A follow-up study of wrist slashers

Shifting Conversations on Girls' and Women's Self-Injury: An Analysis of the Clinical Literature in Historical Context

Through a historical review of girls' and women's episodic and repetitive self-injury -scholarship focusing primarily on white, middle-class women in North America and Britain - in the clinical literature from 1913 to the present, the author identifies four shifts over time. These are: 1) varying degrees of clinical interest in and numbers of publications on self-injury, 2) changing conceptualizations of self-injury, 3) changing treatment approaches for self-injury, and 4) changing characterizations of women who self-injure. Moving from research studies which indicate that self-injury typically presents in females during adolescence, this article elucidates how self-injury may reflect girls' developmental struggles within a patriarchal culture and embody a narrative of women's experiences of violation. Bringing together the history of self-injury and a feminist, relational analysis, it is argued that the historical discourse on self-injury mimics women's experiences of objectification and violence by silencing and distorting their self-injury.

Predictors for self-directed aggression in Italian prisoners include externalizing behaviors, childhood trauma and the serotonin transporter gene polymorphism 5-HTTLPR

Suicidal behavior and self-mutilation can be regarded as the expression of self-directed aggression and both are common in prison populations. We investigated the influence of externalizing behaviors, depressive symptoms, childhood trauma, 5-HTTLPR variants on self-directed aggression (N = 145) in a group of 702 male Italian prisoners. Participants were comprehensively evaluated, including for psychiatric disorders, impulsive traits, lifetime aggressive behavior [Brown-Goodwin Lifetime History of Aggression (BGHA)], hostility, violent behavior during incarceration, depressive symptomatology [Hamilton Depression Rating Scale (HDRS)], childhood trauma [Childhood Trauma Questionnaire (CTQ)]. Logistic regression analysis showed false discovery rate corrected independent main effects of externalizing behaviors: BGHA (P = 0.001), violent behavior in jail (P = 0.007), extraversion (P = 0.015); HDRS (P = 0.0004), Axis I disorders (P = 0.015), CTQ (P = 0.004) and 5-HTTLPR genotype (P = 0.02). Carriers of 5-HTTLPR high (LA LA ), intermediate (LA LG , SLA ) activity variants were more likely to have exhibited self-directed aggression relative to the low activity (LG LG , SLG , SS) variant: high/low: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.27-4.68, P = 0.007; intermediate/low: OR = 1.96, 95% CI 1.09-3.68, P = 0.025. The CTQ main effect was driven by physical abuse. There was no interactive effect of 5-HTTLPR and CTQ. Secondary logistic regression analyses in (1) all suicide attempters (N = 88) and (2) all self-mutilators (N = 104), compared with controls showed that in both groups, childhood trauma (P = 0.008-0.01), depression (P = 0.0004-0.001) were strong predictors. BGHA, violent behavior in jail predicted self-mutilation (P = 0.002) but not suicide attempts (P = 0.1). This study was able to distinguish differing influences on self-directed aggression between groups of closely related predictor variables within the externalizing behavioral domain. 5-HTTLPR had an independent, variant dosage effect.

Defining and refining self-harm: a historical perspective on nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) is a newly proposed diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Some contemporary historiography dismisses NSSI as a fiction of modern psychiatry. Although the exact definition and psychological meaning attributed to self-harm has not been static over history, there is a clear thread that connects Western asylum psychiatrists' thinking about self-harm to the current stand-alone diagnostic category of NSSI. Nineteenth-century psychiatrists identified a clinically meaningful difference between self-harm with and without the intent to die, between self-injurers who were psychotic and those who were not, and between self-injurers who made a single, serious mutilation and those who repetitively self-injured without causing permanent bodily damage. These same distinctions are apparent in the definition of NSSI. Thus, NSSI is a formalization of long-held observations about a category of people who repetitively self-injure without suicidal intent.

Making the cut: The production of 'self-harm' in post-1945 Anglo-Saxon psychiatry

'Deliberate self-harm', 'self-mutilation' and 'self-injury' are just some of the terms used to describe one of the most prominent issues in British mental health policy in recent years. This article demonstrates that contemporary literature on 'self-harm' produces this phenomenon (to varying extents) around two key characteristics. First, this behaviour is predominantly performed by those identified as female. Second, this behaviour primarily involves cutting the skin. These constitutive characteristics are traced back to a corpus of literature produced in the 1960s and 1970s in North American psychiatric inpatient institutions; analysis shows how pre-1960 works were substantially different. Finally, these gendered and behavioural assertions are shown to be the result of historically specific processes of exclusion and emphasis.

Service user involvement in the evaluation of psycho-social intervention for self-harm: a systematic literature review

Background

The efficacy of interventions and treatments for self-harm is well researched. Previous reviews of the literature have highlighted the lack of definitively effective interventions for self-harm and have highlighted the need for future research. These recommendations are also reflected in clinical guidelines published by the National Institute for Health and Clinical Excellence ( NICE, 2004 ) which also call for service user involvement in studies of treatment efficacy.

Aims

A systematic review was undertaken to determine: a) what contributions service users have made to the evaluation of psycho-social interventions; b) by what methods have service users been involved; c) in what ways could service user involvement supplement empirical evidence for interventions.

Methodology

Electronic searches were completed on the 28th January 2011 of the Medline (1950–present), Web of Science (1898–Present), Web of Science (including Science Citation Index and the Social Science Citation Index), the Cochrane database of systematic reviews, and Psychinfo (1979–present) databases using a combination of 13 search terms. References were independently sifted according to set criteria by two of the authors to ensure inter-rater reliability.

Results

Sixty-five references were included in the review. Of these, 59% of studies were empirically based, and 26% used qualitative data collection methods to gather service user narratives. Only 8% of studies used a mixed-methodology to combined qualitative and quantitative data collection. No studies featured service user involvement.

Conclusion

Service user involvement is a rarity in the evaluation of psycho-social interventions, despite its use being mandated by the National Institute for Health and Clinical Excellence and evidenced as effective in other areas of mental health ( Leader, 1998 ). The authors make a number of recommendations for future involvement in future self-harm research.

Self-cutting: patient characteristics compared with self-poisoners

A large ( n = 14,892) consecutive sample of deliberate self-harm (attempted suicide) patients who presented to a general hospital in the United Kingdom during a 23-year study period was examined (over two consecutive time periods) in order to compare the characteristics of those who used self-cutting ( n = 428) and those who self-poisoned ( n = 11,065). Patients who used different methods on other occasions, or were not assessed by the psychiatric service, were excluded. In the first time period (January 1976-June 1988), the self-cutters were distinguished from the self-poisoners by more often being male, single, not employed, and having a history of previous deliberate self-harm. In the second time period (July 1988-December 1998) the self-cutters were again distinguished by more often being male and having a history of previous deliberate self-harm, but also by being more likely to live alone, misuse alcohol, and have low suicidal intent scores. The finding of an excess of males among the self-cutters is contrary to the impression in the literature that self-cutting presentations to general hospitals more often involve females. It also indicates that the treatment needs of those who deliberately cut themselves are likely to differ from those of self-poisoners.

Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions

Contrary to common clinical perceptions, individuals with personality disorders attempt and commit suicide at nearly the same rate as individuals with major depression. In particular, those with borderline personality disorder are at high risk for suicidal behavior and nonsuicidal self-injury. Yet there is significant controversy surrounding the diagnosis of borderline personality disorder in terms of its existence, its definition and symptom structure, its Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis location, and its importance as a contributing factor to suicidality and nonsuicidal self-injury. Furthermore, both suicidal and nonsuicidal self-harm is prominent in borderline personality disorder. There is often confusion between suicidal and nonsuicidal self-injury with one sometimes mistaken for the other. Nonsuicidal self-injury is sometimes met with hospitalization, because it is viewed as life threatening. Alternately, the potential lethality of suicidal behavior is underestimated, because it occurs in the context of multiple low lethality self-harm behaviors. It is possible to view these behaviors as distinct yet on a spectrum in borderline personality-disordered patients. With respect to treatment of self-injury in personality disorders, some recent pharmacotherapy trials have been conducted, though efficacy is often unclear. Findings with respect to psychotherapy, particularly dialectical behavior therapy, a form of cognitive behavioral treatment, are promising.

The functions of self-mutilation

While pathological self-mutilating behavior has been clinically examined for over 65 years, and much of the literature hypothesizes some function for the behavior, there has been little attempt to integrate or differentiate between different functional ideas. This review uses six functional models extracted from the literature to organize a discussion of the multiple functions of self-mutilation, acknowledging the overdetermined nature of the behavior and attempting to understand how self-mutilation can serve multiple functions simultaneously. Contextual information about the definition, prevalence, phenomenology, patient characteristics, associated diagnoses, and associated symptoms of self-mutilation is first presented. Six functional models are then presented: the environmental model, the antisuicide model, the sexual model, the affect regulation model, the dissociation model, and the boundaries model. Support for these models in the empirical and theoretical literature is presented and treatment implications are explored.

The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation

The overall purpose of the present study was to further our understanding of the mechanisms of self-mutilative behavior in a sample of female inpatients. The study found that self-mutilators (n = 103) displayed a greater degree of dissociative symptoms and alexithymia and a greater number of self-injurious behaviors, as well as higher rates of childhood sexual abuse, than nonmutilators (n = 45). In addition, the study found that among these variables, the number of self-injurious behaviors had the strongest relationship to self-mutilation. However, both dissociative symptoms and alexithymia were independently associated with self-mutilative behavior. Implications of our findings for clinicians and researchers are discussed.

The psychopathology of incarcerated self-mutilators

OBJECTIVE

To investigate the symptomatology of severe psychopathology reported by male incarcerated self-multilators.

METHOD

Comparisons were made with a nonmutilating incarcerated group and a nonincarcerated, nonmutilator group.

RESULTS

A distinctive pattern of symptomatology emerged. Self-mutilators evidenced a wide range of elevated scores on general measures of psychological/psychiatric symptoms, particularly depression and hostility. Aspects of hostility that distinguished self-mutilators for other groups included the urge to act out hostile feelings, critical feelings towards others, paranoid feelings of hostility and guilt. Self-mutilators demonstrated substantial problems with substance abuse, particularly alcohol.

CONCLUSION

A pattern of passive-aggressive, schizoid and avoidant personality styles distinguished self-mutilators from other groups.

Personality characteristics of self-mutilating male prisoners

Self-mutilating behavior (SMB) in prisons has long been recognized as a problem. MMPI data were obtained from 30 mutilating and 30 non-mutilating male inmates. Analyses of MMPI scores revealed significant differences on nine of the clinical and validity scales. Mutilators also had more frequent elevations over 70. Interpretation of scale and subscale configurations indicates that mutilators have more somatic complaints, subjective distress, alienation, inmature defenses, and acting out tendencies than controls. This is consistent with descriptions of SMB in the literature. SMB is conceptualized as a form of aggression in a population of impulsive and alienated individuals in a high-stress environment. The frustration-aggression model is proposed as a model for understanding and further investigating this phenomenon.

Personality disorder and self-wounding

At least 1 in 600 adults wound themselves sufficiently to need hospital treatment. More men than women do it, although more women receive psychological treatment. Many have a history of sexual or physical abuse. Self-wounding differs from other self-harm in being aimed neither at mutilation nor at death. Self-wounding coerces others and relieves personal distress. Repeated self-wounding is one criterion of borderline personality disorder but we prefer to consider it an 'addictive' behaviour rather than an expression of a wider disorder. Psychological management may need to be augmented by drug or social treatment. Carers, including professional carers, usually need help to contain the turbulence that self-wounding produces.

Relationship of depression and cognitive impairment to self-injury in borderline personality disorder, major depression, and schizophrenia

Self-injury was studied in 64 adults with borderline personality disorder, major depression, or chronic paranoid schizophrenia. Subjects were rated according to acute depression, chronic depression, self-injurious behaviors, and neurocognitive deficits, as measured by cognitive function examination. Borderline patients showed more self-injurious behaviors and more chronic depressive symptoms than the major depression or schizophrenia groups. Self-injury was not significantly correlated with acute or chronic depression in any group, but self-injury was correlated with neurocognitive deficits in borderline and schizophrenic groups. The results are explained in the context of a neurocognitive model of psychotic thought process in borderline disorder and schizophrenia.

Self-harm behaviors (carving) in female adolescent drug abusers

Deliberate self-lacerations by rebellious or delinquent adolescent girls, known by them as "carving," may be erroneously diagnosed as a suicide gesture. Carving is an important physical sign suggesting possible drug and alcohol abuse during adolescence. Eighty-five adolescent female patients in a long-term outpatient, self-payment, therapeutic community-type of adolescent drug treatment program, participated in a descriptive survey of "carving" behaviors. Forty-one girls (48%) admitted to deliberate cutting of their own wrists, arms, or other body parts without suicidal intent. Fifteen of the 85 girls (18%) cut themselves six or more times. Many girls had scarified their bodies with their boyfriends' initials as a visible means of demonstrating their affection and loyalty. They also carved rock group symbols or a Christian cross. Large and disfiguring scars were noted on 14 patients. The girls explained the behavior as a method of dealing with depressed affect, anger, emotional pain, or emptiness. Suicide attempts, usually by purposeful overdose of medication, had been made by 24 (59%) of 41 girls who carved themselves. Multiple suicide attempts were associated with habitual carving. Epidemics of carving, led by one or more angry, depressed, or lonely adolescents, may occur in closed facilities such as correctional institutions and drug abuse treatment facilities.

Female habitual self-mutilators

Data are presented on 240 female habitual self-mutilators. The typical subject is a 28-year-old Caucasian who first deliberately harmed herself at age 14. Skin cutting is her usual practice, but she has used other methods such as skin burning and self-hitting, and she has injured herself on at least 50 occasions. Her decision to self-mutilate is impulsive and results in temporary relief from symptoms such as racing thoughts, depersonalization, and marked anxiety. She now has or has had an eating disorder, and may be concerned about her drinking. She has been a heavy utilizer of medical and mental health services, although treatment generally has been unsatisfactory. In desperation over her inability to control her self-mutilative behavior this typical subject has attempted suicide by a drug overdose.

The challenge of self-mutilation: a review

The challenge of self-mutilation among humans arises from the imprecision of much of the existing literature, as well as the countertransference such disturbing behavior mobilizes. Self-mutilation is defined as an individual's intentionally damaging a part of his or her own body apparently without a conscious intent to die. The importance of understanding this behavior is reflected in the frequency with which it is encountered among psychiatric patients, particularly those diagnosed with borderline personality disorder or schizophrenia. The distinguishing characteristics of dermal, ocular, and genital self-mutilation illustrate the diverse clinical settings in which mutilation arises. Numerous explanations with differing degrees of complexity and merit have been offered; yet, no clear consensus has emerged. Psychotherapy, behavior therapy, and chemotherapy, while controversial, remain the most compelling treatment options. Salient areas for further study include epidemiology both for specific groups and the general population, possible biologic bases for the behavior, and additional management options.

A clinical study of 30 wrist cutters

Thirty patients who committed wrist cuttings were divided into four groups according to the patients' psychiatric diagnosis: hysteria group, depression group, adolescent behavioral disorder group and other diagnostic group. In the hysteria group, wrist cutting was considered as an expression of the patients' unconscious intention to seek sympathy for themselves from other people. In the depression group, wrist cutting seemed to be a preliminary rehearsal of suicide. In the adolescent behavioral disorder group, internal conflicts in adolescence or discordance with the patients' parents seemed to be the chief motivations of wrist slashing. The core groups were the hysteria and adolescent behavioral disorder groups, and the peripheral groups were the depression group and others.

Psychological models of self-mutilation

The descriptive models of self-mutilation fall into three broad categories. The psychodynamic formulation; the second category includes the anxiety reduction model, the hostility model, the behavioral learning model and the appeal model; the third social learning category includes the group-epidemic model and aspects of the violence and punishment model. The three models support the view that there is no single cause or motive responsible for self-mutilating behavior. Having a number of factors in mind allows for flexibility and enables clinicians to test particular hypotheses during management and gives them the opportunity to alter intervention accordingly. The problems faced by self-mutilating patients are so varied that no single form of treatment is likely to be universally appropriate.

The 'suicide' wrist: epidemiologic study of the injury

One hundred and ninety-one selfinflicted wrist lacerations in 148 different patients who presented to the Sacramento Medical Center Emergency Room from July, 1975, through June, 1977, are analyzed. One hundred and fifty-four (80.6%) involved the skin alone. Of the 37 lacerations with deep structure injury, 31 involved the palmaris longus. Only four of these were isolated injuries, and if this tendon is cut, there is an 87.1% association with a variety of other lacerated structures.

Self-mutilation in antisocial personality (disorder)

In the present study, attempts were made to clarify the characteristics and the background information of persons with antisocial personality (disorder) who had resorted to slashings. These were compared with controls with a similar personality disorder who had not resorted to slashings. It appeared that the former had been more often prone to repeated outbursts of rage or fighting, drug abuse, and even other forms of self-destruction as well as tattooing in prison. They had more often had an alcoholic father. Moreover, they were more withdrawn, anxious and had a tendency to blame their environment. They had more often made efforts to get out of the restricted milieu of prison to the prison's psychiatric department and experienced the confined space of the prison as oppressive. They resorted to slashing usually in prisons and it seemed that the restricted environment with an absence of sufficient stimuli was crucial in triggering self-mutilation.

The phenomenology of self-mutilation in a general hospital setting

Comparison of a series of twenty-four wrist-cutters with a control group of self-poisoners showed a number of significant differences. The wrist-cutters were younger and their acts were regarded as being of low lethality; they are no more likely to have made previous suicide attempts; they complain less often of depression, and more frequently of 'emptiness' and tension as primary complaints. Sudden, unpredictable mood swings are common and there is a greater tendency for their physicians to diagnose personality disorders, often in pejorative terms. They frequently have substantial medical interests and paramedical occupations. A high proportion complain of dysorectic symptoms (anorexia or overeating or combinations of both), use drugs and/or alcohol in excess; show sexual disturbance and distress, and also promiscuity. They more frequently have a negative reaction to menarche and menstruation; have come from broken homes and have experienced parental deprivation. A proportion of the group exhibit difficulty in verbal communication, and absconding from hospital was more common in the group of cutters. Painless cutting after a period of depersonalization, followed by relaxation and repersonalization after bleeding, was the typical pattern.