Psychiatry - November 2008 - (Page 23)

suggested that there is a strong link between NSSI and maltreatment in early childhood, especially child sexual abuse. However, a recent meta-analysis found only a modest correlation between child abuse and NSSI, and this was due to the association of both features with psychiatric risk factors.26 A sizeable percentage of adolescent and young adults who engage in NSSI—almost half—may not meet criteria for depression, anxiety, eating disorder, substance use disorder, or other major psychiatric disorders.18 In fact, NSSI appears to be a common nonspecific psychiatric symptom found in a variety of disorders as well as being found in adolescents without a specific psychiatric diagnosis. It seems more useful to understand NSSI in functional terms rather than as a distinct diagnosis since a separate diagnostic category is not well supported by current research findings. Some adolescents who engage in NSSI have elevated rates of emotional reactivity, intensity, and hyperarousal.19 Interpersonal processes associated with NSSI include increased use of avoidant behavior and decreased emotional expressivity.20,21 Adolescents who self harm are more likely to report being bullied by peers and experiencing discomfort regarding their sexual identity.10,22 A recent British study also found an association with Goth subculture and self-harming behavior among teens.23 Knowledge of self harm in peers is a risk factor for NSSI22 due to an apparent contagion effect,24 and there has been an increase in publicity about this behavior. A variety of internet websites and chat rooms provide information and even encourage selfharming behavior.25 cutting herself on her arms. “It helps me chill,” she said. “My mind slows down, I stop crying, and I just feel better.” She said the razor slicing into her skin did not hurt badly—just enough for her to “feel alive.” She felt so much better after cutting herself that afternoon that she was able to concentrate on her homework and not think any more of her ex-boyfriend and the girl he was kissing. TABLE 1. Functions of nonsuicidal self injury AFFECT REGULATION • Anxiety • Anger • Frustration • Depression CHANGE COGNITIONS • Distraction from problems • Stopping suicidal thoughts SELF PUNISHMENT STOP DISSOCIATION INTERPERSONAL • Secure care and attention • Fit in with peers FUNCTIONS OF NONSUICIDAL SELF-INJURIOUS BEHAVIOR The major purpose of NSSI appears to be affect regulation and management of distressing thoughts.26 For example, in one study of high school students, 55 percent of self injurers indicated their reason for NSSI was, “I wanted to get my mind off my problems,” while 45 percent of adolescents endorsed, “It helped me to release tension or stress and relax.”10 When the teenager feels overwhelmed by negative feelings, NSSI can be an effective, although harmful, strategy to stop or reduce these negative thoughts and emotions. Experimental data support the regulating aspect of NSSI. Adolescents with NSSI demonstrated higher levels of physiological arousal during a stressful task compared with adolescents without NSSI.27 This finding is consistent with primate research. For example, monkeys engaging in self injury, usually self biting, have a blunted cortisol response to mild stress when compared with controls.28 After experiencing a stress-induced escalation in heart rate, these monkeys appear to use self harm as a coping strategy to decrease arousal. In turn, the self harm is associated with a rapid decrease in heart rate.28 NSSI may also regulate emotions by increasing the affective experience. The teen may have the subjective experience of being emotionally “numb” or “empty” or feeling disconnected with others. NSSI may help a teenager to gain a sense of control, to feel excitement, or to stop dissociative experiences.8,29 CASE EXAMPLE, CONTINUED Tina explained to the psychiatrist that she cut herself because it was “calming.” She said that a year ago she first started pinching herself as a way to hurt herself. One day she saw her father’s razor blades and started It also might give the adolescent the experience of being “real.” NSSI may serve interpersonal functions for the adolescent.26 NSSI might elicit positive reinforcement in the form of attention from others, although Gratz29 noted that many who injure themselves do so in private and do not tell others. NSSI might also help the teen to avoid difficult situations. The threat of self harm might cause adults or peers to decrease interpersonal pressure or to stop attempting to get the teenager to complete his or her homework, chores, or other tasks. The interpersonal functions that NSSI sometimes serves can challenge the therapeutic alliance. Clinicians can experience a wide range of negative reactions (sometimes described as a form of countertransference) to adolescents engaging in self injury. Terms such as gamey, manipulative, attentionseeking, or borderline are sometimes used by frustrated clinicians to describe self injurers. These terms can indicate the need for a more therapeutic perspective by consulting with a colleague so that clinical decisions are not based on frustration.30 It is helpful to remember that impulsive NSSI in adolescents generally stems from emotional pain, not malevolent [NOVEMBER] Psychiatry 2008 23

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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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