This paper reflects the research and thoughts of a student at the time the paper was written for a course at Bryn Mawr College. Like other materials on Serendip, it is not intended to be "authoritative" but rather to help others further develop their own explorations. Web links were active as of the time the paper was posted but are not updated.
2006 Second Web Paper
Intentional and often repetitive self injurious behavior (SIB) is exhibited by approximately 1-2 million people the in United States. The typical self-injurer is female (women are 1.5-3 times more likely than men to self injure), adolescent or young adult, single, middle to upper-middle class, and intelligent. Though it is often conceptualized as a "derivation of suicide" (4), the primary objective in approximately 85% of self-injurious events is tension relief opposed to suicide. Favazza classified the nature of self-injurious events into four categories: 1) stereotypic 2) major 3) compulsive 4) impulsive. Stereotypic SIB is primarily exhibited by individuals with developmental disabilities and occurs without regard for social context or without thought and feeling. Major SIB is very dramatic and occurs as an isolated event whereas compulsive SIB occurs repetitively, sometimes multiple times a day. Impulsive SIB is episodic, buffered by periods where no SIB occurs. Generally, SIB is accomplished in the absence of pain due to disassociation the individual achieves and is followed by a feeling of relief or normalcy which continues until the cycle begins again (Yates). Many cases of SIB occur in conjunction with other disorders like alcohol and drug abuse, post traumatic stress disorder, eating disorders, personality disorders, or developmental disabilities. In fact, SIB rarely occurs in isolation from other symptoms or disorders.
According to the current definition of SIB in which it is described as "the destruction or alteration of body tissue [that] occurs in the absence of conscious suicidal intent" (4), an exhaustive list of SIB includes tattooing, piercing, surgical implants, scarification, pigmentation changes, radical dieting, hunger striking, fasting, stigmata inducing, cutting, and burning (2). Because SIB varies etiologically over a continuum, it is impossible to assign a definitive causal argument which becomes problematic in attempting treatment. An important question that arises in the treatment of SIB is whether the behavior is in response to neurochemical stimuli or whether there is something that is being communicated by the individual who is exhibiting self-injurious behavior. If there is something that the SIB is nonverbally articulating, what follows is whether the individual is aware of this and how they themselves interpret their behavior. To address these nuances, motivating factors behind SIB have been categorized as either interpersonal, in which attempts are made to effect change in the interpersonal environment, or intrapersonal, in which attempts are made to "quell intraphysic distress" (4).
At the biological level, SIB is attributed to abnormal neurochemistry involving the neurotransmission of serotonin, dopamine, and endorphins. Serotonergic deficits, or decreased serotonin levels, have been observed in SIB individuals by analyzing the breakdown products (metabolites) of serotonin in spinal fluid. Serotonin levels can also be assessed by measuring imipramine binding sites on platelets; there is a direct relationship between the number of impramine binding sites and serotonin levels. The most precise method used to determine serotonergic levels is through investigation of a hormone called prolactin's response to a drug called d-fenfluamine. A muted response to d-fenfluamine is indicative of lower serotonin levels. Seretonogenic deficits, determined by imipramine binding sites on platelets was linked to aggression and impulsiveness by Stoffetal (1987) and Birmaher et al (1990) which suggests that SIB is akin to impulse disorders like kleptomania and tricholtillomania. Another neurochemical explanation of SIB is that the body becomes addicted to endorphins, pain-relieving neurotransmitters derived from opium, released by self-mutilation. Individuals with SIB have abnormal endogenous opiod systems which may be congenital or a result of neurochemical responses to events in early childhood (4). However the applicability of the endorphin theory is thrown into question by the fact that the vast majority of research on the affect of endorphins on SIB has been conducted on autistic and/or mentally retarded individuals who have unique brain chemistry that differs from that of the non-autistic/mentally retarded population.
SIB is oftentimes treated using psychopharmacology which is the branch of pharmacology that deals with drugs that influence the brain (psychoactive drugs). Favazza (1998) recommended high doses of selective serotonin reuptake inhibitors (SSRI's) which increase synaptic levels of serotonin. Another class of drugs known as opiate antagonists (i.e. naltrexone or nalozone) have been prescribed with the intention of minimizing the need for endorphins. Atypical neuroplectics (i.e. clozapine, risperidone, and olanzapine) which bind to dopamine and serotonin receptors have also been used in SIB treatment. In addition to psychopharmacology, SIB is treated with psychotherapy and support groups, the ultimate goal of which is resocialization by way of finding substitutes for self-injurious behavior and developing alternative coping skills.
In addition to the neurochemical theories of causation, there are a number of psychological and sociological explanations for the occurrence of SIB. Self injury as an adaptive response, is thought to exist in the absence of other coping mechanisms (1). Not only can SIB be tension relieving, but it also allows for self-care to occur which can be a significant function in the case of individuals who have been victims of physical or sexual abuse. Depression and low self-esteem have also been pointed to as likely causes for SIB as has emotional proprioception or a feeling of disconnect between self and body (1). This failure to distinguish self from non-self is paramount in the psychosomatic perspective's explanation of SIB. Experimental evidence (Favazza 1999) has linked parental loss, chronic illness, and emotional neglect to SIB later in life (4). From a psychosnalytic perspective, SIB allows victims of abuse to gain control over traumatic experiences by recreating their victimization. The object relations perspective attributes SIB to a lack of nurturance or protection during early childhood which results in a self-care system which a "false-self" acts as the protector of a "true-self" (4),. According to the attachment perspective, a child will have been made to feel that their caretaker is unreliable or threatening and this can result in the child viewing him/herself as undeserving of care (4),. This confusion centered around attachment to the caregiver according to Liotti (1992) "may render the child more vulnerable to dissaociative defenses" (4), such as SIB that serve to reconcile a caregiver who is at once nurturing and threatening. The psychological explanations heavily rely on the nurture side of the nature vs. nurture dichotomy while downplaying or ignoring the role of genetic predisposition in SIB. It has recently been shown that psychological experiences like the aforementioned examples can actually alter neurochemical pathways which illustrates the effect of environmental stimuli on internal biology.
The commodification of the body, which has been exacerbated by late capitalism (Potter), has been used to explain the use of the "body as text", or a medium or communication. From this sociological perspective, the body is "being used to communicate something that is difficult or impossible to articulate in conventional modes" (2). SIB elicits a particular response from others via a nonverbal system of signs and symbols that is culturally determined. SIB can be religiously, politically, or aesthetically motivated (2), as is the case with religious fasting, hunger strikes, and tattooing. At the individual level wounds can be "event markers" that signify either important or traumatic events or wounds can reflect something much broader than individual experience. For women, the need to feel autonomous and in control that SIB affords may reflect the subordinate position of women in many societies. It may also be a response to fears of being passive victims in violent or sexual attacks (2). Self-loathing is also a likely motivation for SIB particularly for women living in societies where such significance is placed on beauty and outward appearance. From this perspective, SIB becomes less random in that who exhibits SIB and why is predictable based on certain cultural factors. Self-injury is then less a response to neurological stimuli and much more a reflection of cultural stimuli.
Deviance theory argues that SIB serves to set a boundary between what is and what is not acceptable behavior; the distinction between socially acceptable and socially unacceptable SIB is differentiated by social context. Though the end result of all self-injurious behavior is the same, how it is perceived and understood is largely decided by psychiatry and popular culture which classifies "some acts as fashionable, others as transgressive, and still others as pathological" (2). For example, tattoos and piercings may be socially sanctioned (even rites of passage) whereas cutting and/or burning may be interpreted as mental illness. Typically, the delineation between acceptable and unacceptable SIB is made between those self-destructive acts that are committed within the presence of others and motivated by ritualistic, symbolic, or sacred mores and those committed in isolation that lack ritualism, symbolism, or sacredness that extend beyond the individual. SIB that occurs in conjunction with other self-destructive, deviant behaviors, like drug and alcohol abuse, which are behaviors that are already negatively sanctioned by society, further vilifies some types of SIB.
In examining the phenomenon of SIB, it becomes unclear whether or not the cause is neurobiological or psychological? Whether psychological trauma alters neurobiology? Or whether cultural forces influence who will exhibit SIB and how it will be manifested? At this point in time the way to answer these questions in the "least wrong" manner would be to say that there is a complex interplay between all of these psychological, neurological, and sociological factors which cannot be distilled down to a simple equation used to predict who will self-injure, whether treatment is needed, and what treatment is most appropriate.
1)Understanding Self Injurious Behavior, by Lisa R. Ferentz
2)Commodity, Body, Sign, by Nancy Nyquist Potter
4)Developmental Psychopathology, by Tuppett M. Yates
5) Ferentz, Lisa R. "Understanding Self-Injurious Behavior." 3/24/06. www.prponline.net/School/SAJ/Articles/understanding_self_injurious_behavior.htm
6) Potter, Nancy Nyquist. "Commodity/Body/Sign: Borderline Personality Disorder and the Signification of Self-Injurious Behavior." March 2003. The Johns Hopkins University Press. http://muse.jhu.edu
7) "Psychopharmacological Treatment of Self-Injury." 3/24/06. www.palace.net//llama/psych/pharm.html
8) Yates, Tuppett M. "The Developmental Psychopathology of Self-Injurious Behavior: Compensatory Regulation in Posttraumatic Adaptaion." 3/23/06. 2003 www.sciencedirect.com/science?_ob=ArticleURL&_aset=V-WA-A-W-WAW-MsS...
| Course Home | Serendip Home |