Psychiatry - November 2008 - (Page 22)

INTRODUCTION Many clinicians have encountered adolescents who have harmed themselves yet denied suicidal intent. In fact, this stressful experience is increasingly common. Recent community studies have found that one-third to one-half of adolescents in the US have engaged in some type of nonsuicidal self injury (NSSI),1,2 although less recent studies put the rate at 13 to 23 percent.3 Adolescent self-harming behavior is a considerable problem for clinicians, not only because of the obvious danger of the patient harming him- or herself, but also because of the difficulties in ascertaining whether the teen was trying to die. NSSI most commonly includes cutting or burning oneself without suicidal intent.4 Other types of NSSI include hitting, pinching, banging or punching walls and other objects to suicide.9,10 As a result, there is a significant risk of suicide and suicide attempts among teens that engage in NSSI. One recent study found that 70 percent of teenagers engaging in NSSI had made at least one suicide attempt and 55 percent had multiple attempts.17 However, the nonsuicidal and suicidal behaviors serve distinctly different purposes. Some adolescent inpatients report hurting themselves specifically to stop suicidal ideation or to stop themselves from actually attempting suicide.8 Consequently, Favazza11 conceptualizes self-injurious behaviors without suicidal intent as “a morbid form of self help.” interview with Tina, there were insufficient criteria to merit a diagnosis of borderline personality disorder. In fact, despite her obvious problems coping with distress, Tina did not meet the criteria for any major mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR). CHARACTERISTICS OF ADOLESCENTS WITH NSSI Until recently, NSSI was seen as primarily associated with the following three specific psychiatric diagnostic categories: developmental disabilities, eating disorders, and borderline personality disorder (BPD). NSSI occurs in roughly 15 percent of children with developmental disabilities, especially profound and severe mental retardation.12 Among adult women, NSSI accompanies up to 35 percent of those diagnosed with anorexia nervosa, bulimia nervosa, and other eating disorders;13 female adolescents with anorexia nervosa also tend to engage in NSSI more than those without the eating disorder.14 Repetitive NSSI is so common among people with BPD15 that BPD is the only clinical diagnosis in the DSM-IV-TR for which self injury, whether suicidal or nonsuicidal, is a symptom.16 However, no studies have examined the prevalence of NSSI among male or female adolescents exhibiting borderline personality symptoms.17 Recent research calls into question the presumption that adolescent NSSI is primarily limited to people with developmental disabilities, eating disorders, or borderline personality disorder. Psychiatric conditions that are specifically associated with NSSI in adolescents include internalizing disorders (primarily depression, but also posttraumatic stress disorder and generalized anxiety), externalizing disorders (including conduct disorder and oppositional defiant disorder), and substance abuse disorders.3,17 It has been A CASE EXAMPLE Tina was a 15-year-old girl whose boyfriend recently broke up with her. On the way home from school, she saw him kissing another girl. When she arrived home, she immediately Although distinct from suicidal behavior, NSSI frequently occurs in adolescents who, at other times, have contemplated or attempted suicide.9,10 the nonsuicidal and suicidal behaviors serve distinctly different purposes. Some adolescent inpatients report hurting themselves specifically to stop suicidal ideation or to stop themselves from actually attempting suicide.8 induce pain, breaking bones, ingesting toxic substances, and interfering with healing of wounds.5 NSSI typically begins in midadolescence.5 Adolescents who injure themselves are often impulsive, engaging in self harm with less than an hour of planning.6 They commonly report feeling minimal or no pain.7 Once started, self injury seems to acquire addictive characteristics and can be quite difficult for a person to discontinue.8 While some studies indicate that NSSI is more frequent in girls than boys,10 other studies indicate that there are no consistent gender differences.3 Although distinct from suicidal behavior, NSSI frequently occurs in adolescents who, at other times, have contemplated or attempted 22 Psychiatry 2008 [ N O V E M B E R ] went upstairs to her bedroom, locked the door, and cut herself on the wrist several times with a razor blade. Although she wore long sleeves to dinner that evening, her mother spotted the wounds and brought her daughter to the emergency room, saying her daughter had tried to kill herself. Tina, however, stated emphatically that she did not want to die. “I cut myself because it made me feel better,” she said. A consulting psychiatrist interviewed Tina in the emergency room. A nurse had warned the psychiatrist that Tina was “borderline” and “gamey,” stating, “She just cut herself for attention. Don’t let her manipulate you.” However, after an extensive

Table of Contents Feed for the Digital Edition of Psychiatry - November 2008

Psychiatry - November 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Measuring Adverse Events in Psychiatry Nonsuicidal Self Injury in Adolescents Relative Tolerability of Alzheimer's Disease Treatments Biracial Identity Development and Recommendations in Therapy Depression and Cardiovascular Disease: Just an Urban Legend? Three Risk Management Basics Journal Watch Classified Advertising Information for Authors

Psychiatry - November 2008

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