Wrist-cutting syndrome: the meaning of a gesture

"Stop acting like a child - you're immature": The reversed ageism of practicing self-injury as adult women and the reclaiming of our bodies

The practice of self-injury is considered deviant and pathological, and the stereotype of a self-injuring individual is a young, white, middle-class woman. By using an autoethnographic approach, I elucidate how four women and I, aged 35-51, with experiences of self-injury in adulthood, use, internalize, and speak through dominant discourses of self-injury. The practice of self-injury is an embodied one, and self-injury is stereotypically associated with immature, irresponsible, and emotionally unstable young women. As adult women who self-injure, we use and speak through this representation, which, to some extent, affects our self-image and identity as we are often "misrecognized" as full partners in everyday social interaction or when we represent our professions. Still, we resist the idea of self-injury as stemming from immaturity, and we work to reclaim our bodies and agency from the medicalized, ageist assumptions of the practice of self-injury. By doing this, we can also rewrite and transform the meaning of this practice. Our self-inflicted wounds or scars do not define who we are nor our level of maturity, intelligence, and attractiveness. Thus, we acknowledge that we have the right to our own bodies and what we do to that body.

Early Trauma Subtypes are Differentially Related to Anxiety Symptomatology and Suicidal Ideation in Panic Disorder

OBJECTIVE

Early trauma significantly affects the severity of panic disorder (PD) symptoms and suicidal ideation. However, few studies have explored the specific effects of different early trauma subtypes on PD. This study analyzed how childhood trauma subtypes, including general, physical, emotional, and sexual, influence panic and phobia levels and suicidal ideation in adults with PD and healthy controls (HCs).

METHODS

In total, 455 adults with PD and 149 HCs participated in this study. The independent variables were sociodemographic and clinical variables such as coping strategies and early trauma subtypes from the Early Trauma Inventory Self Report-Short Form. The dependent variables were the Albany Panic and Phobia Questionnaire (APPQ), the Panic Disorder Severity Scale, and the Scale for Suicide Ideation (SSI).

RESULTS

Early emotional trauma significantly influenced the APPQ scores, whereas early physical trauma significantly influenced the SSI scores in patients with PD. However, in HCs, only early emotional trauma was significantly associated with the APPQ and SSI scores.

CONCLUSION

These findings highlight the influence of early trauma subtypes on the phobic symptom severity of PD and suicidal ideation among patients with PD. Early emotional trauma is associated with the severity of phobic symptoms, whereas early physical trauma is associated with suicidal ideation, suggesting distinct clinical outcomes based on the type of trauma in patients with PD.

Automutilações: uma problemática dos limites

O objetivo do presente artigo é analisar a estreita relação entre o fenômeno das automutilações e a problemática dos limites, tendo como ponto de partida o ataque à pele como condição de possibilidade para essa prática. A pele remete à sensorialidade e às primeiras noções de eu, tendo como função proteger nossa individualidade e fundamentar nossa troca com o outro. Ela contém uma premissa de integração, constituindo-se como uma fronteira que marca os limites da própria existência. Nas automutilações, a agressão à pele denuncia um prejuízo na construção da diferenciação entre sujeito e objeto, deixando em evidência uma confusão nos limites do sujeito. Nossa hipótese é a de que o recurso ao corpo, mais especificamente o ataque à pele, nas automutilações, surge como uma tentativa de contenção do eu em momentos nos quais o sujeito sente que pode haver o risco da perda da integridade narcísica.

The Prevalence of Adverse Childhood Experiences, Body Shame, and Revision Request Rate in 218 Plastic Surgery Patients: What Drives Postoperative Dissatisfaction?

BACKGROUND

What drives patients who are unhappy despite good results? Adverse childhood experiences are common, can impair adult health, and can cause body shame. Neither adverse childhood experiences nor body shame has been studied in surgical patients. The authors report adverse childhood experience prevalences in a plastic surgical population and investigate associations from adverse childhood experiences to body shame and to postoperative dissatisfaction.

METHODS

Two hundred eighteen consecutive patients (86 percent aesthetic and 14 percent reconstructive) completed the Adverse Childhood Experiences Survey and the Experience of Shame Scale. A one-sample test of proportions, logistic regression, and mediation analysis assessed outcomes.

RESULTS

Compared to the Kaiser/Centers for Disease Control and Prevention medical population, our patients had higher overall adverse childhood experience prevalences (79.8 percent versus 64 percent), emotional abuse (41 percent versus 11 percent), emotional neglect (38 percent versus 15 percent), family substance abuse (36 percent versus 27 percent), and family mental illness (29 percent versus 19 percent, all p < 0.001). Fifty-two percent of our patients had body shame. Adverse Childhood Experiences score predicted body shame (OR, 1.22; p = 0.003). Compared to unshamed patients, body shame was associated with more adverse childhood experiences (85 percent versus 72 percent), higher median Adverse Childhood Experiences score (3.5 versus 2), more cosmetic operations (three versus zero), more health problems (three versus two), higher antidepressant use (39 percent versus 19 percent), substance abuse history (16 percent versus 5 percent), and demands for additional pain medication (18 percent versus 5 percent). Body shame predicted requests for surgical revision (49 percent versus 17 percent; OR, 4.61; all p ≤ 0.0001).

CONCLUSIONS

Adverse childhood experience were common in our patients. Adverse Childhood Experiences score predicted body shame, which predicted revision requests. If body shame preceded and drove surgery, revision requests were likely. Patients desiring revisions had recognizable characteristics.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Patterns of wrist cutting: A retrospective analysis of 115 suicide attempts

Background

Rosenthal et al. classified female, habitual, non-suicidal wrist cutters as a group and introduced the concept of wrist-cutting syndrome. We investigated the characteristics of wrist-cutting patients at our institution in comparison with results reported previously.

Methods

We conducted a retrospective study involving 115 patients who had cut their wrists and been examined at the emergency department of a single hospital in Seoul, Korea, between March 2014 and August 2018.

Results

There were more women (73 patients; 63.5%) than men (42 patients; 36.5%), and the women (mean age, 34.42 years) were significantly younger than the men (mean age, 50.07 years). The patients who had cut their wrists repeatedly were mainly women (22 of 26 patients; 84.6%); however, men caused more severe damage than women. Substance use before a suicide attempt did not significantly increase the severity of wrist cutting. Our institution planned and implemented a suicide prevention intervention program to improve the continuity of outpatient care. The number of patients who continued psychiatric treatment increased significantly after program completion.

Conclusions

We confirmed that most patients were young women who were not suicidal in the true sense because their wounds were not severe. Our study showed a protective role of the barrier tendons (flexor carpi radialis, palmaris longus, flexor carpi ulnaris), and we suggest careful repair of the barrier tendons to protect neurovascular structures against subsequent cutting events. We found that it was possible to improve the continuity of patient counseling by managing patients through a psychiatric treatment program.

Comparison of the demographic and wound characteristics of non-suicidal and suicidal self-wrist cutting injuries

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

Clinical and psychometric features of psychiatric patients after a suicide attempt in relation with menstrual cycle phases

There is evidence that frequency of suicide attempts of fertile women is related to the menstrual cycle phases, while the influence of hormonal and psychiatric features has been hypothesized. This study aims to explore the distribution and possible differences in clinical characteristics of women who attempted suicide in relation to menstrual cycle. Seventy fertile female psychiatric patients, hospitalized in psychiatric department after a suicide attempt, were studied. Depression was assessed using Beck Depression Inventory, suicide intent with the Suicide Intent Scale, and aggression using the Buss-Perry Aggression Questionnaire. A profile of psychopathology was obtained by using Symptom Check List SCL-90-R. Attempts were more frequent during the last 4 days of luteal phase and during the 4 days of menses, with 59% of attempts to occur during these 8 days. Patterns of number of attempts and cycle phase were similar for subgroups regarding diagnosis, violent/non-violent mode of suicide attempt, and one or repeated attempts. Although attempts were unequally distributed during the cycle, none of the psychiatric features assessed in the present study were related to the higher frequency of attempts during premenstrual/menstrual days, indicating the need to include additional aspects of suicidal behavior in future studies.

Nonsuicidal Self-injury: A Systematic Review

Objective: Nonsuicidal self-injury (NSSI) refers to the intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Our paper presents an up-to-date overview on nonsuicidal, self-injurious behaviors.

Method: In accordance with PRISMA guidelines, a systematic literature search was conducted across two databases, PubMed and PsycARTICLES, regarding the main features of NSSI with a focus on epidemiological and etiologic data, diagnostic criteria, and functions. All English articles, published between 1998 and 2016, were considered, and screened against a priori inclusion/exclusion criteria. The search terms include: self-harm, self-injury, NSSI, epidemiology, comorbidity, gender, functions and DSM. We also examined the references of the retrieved articles.

Results: NSSI is most common among adolescents and young adults, and the age of onset is reported to occur between 12 and 14 years. Comorbidity with borderline personality disorder (BPD) and eating disorders is often reported. DSM-5 includes NSSI as a condition requiring further study. This review gives an overview of the prevalence rates (7.5–46.5% adolescents, 38.9% university students, 4–23% adults) and main causes that appear to stem from childhood trauma, comorbidity with many other disorders and several functions of NSSI, and the potential independence of a NSSI disorder.

Conclusion: Over the years, interest in NSSI grew to such an extent that an ongoing debate was instigated on whether NSSI should be considered as a diagnosis in its own right and given its own category. This paper provides an up-to-date overview on self-injury, what is known about it and what remains to be done. Clearly, our understanding of the main issues of NSSI has increased in last two decades. However, future researches is needed to examine the developmental trajectories, cultural backgrounds and shed light on the risk factors and functions as well as clarify its role as an independent diagnostic entity.

Self-inflicted Cut Injury as Common Method of Deliberate Self Harm: A Retrospective Study from Nepal

CONTEXT

Deliberate self-injury, a fairly common condition is present across all culture. It is defined as intentional, direct injuring of body tissue without suicidal intent. We continue to lack a sufficient understanding of this behavior in the context of South East Asian region.

AIMS

This study aims to explore the characteristics of self-cutting, and gender differences in homologous group of youth applying for foreign employment in Nepal.

SETTINGS AND DESIGN

Cross-sectional, single interview method in an out-patient setting.

SUBJECTS AND METHODS

The youths applying for foreign employment were screened for self-harm attempt using single question. Screen positive individuals were applied with inclusion and exclusion criteria. The data were collected in a single interview by consultant psychiatrist.

RESULTS

Males were more than females and the mean age (standard deviation) at the time of act and current presentation were 16.52 (3.13) and 24.70 (5.54) years, respectively. Various methods were used in self-inflicting cut, and certain amount of stress was present in the majority of the participants. There was no significant difference between male and female in all descriptive characteristics except for mean age at the time of presentation.

CONCLUSIONS

The descriptive results from Nepal are keeping with most of the published literature. The study is the first one from Nepal, and we expect that this will help in laying a good foundation for further studies with stronger methodologies.

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.

Injury patterns and the role of tendons in protecting neurovascular structures in wrist injuries

PURPOSE

The purpose of this study was to evaluate the anatomical features of injured structures, investigate the protection provided by the specific tendon of each corresponding important neurovascular structure (radial artery, median nerve, and ulnar nerve/artery) and to compare the results among the three categories of wrist injuries.

METHODS

This study included 114 patients who underwent primary repair for damaged wrist structures; 40 patients sustained accidental damage without intention (group 1), 40 had self-inflicted damage (group 2), and 34 patients had a stab or penetrating wound caused by a sharp instrument during a conflict or violent event involving another person (group 3). The basic demographic factors, distribution pattern, area, and depth of the injured structures were investigated and compared. The barrier roles of the flexor carpi radialis (FCR) for the radial artery, palmaris longus (PL) for the median nerve, and flexor carpi ulnaris (FCU) for the ulnar nerve were estimated.

RESULTS

In group 1, FCU injury was the most common single-structure injury. In group 2, PL±median nerve injuries were the most common. Multiple-structure injuries involving more than five structures occurred more frequently in group 3 than in the other groups. FCU±ulnar nerve injuries were more common in group 3 than in the other groups. Radial-side structures were injured most frequently in group 3, and central-side injuries occurred most frequently in groups 1 and 2. Superficial- and middle-layer injuries occurred at similar frequencies among the three groups. Particularly, deep-layer injuries were most weakly related to group 2 injuries. The barrier effects of the FCR, PL, and FCU were confirmed, respectively.

CONCLUSIONS

Wrist soft tissue injuries showed particular patterns of injured structures and depths according to the injury mechanism. These patterns included features such as single-structure injuries and the locations and depths of multiple-structure injuries with or without neurovascular injuries. In addition, the roles of FCR, PL, and FCU in protecting important wrist neurovascular structures were confirmed.

LEVEL OF EVIDENCE

Therapeutic III.

Beyond medicalization: Self-injuring acts revisited

For too long, medical/psychiatric and psychological studies, with focus on emotional sensitivity, personality traits, and correlation with psychopathology, have dominated research on self-injuring acts. The phenomenon thus has been defined as a predominantly medical issue. However, a large body of community prevalence studies show self-injuring acts to be a common phenomenon in society, and most of those who self-injure are unknown in psychiatric or other clinical settings. This article describes and analyzes the medicalization of self-injuring acts and argues a need to move research on self-injuring acts out of the medical paradigm. There is a need to explicitly explore the impact of social, cultural, structural, and gendered factors surrounding and influencing self-injuring acts. A non-medical approach, beyond the limits of the medical perspective, would feed research forward and create a more nuanced view on this widespread social phenomenon.

Non-suicidal reasons for self-harm: A systematic review of self-reported accounts

BACKGROUND

Self-harm is a major public health problem yet current healthcare provision is widely regarded as inadequate. One of the barriers to effective healthcare is the lack of a clear understanding of the functions self-harm may serve for the individual. The aim of this review is to identify first-hand accounts of the reasons for self-harm from the individual's perspective.

METHOD

A systematic review of the literature reporting first-hand accounts of the reasons for self-harm other than intent to die. A thematic analysis and 'best fit' framework synthesis was undertaken to classify the responses.

RESULTS

The most widely researched non-suicidal reasons for self-harm were dealing with distress and exerting interpersonal influence. However, many first-hand accounts included reasons such as self-validation, and self-harm to achieve a personal sense of mastery, which suggests individuals thought there were positive or adaptive functions of the act not based only on its social effects.

LIMITATIONS

Associations with different sub-population characteristics or with the method of harm were not available from most studies included in the analysis.

CONCLUSIONS

Our review identified a number of themes that are relatively neglected in discussions about self-harm, which we summarised as self-harm as a positiveexperience and defining the self. These self-reported "positive" reasons may be important in understanding and responding especially to repeated acts of self-harm.

Analysis of 41 suicide attempts by wrist cutting: a retrospective analysis

PURPOSE

Self-cutting injuries have a low mortality rate, but this type of injuries has special clinical significance because they have the potential of leading to devastating disability and repeated suicide attempts. The purpose of this study is to analyze the nature and outcomes of wrist-cutting injuries.

MATERIAL AND METHOD

A retrospective study was designed in order to investigate 41 suicide attempts by wrist cutting attended to Uludag University Faculty of Medicine Emergency Department between June 2008 and December 2014. The patients were analyzed for age, gender, alcohol intake, psychological state, prior suicide attempts, and clinical features such as injury side, injury pattern, and used tool.

RESULTS

It was seen that the severity of wrist-cutting injury variates between gender and age.

CONCLUSION

Alcohol or drug consumption and having a diagnosed psychiatric disorder create a higher risk for extensive wrist lacerations. It was seen that skin only lacerations were most likely to repeat the act and therefore are most in need of psychiatric intervention.

LEVEL OF EVIDENCE

Level III, retrospective study.

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.

Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression

Published prevalence estimates of nonsuicidal self-injury (NSSI) among nonclinical samples are highly heterogeneous, raising concerns about their reliability and hindering attempts to explore the alleged increase in NSSI over time. Accordingly, the objectives of this study were to investigate the influence of methodological factors on heterogeneity in NSSI prevalence estimates, explore changes over time, and estimate overall international NSSI prevalence. Results showed that methodological factors contributed over half (51.6%) of the heterogeneity in prevalence estimates, and, after adjusting for these factors, NSSI prevalence did not increase over time. Overall, pooled NSSI prevalence was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults. Clearly, development of standardized methodology in NSSI research is crucial if accurate estimates are desired.

Clinical specificity of acute versus chronic self-injury: measurement and evaluation of repetitive non-suicidal self-injury

Overall, previous studies on the prevalence of non-suicidal self-injury (NSSI) behaviors in the general population have stressed the importance of differentiating between occasional and repetitive NSSI, examining different severity levels (e.g., frequency and variety of methods), as well as investigating the diverse psychopathological correlates of NSSI. However, existing NSSI measures have not been explicitly developed by to comply with the NSSI diagnostic criteria proposed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The purpose of this study is to develop a measure of repetitive NSSI by considering its essential features, as described in the proposed DSM-5 as well as in other clinically relevant aspects emerging from case reports. Two independent samples of participants (N1=383 young adults and 251 adolescents; N2=953 adolescents) belonging to the general population were involved in the present study. The questionnaire showed satisfactory fit statistics and reliably discriminated between occasional and repetitive self-injurers (Area Under Curve, AUC=0.755). The pattern of correlations with psychopathological measures confirmed a more clinically-compromised profile for repetitive rather than occasional self-injurers.

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.

Self-harm and attempted suicide within inpatient psychiatric services: a review of the literature

Self harm is a major public health concern, yet there are considerable challenges in providing support for those who self harm within psychiatric inpatient services. This paper presents the first review of research into self harm within inpatient settings. Searches of the main electronic databases were conducted using key words for self harm and inpatient care. There was substantial variation in the rates of self-harm and attempted suicide between studies, but rates were highest on forensic wards. There was no evidence of differences in prevalence of self-harm between men and women; women, however, were at increased risk of attempting suicide. People were more likely to self-harm in private areas of the ward and in the evening hours, and often self-harmed in response to psychological distress, or elements of nursing care that restricted their freedom. Wards used a variety of strategies to prevent self-harm; however, there is little research into their effectiveness.

[Non-suicidal self-injury as autonomous diagnosis - implications for research and clinic of the DSM-5 proposal to establish the diagnosis of Non-Suicidal Self-Injury in adolescents]

In both classificatory systems DSM-IV and ICD-10 self-injury is a symptom of borderline personality disorder (BPD). But it has been shown empirically that self-injury can also occur independent of BPD, for example, as a component of depressive states or even in adolescents without classifiable psychopathology. The scientific discussion about future diagnostic criteria recently led to a proposal to include Non-Suicidal Self-Injury as an independent disorder in the upcoming DSM-5 classification system. Based on recent epidemiological studies of adolescents in Germany, one may assume that approximately 4% of all youths in middle to late adolescence would fulfill the prevalence criterion (criterion A) of the proposed DSM-5 disorder (that is, at least five self-injury incidents within the previous 12 months). A precise classification of Non-Suicidal Self-Injury based on empirical research is needed to further the research, treatment, and prevention of this diagnosis.

Evaluation of superficial and deep self-inflicted wrist and forearm lacerations

PURPOSE

Self-inflicted wrist or forearm laceration is a specific type of injury presenting to emergency departments. Many investigators have described wrist-cutting from a psychiatric viewpoint. We hypothesized that the character of patients with deep wounds is different from those with superficial wounds. We investigated patients who cut their wrist or forearms as an act of self-mutilation from the viewpoint of wound severity.

METHODS

We reviewed 31 patients with self-inflected wrist injuries who were treated in our medical center from 2004 through 2009. We divided them into 2 groups: deep (15 patients) and superficial (16 patients). We investigated differences in age and gender, sites of self-cutting, frequency of self-injury attempts, object used for wrist cutting, group psychiatric parameters, required wound treatments, and psychiatric history and follow-up.

RESULTS

Younger patients were more likely to have injured themselves severely compared with older patients. Differences in clinical findings between deep and superficial injury groups included the following: (1) all male patients had deep injuries; (2) patients with superficial wounds were more likely to have cut themselves previously; (3) patients in the deep injury group tended to injure themselves at multiple sites; (4) patients in the deep injury group tended to perform self-cutting with any sharp-edged object at hand; (5) 50% of our patients had received no psychiatric care before being seen by us for their injury; and (6) one-third discontinued the psychiatric treatment prematurely.

CONCLUSIONS

There are differences between patients who perform self-inflicted deep versus superficial wrist cutting. We also found that the ages and psychiatric diagnoses of our patients differed from previous reports. This is likely because the available literature includes only patients who received psychiatric care. We found that 50% of our patients had received no psychiatric care, which highlights the importance of hand surgeons treating these patients to initiate psychiatric consultation.

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.

Relationship of intentional self-harm using sharp objects with depressive and dissociative tendencies in pre-adolescence-adolescence

AIMS

The objectives of the present study were to (i) evaluate the prevalence of children and adolescents who have engaged in intentional self-harm using a sharp object; and (ii) investigate the relationship between self-harm with sharp objects and depressive tendencies or dissociative tendencies.

METHODS

A total of 1938 students in grades 5-12 in Yokohama, Japan, were enrolled, and they completed anonymous self-report questionnaires including a question about intentional self-harm with a sharp object, the Depression Self-Rating Scale for Children (DSRSC) and the Adolescent Dissociative Experiences Scale (A-DES).

RESULTS

The prevalence of self-harm using sharp object was 5.4% among male 5th-6th graders, 4.0% among female 5th-6th graders, 5.3% among male 7th-9th graders, 15.1% among female 7th-9th graders, 6.6% among male 10th-12th graders, and 9.6% among female 10th-12th graders. Categorical regression analysis showed that a small amount of variance in self-harm by sharp object was explained by DSRSC and A-DES scores.

CONCLUSIONS

Self-harm with a sharp object was prevalent among pre-adolescents and adolescents and was associated with depressive and dissociative tendencies.

Clinical diagnoses, characteristics of risk behaviour, differences between suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injury

OBJECTIVE

Self-injury (SI), self-injurious behaviour (SIB), including suicidal or non-suicidal self-injury (SSI, NSSI) represent an increasing problem among teenagers amounting to a 6-17% prevalence rate in adolescence, yet little data exists on detailed characteristics and associated factors of SI reaching clinical severity. There is also a scarcity of data distinguishing between suicidal and non-suicidal subsamples of self-injuring patients, i.e. showing which predictors contribute to develop self-injurious behaviour with a previous suicidal history (SSI).

METHOD

Clinical diagnoses and characteristics of risk behaviour were examined in a crosssectional design in suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injurious behaviour. From the total pool of 708 new patients consecutively referred with various psychiatric problems in five regional child psychiatric centres in Western-Hungary over an 18-month period, 105 adolescent outpatients suffering from self-injurious behaviour participated in the study (28 males and 77 females aged from 14 to 18 years, mean age 15.97, SD 1.05). The Ottawa/Queen's self-injury questionnaire (OSI) was used to measure the characteristics of risk behaviour, while the comorbid clinical diagnoses were confirmed by the M.I.N.I. Plus International Neuropsychiatric Interview. Descriptive statistics presented the frequencies of the characteristics of SI, bilateral comparisons were used to reveal relevant items to differentiate between sex, duration of practice and SSI versus NSSI and logistic regression was performed to identify significant predictors of suicidal subtype of self-injuring practice.

RESULTS

A total of 60% of the clinical SI population experienced a present or past episode of major depression. The motivation of patients to resist impulses and to discontinue malpractice was low. Cutting and scratching was the most common self-injuring methods. Two-thirds of the sample practised the impulsive type of SI, while 30% practised premeditated SI having an incubation time from 30 min to days and weeks before carrying out SI. Although duration of SI did not distinguish the sample in important aspects, girls and boys differed in several aspects of SI practice. SSI adolescents differed from their NSSI peers in a number of important characteristics including the frequency of actions, injured areas, methods, specific stresses and motivations. SSI adolescents were more likely to favour cutting of the lower leg and drug overdose as modes of SI. SSI adolescents were more likely to report addictive features than their peers with no suicidal motivation. From the aspect of self-injurious practice, logistic regression analysis found only two significant predictors for the combined pathology.

Suicidality and self-harm among sexual minorities in Japan

In this study, I used ethnographic methods to examine suicidality and nonsuicidal self-harm among gay, lesbian, bisexual, and transgender persons in Japan. Participants (N = 84) indicated that suicidality and self-harm are serious problems among sexual minorities and tend to be driven by (a) a homophobic/transphobic environment and the negative consequences of sexual minorities either disclosing their true selves or remaining hidden and silent within such an environment; (b) various antecedents to poor mental health; and (c) factors not directly related to being a sexual minority, particularly unemployment and debt in the context of a protracted national economic decline in Japan prior to the study period of 2003--2004. Participants also perceived a potentially higher risk for suicidality and self-harm among sexual minority adolescents and persons in their early 20s; those who work in the entertainment, bar, or sex industries; and survivors of violence perpetrated by intimate partners or family members.

Self-mutilation and coping strategies in a college sample

The goal of this study was to examine the use of specific coping strategies among self-mutilating college students. The self-mutilating group (n = 44) reported utilizing avoidance strategies more often than did a control group (n = 44) matched for general psychological distress but with no history of self-mutilation. In addition, female, but not male, self-mutilators endorsed using problem-solving and social support seeking strategies less often than nonmutilators. These findings suggest that coping strategies in general and avoidance-based strategies in particular may be important targets for the treatment of self-mutilative behaviors.

Childhood physical and sexual abuse and lifetime number of suicide attempts: A persistent and theoretically important relationship

BACKGROUND

Research to date has indicated that childhood abuse is associated with suicide, though little research has examined the unique contribution of specific types of abuse to suicidal behavior. We predict that childhood physical and violent sexual abuse will have a greater effect on suicide attempts than molestation and verbal abuse.

METHODS

The National Comorbidity Survey data were used to test these predictions while controlling for a number of psychiatric and psychosocial variables.

RESULTS

As expected, childhood physical and violent sexual abuse showed similar effects on lifetime suicide attempts, which were stronger than the effects of molestation and verbal abuse.

LIMITATIONS

This was a cross-sectional, retrospective study, so true causality cannot be shown. Some measurement limitations exist. Additionally, effect sizes were small but still significant.

CONCLUSIONS

While all forms of childhood abuse are troubling and create risk for future psychopathology and suicidality, the present study indicates that childhood physical and violent sexual abuse should be seen as greater risk factors for future suicide attempts than molestation and verbal abuse.

Deliberate self-harm and childhood hyperactivity in junior high school students

The present study aimed to explore the status of deliberate self-harm (DSH) among junior high-school students, and investigate the relationship between DSH and substance use and childhood hyperactivity. Subjects were 239 boys (mean age = 14.16 years, SD = 0.67) and 238 girls (14.22, 0.68) from a junior high-school in Kanagawa, Japan. A self-reporting questionnaire consisting of original questions on self-cutting, self-hitting, and tobacco and alcohol use was employed with the Wender Utah Rating Scale (WURS) for assessing childhood hyperactivity. Overall, 8.00% and 27.70% of males and 9.30% and 12.20% of females reported self-cutting and self-hitting, respectively. Regarding substance use, 33.10% and 74.10% of males and 14.30% and 63.40% of females reported tobacco and alcohol use, respectively. Comparisons of WURS scores between those with and without experience of problematic behaviors revealed that with all problematic behaviors in both genders, scores of those with experience were significantly higher than those without (P < 0.01 except for self-cutting in females, P < 0.05). The present study indicated that DSH is an important problem, even among children as young as junior high-school age. An association between DSH and childhood hyperactivity was also suggested.

Aggressiveness, anger and eating disorders: a review

Anger and aggressive behaviours, especially those self-directed, are frequent in subjects suffering from anorexia nervosa and bulimia nervosa. They increase the complexity of the clinical features, change the prognosis and cause a more difficult management of these disorders. In order to elucidate the complex relationships between eating disorders, anger and aggressiveness, the history of traumatic experiences, the prevalence of dissociative, obsessive, impulsive and compulsive symptoms, as well as the role of severe personality disorders in subjects suffering from anorexia nervosa, bulimia nervosa and self-injurious behaviours are considered. In the final section of this paper, a model exploring such a relationship in the light of the undefined sense of self is described.

Characteristics of self-cutters among male inmates: association with bulimia and dissociation

It was examined whether bulimia and dissociation are common in male self-cutters, as has been found in female self-cutters. The subjects were 796 male inmates of a juvenile prison. A self-reporting questionnaire was used to assess self-cutting, histories of psychoactive substance use, problem behaviors, and traumatic life events in the subjects. The Adolescent Dissociative Experience Scale and the Bulimia Investigatory Test of Edinburgh were also used. Subjects were divided into two groups: self-cutting and non-cutting. Questionnaire responses and dissociation and bulimia assessments were compared between the groups. Self-cutters began smoking (P < 0.001) and drinking (P < 0.001) earlier, and more frequently used illicit psychoactive drugs (P < 0.001), experienced childhood physical abuse (P < 0.001), and reported suicide attempts (P < 0.001), suicidal ideation (P < 0.001), and outward violence toward a person (P < 0.001) or object (P < 0.001) than non-cutters. Self-cutters also scored significantly higher on the bulimia (P < 0.001) and dissociation tests (P < 0.001). Logistic regression analysis demonstrated that suicide attempt (odds ratio, 4.311) and suicidal ideation (odds ratio, 2.336) could discriminate between male inmates with and without self-cutting. Male self-cutters showed 'multi-impulsive bulimic' tendencies resembling those of female self-cutters, although to a lesser extent. Clinical features of male as opposed to female self-cutters were influenced by gender differences.

Understanding self-mutilation in borderline personality disorder

Self-mutilation is common in borderline personality disorder, but this pattern of behavior does not usually carry suicidal intent. Instead, it serves other functions, including regulation of dysphoric affect, communication of distress, expression of emotions, and coping with dissociative states. Multiple causal factors, including biological, psychological, and social risks, influence thresholds for self-mutilation. Management of this behavior can be informed by understanding its psychological functions.

Self-injurious behavior as a separate clinical syndrome

The field of clinical psychology may benefit from adopting a deliberate self-injury syndrome as a distinct disorder for representation in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The phenomenological and empirical data supporting a deliberate self-injury syndrome are reviewed, and arguments for and against the adoption of a distinct syndrome are explored.

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.

Self-burning versus self-cutting: patterns and implications of self-mutilation; a preliminary study of differences between self-cutting and self-burning in a Japanese juvenile detention center

The purpose of the present paper was to examine the differences in clinical features between self-cutters and self-burners, to clarify clinical implications of self-mutilating behaviors other than self-cutting. Subjects were 201 delinquent adolescents consecutively entering a Japanese juvenile detention center from February 2003 to March 2003. The subjects were assessed using a self-reporting questionnaire to evaluate self-mutilation, traumatic events, and problematic behaviors. Beck Depression Inventory-2 (BDI-2) and Adolescent Dissociative Experience Scale (A-DES) were also tested. Subjects were classified into four groups according to self-mutilating behaviors: non-self-cutting or -burning (NSCB), self-cutting (SC), self-burning (SB), and self-cutting and self-burning (SCB). The questionnaire answers and scores of the BDI-2 and A-DES were compared between the four groups. Of 201 subjects, 33 (16.4%) had cut their wrists or forearms at least once, and 72 of 201 (35.8%) had burned themselves at least once. The SC and SCB group had traumatic events, problematic behavior, and various types of self-mutilating behavior more frequently than the other two groups. The SCB group reported additional types of self-mutilating behavior more than the SC group. The SCB group also experienced multiple body customizations compared to the SC group, and exhibited higher scores on the BDI-2 and A-DES than the other three groups. The self-burning without self-cutting may have limited clinical implications. However, the self-burning with self-cutting may suggest depression and dissociation, as well as possible indication of self-mutilating behavior.

Patterns of self-cutting: a preliminary study on differences in clinical implications between wrist- and arm-cutting using a Japanese juvenile detention center sample

The present study was aimed to clarify the differences in clinical implications between wrist- and arm-cutting. Subjects were 201 delinquent adolescents (178 males and 23 females) who had been admitted to a detention center from February to March 2003. A self-reporting questionnaire and the Adolescent Dissociative Experience Scale (ADES) were given. Traumatic events and other self-injurious behavior were compared among four groups. In total, 33 (16.4%) subjects reported wrist- and/or arm-cutting. Of the females, 60.9% (n = 14) had experienced self cutting behaviors compared to 10.7% of males (n = 19). Subjects were divided into four groups; 'non-cutting' (NC: n = 168, 83.6%), 'wrist-cutting' (WC: n = 5, 2.5%), 'arm-cutting' (AC: n = 19, 9.5%), and 'wrist- and arm-cutting' (WAC: n = 9, 4.5%). WC, AC, and WAC groups reported early separation, bulling in school, and histories of sexual/physical abuse more frequently than NC group. WC and WAC groups reported suicidal ideation and suicide attempts more frequently than NC and AC groups. The ADES scores in AC and WAC groups were significantly higher than in those in NC group (P < 0.001), while the scores in WC were not different from NC groups. WC and WAC groups self-cut due to suicide idea more frequently than the AC group, while AC group self-cut due to anger expression more frequently than WC or WAC groups. Self-cutters experienced early separation, bullying in school, and sexual/physical abuse more frequently than-non-self-cutters. Arm-cutting behavior may predict dissociation, while wrist-cutting may involve with suicidality.

The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation

This article utilizes a developmental psychopathology framework to explicate one pathway, originating in childhood traumatic experience, toward the development of self-injurious behavior (SIB). The descriptive psychopathology of SIB is summarized first, followed by an overview of theoretical interpretations of SIB within psychoanalytic, neo-analytic, behavioral, and biological paradigms. Building on these empirical and theoretical foundations, a developmental psychopathology framework is used to model the development of SIB in the aftermath of childhood traumatic experience, particularly maltreatment. In this model, maltreatment undermines positive adaptation at motivational, attitudinal, instrumental, emotional, and/or relational levels of competence. In turn, vulnerabilities in the child's adaptive resources necessitate the application of alternative regulatory and relational strategies, such as self-injury, to the negotiation of contemporaneous and prospective developmental issues. The article concludes with a discussion of the empirical and clinical implications of a developmental understanding of SIB as a compensatory regulatory strategy in posttraumatic adaptation.

Habitual self-mutilation in Japan

The purpose of the present study was to clarify the relationship between bulimic behavior, dissociative phenomenon and sexual/physical abuse histories in Japanese subjects with habitual self-mutilation. Subjects consisted of 34 female outpatients who had cut their wrists or arms on more than 10 occasions. Two age-matched groups, which consisted of 31 general psychiatric outpatients and 26 non-clinical volunteers, served as controls. They were assessed with the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, Adolescent Dissociative Experience Scale, and an original self-reporting questionnaire concerning various problematic behaviors and sexual/physical abuse histories. The habitual self-mutilation and the two control groups were compared. The habitual self-mutilation group had significantly higher scores on the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, and Adolescent Dissociative Experience Scale than either of the two control groups (P < 0.001). Furthermore, the habitual self-mutilation group more frequently had a history of illicit psychoactive drug use (P = 0.001), shoplifting (P < 0.001), suicide attempts (P < 0.001), overdosing with medicine (P < 0.001), sexual abuse (P = 0.011), and childhood physical abuse (P = 0.001) than the general psychiatric controls. These results are consistent with those in Western studies. Habitual self-mutilation is likely to coexist with depression, bulimia, and dissociation. Such patients frequently have clinical features similar to those of 'multi-impulsive bulimia'. Evidence supports the association between habitual self-mutilation and sexual/childhood physical abuse in Japan.

Self-injurious behaviors in eating-disordered patients

High rates of self-injurious behaviors (SIBs) have been described in eating-disordered patients. The present study in 134 female inpatients suffering from an eating disorder (ED) confirmed this: 44% of the total group reported at least one form of SIB (mostly hair pulling, scratching, cutting, or bruising) with a mean age at onset of 17.5 years. No major differences have been found between the subgroups (anorexics, bulimics). The considerable number of patients who did not feel any pain during SIB showed more tendency towards dissociative experiences. Those who admitted SIB reported higher levels of psychological dysfunctioning, dissociative experiences, and impulsiveness.

Deliberate self-harm in a nonclinical population: prevalence and psychological correlates

OBJECTIVE

Research on deliberate self-harm (intentionally injuring oneself without suicidal intent) has focused on clinical and forensic populations. Studying only these populations, which typically have serious psychopathology, may lead to inflated estimates of the association between self-harm and psychiatric disorder, as well as of the prevalence of deliberate self-harm. The present study investigated the prevalence and correlates of deliberate self-harm in a large group of nonclinical subjects.

METHOD

Participants were 1,986 military recruits, 62% of whom were men, who were participating in a study of peer assessment of personality traits and pathology. Individuals who did and did not report a history of self-harm were compared on measures of personality and psychopathology.

RESULTS

Approximately 4% of the participants reported a history of deliberate self-harm. Compared with participants without a history of deliberate self-harm, self-harmers scored higher on self- and peer-report measures of borderline, schizotypal, dependent, and avoidant personality disorder symptoms and reported more symptoms of anxiety and depression. Item-level analyses indicated that peers viewed self-harmers as having strange and intense emotions and a heightened sensitivity to interpersonal rejection.

CONCLUSIONS

About one of every 25 members of a large group of relatively high-functioning nonclinical subjects reported a history of self-harm. Self-harmers had more symptoms of several personality disorders than non-self-harmers, and their performance across measures suggested that anxiety plays a prominent role in their psychopathology. Future research should investigate whether psychotherapies or psychiatric medications known to reduce symptoms of anxiety can be effective in treating deliberate self-harm.

Repetitive self-mutilation among Japanese eating disorder patients with drug use disorder: comparison with patients with methamphetamine use disorder

Repetitive self-mutilation and drug use disorder are less prevalent in Japan, although the prevalence of eating disorder is comparable with rates in Western countries. However, repetitive self-mutilation has not previously been described in relation to eating disorder and drug use disorder in Japan. Subjects consisted of 19 patients with eating disorders and drug use disorders (ED+DUD) and 12 patients with methamphetamine use disorders (MAP). Subjects were drawn from 180 patients who were referred because of eating disorders and 22 patients who were referred because of methamphetamine-related problems. All subjects underwent a semistructured interview. Repetitive self-mutilation tended to be more prevalent among ED+DUD patients than MAP patients. Conversely, history of oppositional defiant disorder and antisocial personality disorder tended to be more prevalent in MAP patients than in ED+DUD patients. The low prevalence of repetitive self-mutilation appears to be due to low risk factors in Japan, even though the pathogenesis of these behaviors seems to be universal.