Evidence-Based Reviews

Evaluating teen self-injury: Comorbidities and suicide risk

Current Psychiatry. 2008 February;7(2):69-76

References

1. Simeon D, Favazza AR. Self-injurious behaviors: phenomenology and assessment. In: Simeon D, Hollander E, eds. Self-injurious behaviors: assessment and treatment. Washington, D.C: American Psychiatric Publishing; 2001:1-28.

2. Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med 2007;37(8):1183-92.

3. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res 2007;11(2):129-47.

4. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev 2007;27(2):226-39.

5. Leibenluft E, Gardner DL, Cowdry RW. The inner experience of the borderline self-mutilator. J Personal Disord 1987;1:317-24.

6. Guralnik O, Simeon D. Psychodynamic theory and treatment of impulsive self-injurious behaviors. In: Simeon D, Hollander E, eds. Self-injurious behaviors: assessment and treatment. Washington, DC: American Psychiatric Publishing; 2001:175-97.

7. Nock MD, Joiner TE, Jr, Gordon KL, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relationship to suicide attempts. Psychiatry Res 2006;144(1):65-72.

8. Muehlenkamp JJ, Gutierrez PM. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res 2007;11(1):69-82.

9. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991;48:1060-4.

Inducing pain or bleeding as a means of relieving intolerable stress may be an attempt to:

turn emotional pain into more manageable physical pain
direct anger that cannot be expressed at others onto oneself
punish oneself for perceived misdeeds.⁴

SIB tends to escalate over time. Those who engage in it may require more frequent or intensive self-injury to achieve relief. Because the emotional state improves quickly and the adolescent feels a sense of control over the behavior, SIB rapidly can become habitual and difficult to interrupt.

Box

Anger, fear can trigger manipulative SIB

Peter, age 17, is fighting with his girlfriend, who threatens to leave. He grabs a knife and threatens to cut his arm. The girlfriend tries to take the knife. In their struggle, Peter accidentally cuts a tendon in his arm, which results in a permanent loss of function in his hand.

Unlike SIB for affective or tension release, manipulative or “in your face” SIB is not secretive. Adolescents who engage in manipulative SIB do so as a threat to control or induce guilt in others.⁴ This behavior is triggered primarily by attempts to change another person’s behavior or decision. Unlike the dynamics of impulsive SIB, this type of SIB does not seem to relieve tension; in fact, tension may increase. Manipulative SIB can be particularly dangerous because adolescents may accidentally cause injuries more severe than they intended.

CASE 2: Lingering effects of trauma

Melissa, age 13, has been sexually abused by her foster brother. She briefly returns to the home where her foster brother still resides. He has torn up her room, and her mother—who supports the foster brother—has left the room that way for her to find. Melissa returns to her current residence, cuts her arm 15 times, and pierces her tongue.

In therapy, she denies being angry or upset and does not know why she cut her arm or pierced her tongue.

Clinical Point

Over time, patients who engage in SIB may require more frequent or intensive self-injury to achieve relief of intolerable stress

An adolescent with a history of childhood trauma might have difficulty identifying and expressing internal states and developing trusting relations with others. He or she also can have high levels of anger and shame.

Even an adolescent who experienced neglect or loss of attachment object without overt physical or sexual abuse might have trouble establishing a therapeutic alliance because of difficulty with trust.⁶ He or she may have little or no capacity to identify emotional states, which limits insight into the behavior.⁵

Dissociation. Some adolescents use SIB to try to feel something or to bring themselves back from a dissociative state. They report feeling lost, alone, and disconnected from others and themselves. Some report seeing blood as a way of reconnecting with being alive.

Dissociation may occur in adolescents with a history of trauma, particularly in childhood. Abused individuals who engage in SIB may be identifying with the aggressor, attempting to cut away internalized negative images of the abuser or to control anger they are unable to acknowledge.⁶

Clues prompt further assessment

SIB assessment begins with screening for the behavior. If you find any indicators that suggest SIB (Table 2), question the adolescent about self-injury. Many adolescents want help—and will respond accurately to questions about self-injury—but need to be asked. They usually won’t volunteer the information during an initial evaluation.

Clinical Point

Because the line between SIB and passive suicide can be thin, monitor SIB patients for suicidal ideation and behavior

Once you have identified SIB, explore the behavior. Document:

number, location, and age of injuries
depth of cuts (if applicable)
signs of infection.

Determine if the adolescent needs medical intervention. Discuss how the adolescent causes the injury, and what precipitates it. If possible, obtain some form of safety contract in which the adolescent agrees to not engage in SIB and to notify a designated adult if he or she feels like engaging in SIB or has done so.

Suicide screening. By definition, SIB does not include an intention to die, and most teenagers with SIB will deny suicidal intent. However, because the line between SIB and passive suicide can be thin, careful screening and ongoing monitoring for suicidal ideation and behavior in teens with SIB is essential. In one study:

70% of adolescents who engaged in SIB had made one suicide attempt
55% had made multiple attempts.⁷

A separate study found suicidal ideation and depression are keys to identifying adolescents with SIB at risk for suicide attempts.⁸ Because SIB and suicidal ideation/behaviors can co-occur, SIB safety contracts must cover both.

Evaluating teen self-injury: Comorbidities and suicide risk

References

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