
                     Diagnoses associated with self-injury
                                       
   In the DSM-IV, the only diagnoses that mention self-injury as a
   symptom or criterion for diagnosis are borderline personality
   disorder, stereotypic movement disorder (associated with autism and
   mental retardation), and factitious (faked) disorders in which an
   attempt to fake physical illness is present (APA, 1995; Fauman, 1994).
   It also seems to be generally accepted that extreme forms of
   self-mutilation (amputations, castrations, etc) are possible in
   psychotic or delusional patients. Reading the DSM, one can easily get
   the impression that people who self-injure are doing it willfully, in
   order to fake illness or be dramatic. Another indication of how the
   therapeutic community views those who harm themselves is seen in the
   opening sentence of Malon and Berardi's 1987 paper "Hypnosis and
   Self-Cutters":
   
     Since self-cutters were first reported on in 1960, they have
     continued to be a prevalent mental health problem. (emphasis added)
     
   To these researchers, self-cutting is not the problem, the
   self-cutters are.
   
   However, self-injurious behavior is seen in patients with many more
   diagnoses than the DSM suggests. In interviews, people who engage in
   repetitive self-injury have reported being diagnosed with depression,
   bipolar disorder, anorexia, bulimia, obsessive-compulsive disorder,
   post-traumatic stress disorder, many of the dissociative disorders
   (including depersonalization disorder, dissociative disorder not
   otherwise specified, and MPD/DID), anxiety and panic disorders, and
   impulse-control disorder not otherwise specified. In addition, the
   call for a separate diagnosis for self-injurers is being taken up by
   many practitioners.
   
   It is beyond the scope of this page to provide definitive information
   about all of these conditions. I will try, instead, to give a basic
   description of the disorder, explain when I can how self-injury might
   fit into the pattern of the disease, and give references to pages
   where much more information is available. In the case of borderline
   personality disorder (BPD), I devote considerable space to discussion
   simply because the label BPD is sometimes automatically applied in
   cases where self-injury is present, and the negative effects of a BPD
   misdiagnosis can be extreme.
   
    Conditions in which self-injurious behavior is seen
    
     * [1]Borderline Personality Disorder
     * [2]Mood Disorders
     * [3]Eating Disorders
     * [4]Obsessive-Compulsive Disorder
     * [5]Post-Traumatic Stress Disorder
     * [6]Dissociative Disorders
     * [7]Anxiety and/or Panic
     * [8]Impulse-control Disorder Not Otherwise Specified
     * [9]Self-injury as itself a diagnosis
       
   As mentioned, self-injury is often seen in those with autism or mental
   retardation; you can find a good discussion of self-harm behaviors in
   this group of disorders at the website of [10]The Center for the Study
   of Autism.
   
  Borderline Personality Disorder
  
     "Every time I say something they find hard to hear, they chalk it
     up to my anger, and never to their own fear."
     
                               --Ani DiFranco
                                      
   Unfortunately, the most popular diagnosis assigned to anyone who
   self-injures is [11]borderline personality disorder. Patients with
   this diagnosis are frequently treated as outcasts by psychiatrists;
   Herman (1992) tells of a psychiatric resident who asked his
   supervising therapist how to treat borderlines was told, "You refer
   them." Miller (1994) notes that those diagnosed as borderline are
   often seen as being responsible for their own pain, more so than
   patients in any other diagnostic category. BPD diagnoses are sometimes
   used as a way to "flag" certain patients, to indicate to future care
   givers that someone is difficult or a troublemaker. I sometimes used
   to think of BPD as standing for "Bitch Pissed Doc."
   
   This is not to say that BPD is a fictional illness; I have encountered
   people who meet the DSM criteria for BPD. They tend to be people in
   great pain who are struggling to survive however they can, and they
   often unintentionally cause great pain for those who love them. But I
   have met many more people who don't meet the criteria but have been
   given the label because of their self-injury.
   
   Consider, however, the DSM-IV Handbook of Differential Diagnosis
   (First et al. 1995). In its decision tree for the symptom
   "self-mutilation," the first decision point is "Motivation is to
   decrease dysphoria, vent angry feelings, or to reduce feelings of
   numbness... in association with a pattern of impulsivity and identity
   disturbance." If this is true, then a practitioner following this
   manual would have to diagnose someone as BPD purely because they cope
   with overwhelming feelings by self-injuring.
   
   This is particularly disturbing in light of recent findings (Herpertz,
   et al., 1997) that only 48% of their sample of self-injurers met the
   DSM criteria for BPD. When self-injury was excluded as a factor, only
   28% of the sample met the criteria.
   
   Similar results were seen in a 1992 study by Rusch, Guastello, and
   Mason. They examined 89 psychiatric inpatients who had been diagnosed
   as BPD, and summarized their results statistically.
   
   Different raters examined the patients and the hospital records and
   indicated the degree to which each of the eight defining BPD symptoms
   were present. One fascinating note: only 36 of the 89 patients
   actually met the DSM-IIIR criteria (five of eight symptoms present)
   for being diagnosed with the disorder. Rusch and colleagues ran a
   statistical procedure called factor analysis in an effort to discover
   which symptoms tend to co-occur.
   
   The results are interesting. They found three symptom complexes: the
   "volatility" factor, which consisted of inappropriate anger, unstable
   relationships, and impulsive behavior; the
   "self-destructive/unpredictable" factor, which consisted of self-harm
   and emotional instability; and the "identity disturbance" factor.
   
   The SDU (self-destructive) factor was present in 82 of the patients,
   while the volatility was seen in only 25 and the identity disturbance
   in 21. The authors suggest that either self-mutilation is at the core
   of BPD or clinicians tend to use self-harm as a sufficient criterion
   to label a patient BPD. The latter seems more likely, given that fewer
   than half of the patients studied met the DSM criteria for BPD.
   
   One of the foremost researchers into Borderline Personality Disorder,
   Marsha Linehan, does believe that it is a valid diagnosis, but in a
   1995 article notes: "No diagnosis should be made unless the DSM-IV
   criteria are strictly applied. . . . the diagnosis of a personality
   disorder requires the understanding of a person's long-term pattern of
   functioning." (Linehan, et al. 1995, emphasis added.) That this does
   not happen is evident in the increasing numbers of teenagers being
   diagnosed as borderline. Given that the DSM-IV refers to personality
   disorders as longstanding patterns of behavior usually beginning in
   early adulthood, one wonders what justification is used for giving a
   14-year-old a negative psychiatric label that will stay with her all
   of her life? Reading Linehan's work has caused some therapists to
   wonder if perhaps the label "BPD" is too stigmatized and too
   over-used, and if it might be better to call it what it really is: a
   disorder of emotional regulation.
   
   If a care giver diagnoses you as BPD and you're fairly certain the
   label is inaccurate and counterproductive, find another doctor.
   Wakefield and Underwager (1994) point out that mental health
   professionals are no less likely to err and no less prone to the
   cognitive shortcuts we all take than anyone else is:
   
     When many psychotherapists reach a conclusion about a person, not
     only do they ignore anything that questions or contradicts their
     conclusions, they actively fabricate and conjure up false
     statements or erroneous observations to support their conclusion
     [note that this process can be unconscious] (Arkes and Harkness
     1980). When given information by a patient, therapists attend only
     to that which supports the conclusion they have already reached
     (Strohmer et al. 1990). . . . The frightening fact about
     conclusions reached by therapists with respect to patients is that
     they are made within 30 seconds to two or three minutes of the
     first contact (Ganton and Dickinson 1969; Meehl 1959; Weber et al.
     1993). Once the conclusion is reached, mental health professionals
     are often impervious to any new information and persist in the
     label assigned very early in the process on the basis of minimal
     information, usually an idiosyncratic single cue (Rosenhan 1973)
     (emphasis added).
     
   [NOTE: My inclusion of a quote from these authors does not constitute
   a full endorsement of their entire body of work.]
   
  Mood Disorders
  
   Self-injury is seen in patients who suffer from major depressive
   illness and from bipolar disorder. It is not exactly clear why this is
   so, although all three problems have been linked to deficiencies in
   the amount of serotonin available to the brain. It is important to
   separate the self-injury from the mood disorder; people who
   self-injure frequently come to learn that it is a quick and easy way
   of defusing great physical or psychological tension, and it is
   possible for the behavior to continue after the depression is
   resolved. Care should be taken to teach patients alternative ways to
   cope with distressing feelings and over-stimulation.
   
   Both major depression and bipolar disorder are enormously complex
   diseases; for a thorough education on depression, go to [12]The
   Depression Resources List or [13]Depression.com. Another good source
   of information about depression is the newsgroup
   alt.support.depression, its FAQ, and the associated web page,
   [14]Diane Wilson's ASD Resources page.
   
   To find out more about bipolar disorder, try [15]The Pendulum Resource
   Page, presented by members of one of the first mailing lists created
   for bipolar people.
   
  Eating Disorders
  
   Self-inflicted violence is often seen in women and girls with anorexia
   (a disease in which a person has an obsession with losing weight,
   dieting, or fasting, and as a distorted body image -- seeing his/her
   skeletal body as "fat") or bulimia (an eating disorder marked by
   binges where large amounts of food are eaten followed by purges,
   during which the person attempts to remove the food from her/his body
   by forced vomiting, abuse of laxatives, excessive exercise, etc).
   
   There are many theories as to why SI and eating disorders co-occur so
   frequently. Cross is quoted in Favazza (1996) as saying that the two
   sorts of behavior are
   
     attempts to own the body, to perceive it as self (not other), known
     (not uncharted and unpredictable), and impenetrable (not invaded or
     controlled from the outside. . . . [T]he metaphorical destruction
     between body and self collapses [ie, is no longer metaphorical]:
     thinness is self-sufficiency, bleeding emotional catharsis,
     bingeing is the assuaging of loneliness, and purging is the moral
     purification of self. (p.51)
     
   Favazza himself favors the theory that young children identify with
   food, and thus during the early stages of life, eating could be seen
   as a consuming of something that is self and thus make the idea of
   self-mutilation easier to accept. He also notes that children can
   anger their parents by refusing to eat; this could be a prototype of
   self-mutilation done to retaliate against abusive adults. In addition,
   children can please their parents by eating what they are given, and
   in this Favazza sees the prototype for SI as manipulation.
   
   He does note, though, that self-injury brings about a rapid release
   from tension, anxiety, racing thoughts, etc. This could be a
   motivation for an eating-disordered person to hurt him/herself --
   shame or frustration at the eating behavior leads to increased tension
   and arousal and the person cuts or burns or hits to obtain quick
   relief from these uncomfortable feelings. Also, from having spoken to
   several people who both have an eating disorder and self-injure, I
   think it's quite possible that self-injury offers some an alternative
   to the disordered eating. Instead of fasting or purging, they cut.
   
   There haven't been many laboratory studies probing the link between SI
   and eating disorders, so all of the above is speculation and
   conjecture.
   
   Two eating-disorders web pages -- the ED section of [16]Something
   Fishy and its associated site, [17]Mirror, Mirror -- are probably the
   best sources for detailed information on eating disorders.
   
  Obsessive-Compulsive Disorder
  
   Self-injury among those diagnosed with [18]OCD is considered by many
   to be limited to compulsive hair-pulling (known as trichotillomania
   and usually involving eyebrows, eyelashes, and other body hair in
   addition to head hair) and/or compulsive skin
   picking/scratching/excoriation. In the DSM-IV, though,
   trichotillomania is classified as an impulse-control disorder, and OCD
   as an anxiety disorder. Unless the self-injury is part of a compulsive
   ritual designed to ward off some bad thing that would otherwise
   happen, it should not be considered a symptom of OCD. The DSM-IV
   diagnosis of OCD requires:
    1. the presence of obsessions (recurrent and persistent thoughts that
       are not simply worries about everyday matters) and/or compulsions
       (repetitive behaviors that a person feels a need to perform
       (counting, checking, washing, ordering, etc) in order to stave off
       anxiety or disaster);
    2. recognition at some point that the obsessions or compulsions are
       unreasonable;
    3. excessive time spent on obsessions or compulsions, reduction of
       quality of life due to them, or marked distress due to them;
    4. the content of the behaviors/thoughts is not confined to that
       associated with any other Axis I disorder currently present;
    5. the behavior/thoughts not being a direct result of medication or
       other drug use.
       
   The current consensus seems to be that OCD is due to a serotonin
   imbalance in the brain; SSRI's are the drug of choice for this
   condition. A 1995 study of self-injury among female OCD patients
   (Yaryura-Tobias et al.) showed that clomipramine (a tricyclic
   antidepressant known as Anafranil) reduced the frequency of both
   compulsive behaviors and of SIB. It is possible that this reduction
   came about simply because the self-injury was a compulsive behavior
   with different roots than SIB in non-OCD patients, but the study
   subjects had much in common with them -- 70 percent of them had been
   sexually abused as children, they showed the presence of eating
   disorders, etc. The study strongly suggests, again, that self-injury
   and the serotonergic system are somehow related.
   
   For a wealth of information on OCD and trichotillomania, see the
   excellent pages at [19]Fairlite.com.
   
  Post-Traumatic Stress Disorder
  
   Post-Traumatic Stress Disorder refers to a collection of symptoms that
   may occur as a delayed response to a serious trauma (or series of
   traumas). More information on the concept is available in my quick
   [20]Trauma/PTSD FAQ. It's not meant to be comprehensive, but just to
   give an idea of what trauma is and what PTSD is about. Herman (1992)
   suggests an expansion of the PTSD diagnosis for those who have been
   continually traumatized over a period of months or years. Based on
   patterns of history and symptomology in her clients, she created the
   concept of [21]Complex Post-Traumatic Stress Disorder. CPTSD includes
   self-injury as a symptom of the disordered affect regulation severely
   traumatized patients often have (interestingly enough, one of the main
   reasons people who hurt themselves do so is in order to control
   seemingly uncontrollable and frightening emotions). This diagnosis,
   unlike BPD, centers on why patients who self-harm do so, referring to
   definite traumatic events in the client's past. Although CPTSD is not
   a one-size-fits-all diagnosis for self-injury any more than BPD is,
   Herman's book does help those who have a history of repeated severe
   trauma understand why they have so much trouble regulating and
   expressing emotion.
   
   Cauwels (1992) calls PTSD "BPD's identical cousin." Herman seems to
   favor a view in which PTSD has been fragmented into three separate
   diagnoses:
   
   Area of most prominent dysfunction Diagnosis given
   Somatic/physioneurotic (Bodily dysregulation -- problems regulating or
   understanding messages from the body and/or expression of emotional
   distress in physical symptoms) Conversion Disorder
   (formerly Hysterical Neurosis)
   Consciousness Deformation (breakdown in the ability to perceive
   oneself as a single entity with an uninterrupted history or to
   integrate body and consciousness) Dissociative Identity Disorder/
   Multiple Personality Disorder
   Dysregulation of identity, emotions, and relationships Borderline
   Personality Disorder
   
   For an incredible amount of information on trauma and its effects,
   including post-trauma stress syndromes, definitely visit David
   Baldwin's [22]Trauma Information Pages.
   
  Dissociative Disorders
  
   The dissociative disorders involve problems of consciousness --
   amnesia, fragmented consciousness (as seen in DID), and deformation or
   alteration of consciousness (as in Depersonalization Disorder or
   Dissociative Disorder Not Otherwise Specified ).
   
   Dissociation refers to a sort of turning off of consciousness. Even
   psychologically normal people do it all the time -- the classic
   example is a person who drives to a destination while "zoning out" and
   arrives not remembering much at all about the drive. Fauman (1994)
   defines it as "the splitting off of a group of mental processes from
   conscious awareness." In the dissociative disorders, this splitting
   off has become extreme and often beyond the patient's control.
   
    Depersonalization Disorder
    
   Depersonalization is a variety of dissociation in which one suddenly
   feels detached from one's own body, sometimes as if they were
   observing events from outside themselves. It can be a frightening
   feeling, and it may be accompanied by a lessening of sensory input --
   sounds may be muffled, things may look strange, etc. It feels as if
   the body is not part of the self, although reality testing remains
   intact. Some describe depersonalization as feeling dreamlike or
   mechanical. A diagnosis of depersonalization disorder is made when a
   client suffers from frequent and severe episodes of depersonalization.
   Some people react to depersonalization episodes by inflicting physical
   harm on themselves in an attempt to stop the unreal feelings, hoping
   that pain will bring them back to awareness. This is a common reason
   for SI in people who dissociate frequently in other ways.
   
    DDNOS
    
   DDNOS is a diagnosis given to people who show some of the symptoms of
   other dissociative disorders but do not meet the diagnostic criteria
   for any of them. A person who felt she had alternate personalities but
   in whom those personalities were not fully developed or autonomous or
   who was always the personality in control might be diagnosed DDNOS, as
   might someone who suffered depersonalization episodes but not of the
   length and severity required for diagnosis. It can also be a diagnosis
   given to someone who dissociates frequently without feeling unreal or
   having alternate personalities. It's basically a way of saying "You
   have a problem with dissociation that affects your life negatively,
   but we don't have a name for exactly the sort of dissociation you do."
   Again, people who have DDNOS often self-injure in an attempt to cause
   themselves pain and thus end the dissociative episode.
   
    Dissociative Identity Disorder
    
   In DID, a person has at least two personalities who alternate taking
   full conscious control of the patients behavior, speech, etc. The DSM
   specifies that the two (or more) personalities must have distinctly
   different and relatively enduring ways of perceiving, thinking about,
   and relating to the outside world and to the self, and that at least
   two of these personalities must alternate control of the patient's
   actions.
   
   DID is somewhat controversial, and some people claim that it is
   over-diagnosed. Therapists must be extremely careful in diagnosing
   DID, probing without suggesting and taking care not to mistake
   undeveloped personality facets for fully-developed separate
   personalities. Also, some people who feel as if they have "bits" of
   them that sometimes take over but always while they're consciously
   aware and able to affect their own actions may run a risk of being
   misdiagnosed as DID if they also dissociate.
   
   When someone has DID, they may self-injure for any of the reasons
   other people do. They may have an angry alter who attempts to punish
   the group by damaging the body or who chooses self-injury as a way of
   venting his/her anger.
   
   It's extremely important that diagnoses of DID be made only by
   qualified professionals after lengthy interviews and examinations. For
   more information on DID, check out [23]Divided Hearts. For reliable
   information on all aspects of dissociation including DID, the
   [24]International Society for the Study of Dissociation web site and
   [25]The Sidran Foundation are good sources.
   
   [26]The depersonalization discussion board homepage offers
   information, message boards, links, and chat rooms for those seeking
   to understand Depersonalization Disorder.
   
   [27]Kirsti's essay on "bits" and [28]"The Wonderful World of the
   Midcontinuum" provide reassuring and valuable information about DDNOS,
   the space between normal daydreaming and being DID.
   
  Anxiety and/or Panic
  
   The DSM groups many disorders under the heading of "Anxiety
   Disorders." The symptoms and diagnoses of these vary greatly, and
   sometimes people with them use self-injury as a self-soothing coping
   mechanism. They've found that it brings fast temporary relief from the
   incredible tension and arousal that build up as they grow
   progressively more anxious. For a good selection of writings and links
   about anxiety, try [29]tAPir (the Anxiety-Panic internet resource).
   
  Impulse-control Disorder Not Otherwise Specified
  
   I include this diagnosis simply because it is becoming a preferred
   diagnosis for self-injurers among some clinicians. This makes
   excellent sense when you consider that the defining criteria of any
   impulse-control disorder are (APA, 1995):
     * Failure to resist an impulse, drive, or temptation to perform some
       act that is harmful to the person or others. There may or may not
       be conscious resistance to the impulse. The act may or may not be
       planned.
     * An increasing sense of tension or [physiological or psychological]
       arousal before committing the act.
     * An experience of either pleasure, gratification, or release at the
       time of committing the act. The act . . . is consistent with the
       immediate conscious wish of the individual. Immediately following
       the act there may or may not be genuine regret, self-reproach, or
       guilt.
       
   This describes the cycle of self-injury for many of the people I've
   talked to.
   
  Self-injury as itself a diagnosis
  
   Favazza and Rosenthal, in a 1993 article in Hospital and Community
   Psychiatry, suggest defining self-injury as a disease and not merely a
   symptom. They created a diagnostic category called [30]Repetitive
   Self-Harm Syndrome. This would be an Axis I impulse-control syndrome
   (similar to OCD), not an Axis II personality disorder. Favazza (1996)
   pursues this idea further in Bodies Under Siege. Given that it often
   occurs without any apparent disease and sometimes persists after other
   symptoms of a particular psychological disorder have subsided, it
   makes sense to finally recognize that self-injury can and does become
   a disorder in its own right. Alderman (1997) also advocates
   recognizing self-inflicted violence as a disease rather than a
   symptom.
   
   Miller (1994) suggests that many self-harmers suffer from what she
   calls [31]Trauma Reenactment Syndrome. Miller proposes that women
   who've been traumatized suffer a sort of internal split of
   consciousness; when they go into a self-harming episode, their
   conscious and subconscious minds take on three roles: the abuser (the
   one who harms), the victim, and the non-protecting bystander. Favazza,
   Alderman, Herman (1992) and Miller suggest that, contrary to popular
   therapeutic opinion, there is hope for those who self-injure. Whether
   self-injury occurs in concert with another disorder or alone, there
   are effective ways of treating those who harm themselves and helping
   them find more productive ways of coping.
   
   [INLINE]
   
  next section: [32]Therapeutic Approaches
  return to [33]SI main page

References

   1. file://localhost/usr/home/llama/Web/psych/diag.html#bpd
   2. file://localhost/usr/home/llama/Web/psych/diag.html#mood
   3. file://localhost/usr/home/llama/Web/psych/diag.html#eat
   4. file://localhost/usr/home/llama/Web/psych/diag.html#ocd
   5. file://localhost/usr/home/llama/Web/psych/diag.html#ptsd
   6. file://localhost/usr/home/llama/Web/psych/diag.html#dis
   7. file://localhost/usr/home/llama/Web/psych/diag.html#anx
   8. file://localhost/usr/home/llama/Web/psych/diag.html#icd
   9. file://localhost/usr/home/llama/Web/psych/diag.html#rsh
  10. http://www.autism.org/sib.htmltarget=
  11. http://www.palace.net/~llama/psych/bpd.html
  12. http://www.execpc.com/~corbeau/
  13. http://depression.com/
  14. http://www.lava.net/~dewilson/asd/resources.html
  15. http://www.pendulum.org/
  16. http://www.something-fishy.com/
  17. http://www.mirror-mirror.org/eatdis.htm
  18. http://www.fairlite.com/ocd/defs/dsmocd.shtml
  19. http://www.fairlite.com/
  20. file://localhost/usr/home/llama/Web/psych/trauma.html
  21. http://www.palace.net/~llama/psych/cptsd.html
  22. http://www.trauma-pages.com/
  23. http://www.dhearts.org/
  24. http://www.issd.org/
  25. http://www.sidran.org/
  26. http://www.users.globalnet.co.uk/~nogin/
  27. http://www.geocities.com/Wellesley/1520/bits.html
  28. http://www.asarian.org/~vickis/continuum.html
  29. http://www.algy.com/anxiety/menu.shtml
  30. http://www.palace.net/~llama/psych/rshs.html
  31. http://www.palace.net/~llama/psych/trs.html
  32. file://localhost/usr/home/llama/Web/psych/ther.html
  33. file://localhost/usr/home/llama/Web/psych/injury.html
