Self-Injurious Behavior

September 26, 2011

Although mental health professionals have yet to establish a universally accepted definition of self-injurious behavior (SIB), the term generally encompasses any intentional, nonsuicidal act upon one’s own body that results in organ or tissue damage. Notably, acts embodied in cultural practices or rituals that are shared by many members of a given society and may have symbolic significance (e.g., ear piercing in our own culture, the Sun Dance of the Plains Indians) are commonly excluded from this definition. Specific behaviors covered by the umbrella term of Self-Injurious Behavior vary greatly with respect to severity, with those associated with the least damage (e.g., hair pulling, self-hitting, and skin picking) and those associated with the most damage (e.g., castration, eye gouging, and limb amputation) lying on opposite ends of a continuum. To add to the complexity of the phenomenon, Self-Injurious Behavior crosses the boundaries of diagnostic categories and similar behaviors may be exhibited by individuals with different psychiatric conditions, such as developmental disabilities, eating disorders, personality disorders, and schizophrenia. Given the heterogeneous nature of Self-Injurious Behavior, it is useful to classify the behavior into categories. The most widely used system for classifying Self-Injurious Behavior identifies four major categories: stereotypic, major, compulsive, and impulsive.

Stereotypic Self-Injurious Behavior is behavior that is fixed, highly repetitive, monotonous, and often rhythmic. It occurs in individuals with mental retardation, autism, and various congenital disorders. It can sometimes result in severe injury and usually includes head banging, self-hitting, skin picking, self-biting, and hair pulling. In individuals with mental retardation, prevalence estimates of Self-Injurious Behavior range from 3% to 46%. Interestingly, within the female members of this population, rates of Self-Injurious Behavior appear to fluctuate with the menstrual cycle. Some medications may be helpful in the treatment of stereotypic Self-Injurious Behavior. However, behavioral interventions utilizing applied behavior analysis have shown the most promise in eliminating these behaviors.

Major Self-Injurious Behavior includes isolated incidents of severe or life-threatening Self-Injurious Behavior such as castration, eye gouging, and limb amputation. Frequently, these behaviors have symbolic meaning to the individual. Major Self-Injurious Behavior is most commonly associated with psychosis due to schizophrenia or a severe mood disorder. Genital mutilation is the most common form of major Self-Injurious Behavior and appears to be 10 times more common in men than in women. The recommended treatment for major Self-Injurious Behavior is antipsychotic medication.

Compulsive Self-Injurious Behavior is classified as compulsive, repetitive, and high-frequency behaviors of mild to moderate severity, such as hair pulling (trichotillomania), skin picking, and nail biting. Individuals with compulsive Self-Injurious Behavior usually experience the urge to engage in Self-Injurious Behavior as difficult to resist, as the behavior results in a decrease in tension or anxiety. Some experts have hypothesized that compulsive Self-Injurious Behavior is related to obsessive-compulsive disorder. While compulsive nail biting is most common in the general population, it is usually benign and decreases in frequency over the life span. Trichotillomania is the most studied of these behaviors, and can cause marked distress. Women and girls more frequently present for treatment of trichotillomania than do boys and men. However, this finding may be confounded by women’s greater likelihood of seeking mental health services in general. Effective treatments of compulsive Self-Injurious Behavior are behavioral treatments including self-monitoring, response prevention, and contingency management strategies (e.g., rewarding the absence of the behavior). Medications are also sometimes used in addition to behavior therapy.

Impulsive Self-Injurious Behavior includes behavior such as skin cutting, skin burning, and self-hitting. This behavior generally functions to temporarily relieve distress that is perceived as intolerable. Impulsive Self-Injurious Behavior is commonly associated with borderline personality disorder, with estimates that 70-75% of these individuals have engaged in at least one act of Self-Injurious Behavior. It is also seen in individuals with antisocial personality disorder, eating disorders, dissociative disorders, and posttraumatic stress disorder. It is associated with having had traumatic experiences, particularly childhood sexual abuse experiences. Available data suggest that women are more likely than men to engage in impulsive Self-Injurious Behavior. Treatment of impulsive Self-Injurious Behavior frequently focuses on helping individuals replace the Self-Injurious Behavior with more adaptive strategies for tolerating and expressing painful emotions. Dialectical behavior therapy for borderline personality disorder is an effective treatment approach for Self-Injurious Behavior as it occurs in that population. This treatment emphasizes behavioral analysis of the Self-Injurious Behavior and intensive skills training in alternative behaviors. Little data are available on pharmacological treatments for impulsive Self-Injurious Behavior, but certain antidepressant medications may be helpful in alleviating painful emotional states and reducing impulsive Self-Injurious Behavior.

See Also: Mental illness, Personality disorders, Schizophrenia, Trichotillomania

Suggested Reading

  • Conterio, K., & Lader, W. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York: Hyperion.
  • Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
  • Simeon, D., & Hollander, E. (Eds.). (2001). Self-injurious behaviors: Assessment and treatment. Washington, DC: American Psychiatric Press.
  • Spradlin, S. E. (2003). Don’t let your emotions run your life: How dialectical behavior therapy can put you in control. New York: New Harbinger.

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