long sleeves or pants in hot weather; claiming to have frequent accidents or mishaps; spending time alone; pervasive difficulties in interpersonal relationships; personal identity problems; behavioral and emotional instability; impulsivity; unpredictability; statements about helplessness, hopelessness, and/or worthlessness

Etiology: inability to cope with psychologic pain; difficulty regulating, expressing, or understanding emotions (eg, feelings of worthlessness, loneliness, panic, guilt, rejection, anger, self-hatred, confused sexuality); attempt to reduce severe distress or anxiety, ie, distraction from painful emotions through physical pain (some patients who cut state that they do not feel pain, while others relish feeling of pain); feeling of sense of control over body; way of expressing internal feelings externally; perceived as punishment for, eg, indiscretion, faults

Complications: worsening feelings of shame, guilt, and low self-esteem; infection; major blood loss; permanent scarring or disfigurement; severe or fatal injury; worsening of underlying issues or disorders

Treatment: usually prompted by, eg, family member; psychiatric hospitalization recommended in severe cases; other options include day programs and psychotherapy; patient must admit, “I’m doing this” (but all express not knowing why); therapy helps patients verbalize thoughts on cause of their actions; psycho- and pharmacotherapy options — psychodynamic psychotherapy; cognitive behavioral therapy; dialectic behavioral therapy; mindfulness-based therapy; medications also used

Evaluation: obtain psychiatric history (although many young adults do not have formal psychiatric history); questions to ask — “when did you first begin harming yourself?” “what methods do you use?” “how often do you do this?” “what feelings and thoughts do you have before, during, and after self-injury?” “are you aware of any triggers?” “what makes you feel better or worse?”; ask about friends and relationships, and whether friends involved in same activities; ask about use of social media (eg, websites that support self-injury), emotional issues, and history of treatment; “do you ever have suicidal thoughts?”; ask about tobacco, alcohol, and drug use

Other behaviors: body piercing — many young individuals with piercings of, eg, tongue, nipple, or penis, struggle with self-identity; trichotillomania — hair-pulling disorder (usually one strand at a time); included in Diagnostic and Statistical Manual of Mental Disorders Fifth Edition; DSM-5); excessive scratching — seen in older population; multiple plastic surgery procedures — classification as self-injury debatable

Conditions for further studies in DSM-5: proposed criteria — A) in last year, individual has on ≥5 days engaged in intentional self-inflicted damage to surface of his or her body of sort likely to induce bleeding, bruising, or pain (eg, cutting, burning, stabbing, hitting, excessive rubbing), with expectation that injury leads to only minor or moderate physical harm (ie, no suicidal intent); B) individual engages in self-injurious behavior with ≥1 expectation (ie, to obtain relief from negative feelings or cognitive states, to resolve interpersonal difficulty, or to induce positive feeling state); C) intentional self-injury associated with ≥1 issues (ie, interpersonal difficulties, or negative feelings or thoughts [eg, depression, anxiety, tension, anger, generalized distress, self-criticism], occurring in period immediately prior to self-injurious act); prior to engaging in act, period of preoccupation with intended behavior difficult to control; thinking about self-injury occurs frequently even when not acted on; D) behavior not socially sanctioned or part of religious or cultural ritual, and not restricted to picking scab or nail biting; E) behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of function; F) behavior does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal, or in individuals with neurodevelopment disorder; behavior not part of pattern of repetitive stereotypes; G) behavior not better explained by another mental disorder or medical condition (eg, psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury, trichotillomania, or excoriation disorder)

Lesch-Nyhan syndrome: incidence 1 in 380,000; rare inherited disorder; deficiency of hypoxanthine-guanine phosphoribosyltransferase results in build-up of uric acid; poor muscle control and failure to meet milestones seen during first year of life; self-mutilating behavior (eg, finger biting) occurs by second year of life

Case patient: speaker treated young woman with cutting behavior who had history of sexual abuse by family members and church counselor; self-mutilation gradually improved with intensive psychotherapy; patient has become fully functional, but occasionally needs anxiolytic medication (while cutting, patient unaware of feelings of anxiety)

Theory about self-cutting: suggested by Louise Kaplan; cutting attributed to identity crisis in women related to confusion about sexual identification; use of razor creates bleeding wound that mimics menstruation

Helpful websites: National Alliance on Mental Illness (www.nami.org); www.self-injury.org (nationally recognized treatment approach, professional network, educational resources); Depression and Bipolar Support Alliance (www.dbsalliance.org)

Acknowledgements

Dr. Hohman was recorded in San Diego, CA, at State of the Art in Addiction Medicine, presented October 16-19, 2013, by the California Society of Addiction Medicine. Please visit www.csam-asam.org/events for information about upcoming courses from this sponsor. Dr. Ball spoke in Miami, FL, at the American College of Osteopathic Neurologists and Psychiatrists’ Mid-Year Meeting and Scientific Seminar, presented March 5-8, 2014. Please visit www.acn-aconp.webs.com/Conferences for information about upcoming meetings from this sponsor. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Ball spoke in Miami, Florida at the American College of Osteopathic Neurologists and Psychiatrists' Mid-Year Meeting and Scientific Seminar, presented March 5-8, 2014.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PG031602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation