Ecological Variation in Self-Injury Behavior

ABSTRACT: Only recently have efforts been made to discover the extent of self-injury behavior in the general population. The study reported here was designed to ascertain and examine the degree of relationship between the ecological distribution of self-injury behavior and the indices of economic and ethnic status. The general hypothesis predicts that high rates of self-injury behavior are associated with low economic status and high ethnic status census tract populations in a northern metropolitan area. A total of 2,755 cases of self-injury were collected for the year 1972 from the records of the city and county police departments, hospital emergency facilities, and a sample of private physicians. Self-injury behavior was defined as any case of self-inflicted overdosage, asphyxiation, or injury, whether or not there was evidence of suicidal intent. The indices of economic and ethnic status for the various census tracts were computed in the manner suggested by Shevky and Bell (1955) . All the measures of economic status were found significantly related to self-injury in the predicted direction. The relationship between ethnic status and self-injury rates was not significant. When ethnic status was disaggregated, a significant relationship was found between self-injury rates for nonwhites and foreign-born whites. The explanation was offered that ethnic differences in self-injury are mediated by economic status variables and subcultural factors.     

Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis

People with mental retardation, autism, and related developmental disabilities who self-injure are treated with a wide array of behavioral techniques and psychotropic medications. Despite numerous reports documenting short-term and some long-term changes in self-injury associated with the opiate antagonist naltrexone hydrochloride, no quantitative review of its efficacy has been reported. We conducted a quantitative synthesis of the peer-reviewed published literature from 1983 to 2003 documenting the use of naltrexone for the treatment of self-injurious behavior (SIB). Individual-level results were analyzed given subject and study characteristics. A sample of 27 research articles involving 86 subjects with self-injury was reviewed. Eighty percent of subjects were reported to improve relative to baseline (i.e., SIB reduced) during naltrexone administration and 47% of subjects SIB was reduced by 50% or greater. In studies reporting dose levels in milligrams, males were more likely than females to respond. No significant relations were found between treatment outcomes and autism status or form of self-injury. Results are discussed with respect to future efficacy work related to study outcomes and the pharmacological treatment of self-injury.     

Seeking help for non-suicidal self-injury: A social network analysis approach

Individuals who self-injure have consistently reported less perceived social support; yet, little is actually known about the support they seek out from others specifically for non-suicidal self-injury. The goal of this study was to explore characteristics of support networks of those who self-injure. Twenty-three percent reported not seeking support for self-injury, while the remaining reported smaller social networks than typical. Most participants sought help infrequently, and when they did, found supporters to be only moderately helpful. Network characteristics were found to relate to self-injury behavior and patterns emerged regarding supporters in the networks. Implications for advocacy and education are provided.     

Self-destructive behavior in patients with dissociative disorders

Highrates of self-injury have been reported in patients with dissociative disorders, yet no prior study has directly compared these patients with other psychiatric patients. The present study assesses self-destructive behavior in a group of inpatients who have dissociative disorders compared to those who report few dissociative symptoms. These patients more frequently engage in self-destructive behaviors, use more methods of self-injury, and begin to injure themselves at an earlier age then patients who do not dissociate. Results have important implications for understanding the relationship between dissociation, childhood trauma, and self-injury and for assessment and treatment of patients with dissociative disorders.     

Adolescent dress, Part I: Dress and body markings of psychiatric outpatients and inpatients

This paper investigated the dress and body markings of 100 adolescent psychiatric patients (both hospitalized and never-hospitalized). Data were obtained from in-depth interviews conducted by a child psychiatrist. In contrast to nonhospitalized patients, hospitalized patients had a higher incidence of self-scarring, i.e., marks applied to self, either as a self-mutilation/suicide gesture or serving another purpose (for example, carving a boyfriend's initials into one's arm). Other individual expressions of appearance did not differentiate hospitalized from nonhospitalized patients. Detailed dress and appearance observations, questionnaires, photo reviews, self-portraits, and family discussions contributed to the beneficial effect of psychotherapy by focusing on feelings evoked and symbolized in dress and body markings.     

A Daily Diary Investigation of the Defective Self Model Among College Students With Recent Self-Injury

The Defective Self Model of self-injury (Hooley, Ho, Slater, & Lockshin, 2010) asserts that individuals choose to self-injure to gratify the desire for self-punishment associated with a self-critical cognitive style. Specifically, self-injury is used to regulate negative self-directed thoughts and emotions and is made accessible via the belief that the individual deserves punishment. This study sought to test primary assumptions of the Defective Self Model using a 2-week daily diary protocol. It was hypothesized that trait self-criticism would predict daily self-injury urge intensity and behaviors directly, as well as indirectly, through daily thoughts about deserving punishment. We also posited that guilt would predict self-injury urge intensity and behaviors beyond sadness, hostility, and fear. Support for primary hypotheses was mixed. Self-criticism did not directly predict self-injury outcomes, but did indirectly predict urge intensity through daily thoughts about punishment. Daily guilt predicted self-injury urge intensity beyond daily sadness, hostility and fear and was the only type of negative affect associated with self-injury behavior. Results are primarily contextualized through a social cognitive lens in which self-injury urge is precipitated by the activation of a self-critical schema in daily life. Alternatively, self-criticism may serve as a gateway to initial self-injury but lack the sensitivity to predict individual self-injury episodes. Treatments designed to reduce self-critical thoughts and bolster self-compassion may decrease self-injury urge intensity, thereby affecting the frequency of self-injury episodes.     

大学生自伤行为的强化敏感性基础

强化敏感性包括惩罚敏感性和奖励敏感性, 它影响个体的情绪、动机和行为过程, 与个体的情绪反应性密切相关。极端的强化敏感性与情绪管理障碍及多种自伤相关行为存在密切联系。为探索强化敏感性与自伤行为的关系, 研究1采用BIS/BAS量表和青少年自我伤害问卷, 对717名大学生进行了调查。研究2在研究1的基础上, 采用Q−任务和CARROT范式, 由127名大学生参加实验, 进一步考察不同功能的自伤行为的强化敏感性基础。结果表明：①惩罚敏感性、奖励敏感性及其愉悦寻求维度均对自伤行为有正向预测作用; ②情绪管理组自伤被试以高惩罚敏感性和接近正常的奖励敏感性为特征, 刺激寻求组自伤被试以高奖励敏感性和接近正常的惩罚敏感性为特征。结论：强化敏感性可有效预测自伤行为; 情绪管理和刺激寻求两种功能的自伤行为具有不同的强化敏感性基础; 对自伤行为进行分类研究十分必要。     

Dual realities – The search for meaning: Psychodynamic therapy with physically ill people

Abstract

We summarize Kohut's (1971) bi-polar self which enables counsellors to understand and treat narcissistic behaviours and narcissistic personality disorders in a psychoanalytic framework. After Patton and Meara (1992), we describe Kohut's formulations regarding self-development and disorders of self and how such formulations inform critical components of psychoanalytic counselling with particular emphasis on the explicit and implicit strategies and characteristics the counsellor brings to the process. Finally, we suggest that a promising arena for future theorizing and applications of Kohut's ideas is consultation with parents, teachers and other community leaders to help prevent or remedy psychological self-injuries with systemic interventions outside short-term counselling or long-term therapy.

We have suggested that Kohut's self psychology is a good vehicle for understanding what brings a client to counselling: namely, disorders of the self or self-injury. We review strategies and ‘ways of being’ a counsellor must bring to and offer in the counselling encounter if the work is to succeed. We also examine implicit qualities (beyond the achievement of a mature bipolar self) we believe a counsellor or any facilitator must have if counselling or other helping relationships are to be effective. We purpose further conversations and empirical analyses which specifically and conceptually link critical components of psychoanalytic counselling to self psychology and to essential counsellor traits or virtues that seem intrinsic to good counselling practice.     

THE USE OF PHYSICAL RESTRAINT IN THE TREATMENT OF SELF-INJURY AND AS POSITIVE REINFORCEMENT

Two experiments investigated the effects of a treatment package on the self-injurious behavior of three profoundly retarded persons who appeared to enjoy the physical restraints used to prevent their self-injury. The treatment package included physically restraining subjects contingent on increasing periods of time during which no self-injury occurred, and providing them with toys and attention during intervals between restraints. A reversal and multiple-baseline analysis documented that the rapid and complete reduction in self-injury by all subjects was due to this treatment package. Because these results suggested that physical restraint might function as a positive reinforcer, in a third experiment physical restraint was applied contingent on a marble placement response with one subject. A reversal design demonstrated that toy play systematically increased when each response resulted in restraint. The experiments have implications for the nonaversive remediation of self-injury in individuals who are restrained, as well as for the development and maintenance of self-injury in natural settings.     

The Ecology of Self-Injury: A Multivariate Approach

ABSTRACT: In an ecological study of the distribution of self-injury in London, Canada, the authors found that self-injury occurred more frequently in the central areas of the city. Multivariate analysis revealed that living arrangements, such as high density of housing and single-person households, are closely associated with inflated rates on self-injury. Low socio-economic status is also related to self-injury but neither family status nor mobility are significant predictors. Ecological relationships such as these suggest directions for future research on individuals and may also be of direct use to planners who wish to locate treatment services advantageously.     

Safer self-injury or assisted self-harm?

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered.     

Comparison of non-suicidal self-injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit

The aim of the current study was to examine differences in personality, coping skills, and select psychopathology symptoms in psychiatric patients with and without non-suicidal self-injury and/or suicide attempts. We collected data in a sample of 128 psychiatric patients by means of self-report questionnaires measuring self-harm, psychological symptoms, personality and coping skills. Results support a continuum of self-harm such that patients with both non-suicidal self-injury and suicide attempts exhibit significantly greater levels of psychopathology and lower levels of adaptive personality traits and coping skills. The findings point to the clinical importance of making a distinction between non-suicidal self-injury and suicide attempts, and offers additional variables to consider outside of intent when appraising suicide risk.     

Female self-injury and suicide attempts: Culturally reinforced techniques in human relations

There is a consistent and significant higher ratio of females who engage in self-injury or who attempt suicide as compared to males, or as compared to suicidal commits by both sexes. This paper focuses on the problem of female excess in self-injury and suicide attempts. Biological/psychological variables which have been linked to these female self-destructive behaviors are enumerated and an alternative sociocultural explanation is suggested. Sex-role expectations are shown to be essential in explaining female self-injury and suicide attempts. The notion that these female self-destructive behaviors offer self-preservation is criticized, as is the failure in the literature to investigate what female self-injury and suicidal attempts actually do accomplish. Direction for solutions is mentioned in terms of research findings on self-actualization and on androgynous persons.     

The construction of self-injury in the clinical literature: a sociological exploration

This article presents a sociologically informed critique of a range of academic literatures relating to self-injury. It is noted how a lack of consensus on definitional issues, together with the inaccurate portrayal of the "typical self-injurer" in the clinical literature, has impeded the development of a sound understanding of self-injury. Some of the more problematic explanations for self-injury are explored. The individualistic focus of existing research is found to be inadequate, since it fails to account for the social context in which self-injury occurs. Social scientific approaches critically examine psychiatric and psychological constructions of self-injury, explore wider social and cultural meanings of the behavior, and examine its distribution across different social groups. The inclusion of social scientific perspectives into current debates will greatly improve understanding of self-injury.     

青少年抑郁与自伤关系的追踪研究：亲子沟通的调节作用

为考察青少年抑郁与自伤的双向关系及亲子沟通的调节效应,采用青少年自我伤害问卷、流动中心用抑郁量表和亲子沟通量表对595名初一学生进行为期10个月的追踪研究。结果发现,从初一到初二,抑郁呈增长趋势,且性别差异显著,而自伤的增长趋势不明显,但到初二后表现出了明显的性别差异;抑郁和自伤的同时性相关和继时性相关均显著;前测抑郁对后测自伤有明显的预测作用,但前测自伤对后测抑郁的预测作用不明显;父子沟通和母子沟通在前测抑郁与后测自伤水平之间有显著的负向调节作用。     

THE ROLE OF ATTENTION IN THE TREATMENT OF ATTENTION-MAINTAINED SELF-INJURIOUS BEHAVIOR: NONCONTINGENT REINFORCEMENT AND DIFFERENTIAL REINFORCEMENT OF OTHER BEHAVIOR

Because there are potentially serious limitations to differential reinforcement of other behavior (DRO) (which is probably the most widely used treatment procedure for behavior problems), we examined an alternative procedure—noncontingent reinforcement (NCR). Three females with developmental disabilities, all of whom engaged in severe self-injurious behavior, participated. During a pretreatment functional analysis, each subject's self-injury was shown to be differentially sensitive to social attention as a maintaining consequence. Next, each subject was exposed to a DRO treatment and an NCR treatment. During DRO, attention was delivered contingent on the absence of self-injury for prespecified intervals. During NCR, attention was delivered on a fixed-time schedule that was not influenced by the subject's behavior. Results showed that both procedures were highly effective in reducing self-injury, probably because the functional reinforcer for self-injury was used during treatment. Furthermore, there was evidence that NCR attenuated several of the limitations of DRO. These results are particularly interesting in light of the long experimental history of NCR as a control rather than as a therapeutic procedure.     

Parents’ Experiences of Nonsuicidal Self-Injury Among Adolescents and Young Adults

We assessed the impact of adolescent nonsuicidal self-injury (NSSI) on parents in two studies. In Study 1, 16 Australian parents of adolescents with a history of nonsuicidal self-injury responded to open-ended questions about their child’s nonsuicidal self-injury. Data from 10 of the adolescents were matched with parents’ responses regarding the nature and extent of nonsuicidal self-injury, revealing that parents underestimated the frequency of nonsuicidal self-injury, the age of onset, and the likelihood their child would continue to self-injure. In Study 2, 22 American parents of adolescents with a history of nonsuicidal self-injury participated in interviews about their experiences. Parents in both studies reported changes in the parent–adolescent relationship after self-injury, which posed challenges to the family unit. When professional help had been sought, experiences were largely negative. Results support further investigation into family-based interventions to equip parents with tools to better relate to, and communicate with, their adolescent following self-injury. Results also suggest that mental-health professionals and general practitioners may require further training for nonsuicidal self-injury.     

Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol

This study focused on the development and pilot testing of a protocol based on Prolonged Exposure (PE) that can be added to Dialectical Behavior Therapy (DBT) to treat PTSD in suicidal and self-injuring individuals with borderline personality disorder (BPD). Women with BPD, PTSD, and recent and/or imminent serious intentional self-injury (n = 13) received one year of DBT with the DBT PE Protocol, plus three months of follow-up assessment. The treatment was associated with significant reductions in PTSD, with the majority of patients no longer meeting criteria for PTSD at post-treatment (71.4% of DBT PE Protocol completers, 60.0% of the intent-to-treat sample). A minority of patients (27.3%) engaged in intentional self-injury during the study. Improvements were also found for suicidal ideation, dissociation, trauma-related guilt cognitions, shame, anxiety, depression, and social adjustment. There was no evidence that the DBT PE Protocol led to exacerbations of intentional self-injury urges or behaviors, PTSD, treatment dropout, or crisis service use. Overall, the results indicate that this integrated BPD and PTSD treatment is feasible to implement within one year of treatment, highly acceptable to patients and therapists, safe to administer, and shows promise as an effective intervention for PTSD in this complex and high-risk patient population.     

父母“低头族”对青少年自伤行为的影响:基于体验回避模型的视角

本研究基于自伤的体验回避模型,考察父母“低头族”对青少年自伤行为的影响,并检验焦虑和体验回避的序列中介作用。以808名中学生为被试,采用父母低头族量表、抑郁-焦虑-压力简版量表、接纳与行动问卷第二版和青少年自我伤害行为问卷进行测试,结果发现：（1）父母“低头族”与青少年焦虑、体验回避、自伤行为呈显著正相关;焦虑、体验回避与自伤行为呈显著正相关;（2）焦虑和体验回避在父母“低头族”和青少年自伤行为之间均起部分中介作用;（3）焦虑和体验回避在父母“低头族”和青少年自伤行为之间构成序列中介,即父母“低头族”通过增加青少年的焦虑,从而提高体验回避倾向,进而增加青少年自伤行为。研究从情绪和应对手段角度来考察父母“低头族”对青少年自伤行为的作用机制,对青少年自伤行为的预防和干预具有启示意义。     

社会排斥对青少年自伤的影响:羞耻感的中介和认知重评的调节

通过3个行为实验考察了社会排斥对青少年自伤的影响。实验1发现,社会排斥和自伤经历能明显增加青少年的自伤时长(假设1);实验2进一步验证假设1,并验证了羞耻感的中介作用(假设2);实验3验证了认知重评对羞耻感中介效应的调节作用(假设3)。结果表明,社会排斥通过诱发羞耻感影响青少年自伤,但采用认知重评的情绪管理策略能够有效阻断羞耻感的中介作用。本研究为青少年自伤的认知干预提供了有力的实证支持。