It can sometimes be hard to distinguish normal adolescence from borderline personality disorder. Both may be characterized by unstable, tumultuous relationships, emotional dysregulation, and incomplete identity formation. Not all adolescents go through such turmoil, of course, but it is common enough that when you see a patient who has cuts on her arms, don’t jump immediately to the “borderline” diagnosis. In community samples, up to 46% of adolescents report some experience with deliberate self injury, both boys and girls (Lloyd-Richardson EE, Psychol Med 2007;37(8):1183–1192).
When presented with a self-injuring patient, the first thing I try to find out is what the function of the self injury is. Is it suicidal? Did the patient want to die or think he or she might die? Often the answer is “no”: the patient knew full well he or she would not die, and had no desire to die.
Reasons for Self Harm In my observation of my own patients, self harm is a way to tolerate inescapable and unbearable emotions, most often intense anxiety. When I talk with patients about their cutting episodes—what happened first, what happened next—the picture emerges of someone who is stuck in a bad situation and can’t find another way to cope with the misery of it.
For example, one patient cuts when she hears her parents violently arguing in another room. Unable to leave, unable to bear the emotional distress, she cuts herself as a way of coping. Another patient cuts herself when she is humiliated in front of her peers. A third burns himself when his love interests are not interested in him.
Studies bear out this observation. Experts theorize that self harm is reinforced and therefore repeated to the extent that the behavior is effective. Studies describe four categories of self harm that are reinforcing; two intrapersonal (internal) and two social. The idea is that if people try self harm and it “works,” they keep doing it.
Self harm can be supported by both positive and negative reinforcement. For those of us who are a long way from our Psychology 101 classes: “negative reinforcement” is rewarding by making an unpleasant situation stop, like taking off tight shoes, while “positive reinforcement” is rewarding by gaining something after the behavior, like getting a piece of chocolate when you turn in your compliance forms.
When self harm is negatively reinforced, it generally relieves uncomfortable emotions like anger, anxiety, sadness, guilt, loneliness, or a feeling of numbness. Common reasons for positive reinforcement of self harm include “feeling something even if it was pain,” punishing oneself, and feeling relaxed. However, self harm also engenders feelings of shame and guilt, and can therefore lead to more self harm.
In the social world, common negative reinforcers for self harm include the desires to avoid school work and other things you don’t want to do, to avoid punishment, and to simply avoid people. Positive self harm reinforcers include making other people angry, getting your parents to notice you, feeling part of a group, and getting attention from others.
In my experience, most adolescents say they self harm for several reasons at once, on average four or five. Boys are more likely to identify “to make others angry,” while girls are more likely to endorse “to punish myself ” (Lloyd-Richardson op.cit).
Endogenous Opiates Endogenous opiates—those feel-good chemicals in our bodies that mimic the feeling of a narcotic—offer a different explanation for self harm. The basic theory is that tissue damage causes a pain signal that in turn causes the release of endogenous opiates. People have varying sensitivities to the effect of opiates, which is why some people absolutely love the feeling they get when they take a Percocet, and others mostly just want to throw up. Those who experience nausea from narcotics have a different ratio, density, and location of opiate receptors, especially in the GI tract, than those who experience pleasure.
In addition, endogenous opiates, specifically beta-endorphin, vary in response to stress and to affective states, especially, but not exclusively, to those induced by pain. It appears that the body releases beta-endorphin to comfort a negative mood (Stanley B et al, J Affec Disord 2010;124(1-2):134–140).
In self harm, it is hypothesized that the injury induces the release of endogenous opiates, which then are rewarding. Beta-endorphins are also the source of the “runner’s high” or the “hurts so good” feeling of an intense workout.
Because early childhood experiences like trauma can change both the density of opiate receptors and the levels of beta-endorphin at baseline, people who self-injure may find self harm less painful and the subsequent endorphin release more rewarding than other people do.
In a study of adults with cluster B personality disorders, a lower baseline level of endogenous opiates was found in the cerebrospinal fluid in those who frequently engaged in self harm—and found it less painful—as compared with those who did not (Stanley ibid). In my practice, the patients who tried cutting just once almost always make a face and tell me that they didn’t do it again because “it hurt!”
The Connection to Other Disorders So is non-suicidal self injury (NSSI) truly separate from suicidality? A study by Wilkinson et al indicates that the best predictor of suicide attempt is not previous suicide attempt but rather nonsuicidal self injury (Wilkinson P et al, Am J Psychiatry 2011; Feb 1: online ahead of print). In fact, 70% of people who engage in non-suicidal self injury eventually attempt suicide.
Several studies have reported data that help us to predict which self-harming adolescents are more or less likely to go on to attempt suicide. Adolescents who engaged in self harm without suicide attempt at the time of the study had better self esteem, more reasons for living, better family and peer support, fewer and less severe symptoms of depression, more symptoms of anxiety, and were likely to be younger. Loneliness, on the other hand, is a predictor of future suicide (Brausch AM and Gutierrez PM, J Youth Adolescence 2010;39(3):233–242; Guertin T et al, J Am Acad Child Adolesc Psychiatry 2001;40(9):1062-1069).
Contrary to the belief of some, NSSI is not the same as borderline personality disorder. Adolescent inpatients who engage in NSSI may have any of several disorders; the most common are conduct disorder, oppositional defiant disorder, major depression, PTSD, and generalized anxiety disorder (Nock MK et al, Psychiatry Res 2006;144(1):65–72). They may also have no disorder at all. Interestingly, while two thirds of the female patients in Nock’s study also met criteria for a personality disorder, only half met criteria for borderline personality disorder. The next most frequent were avoidant personality disorder and paranoid personality disorder.
NSSI in DSM-5 Among the proposed changes to DSM-5 is making NSSI a separate diagnosis, with the criteria summarized as follows: “Five days of minor to moderate self harm (cutting, burning, or other surface tissue damage) without intent or expectation of lethal potential.” It can’t be nail biting or wound picking, which are apparently ubiquitous adolescent behaviors. It must be accompanied by two of the following: negative thoughts or feelings just before the event, preoccupation with the urge to self harm, frequent urges to self harm, and/or a deliberate purpose for the self harm. It must also cause distress or impaired functioning.
There are two proposed NOS categories, one for subthreshold symptoms, and one for “uncertain intent.” (You can read all the details at http://bit.ly/a5X1Rz.) The rationale for this new diagnosis is that NSSI is currently thought of as pathognomonic for borderline personality disorder, and it is not so in adolescents and perhaps also not in adults. It is also not clearly a suicide attempt either, as discussed above. A new diagnosis allows the phenomenon to be studied and addressed more specifically.
NSSI is strictly defined in the DSM-5, but many other behaviors may be thought of as deliberate self harm, including multiple piercings, binge drinking, self-induced vomiting, and so on. I had a patient who got together with his friends and they beat each other with sticks. Another allowed her friends to carve their names in her arm. Research shows that the number of different ways that a person engages in self harm correlates with the likelihood of suicide attempt (Nock ibid).
Treatment Options for Self Harm In addition to diagnosing and treating any underlying disorder or environmental situation, the goal of therapy should be to address the various reasons that might make self harm rewarding. To that end, improving distress tolerance addresses most of the internal reasons for self harm, and improving interpersonal effectiveness addresses most of the interpersonal reasons for self harm, and as such, one can see Marsha Linehan’s particular genius in developing dialectical behavioral therapy. Cognitive behavioral therapy also has much to offer by helping adolescents stay out of the ruminative negativity that drives the sense of overwhelming distress to start with. Concretely developing alternatives to self harm, such as music, can be helpful too.
The endogenous opiate theory of self harm suggests that an opiate antagonist like naltrexone could be beneficial by interrupting the pain-reward circuit. There is some evidence to support this in autistic and developmentally disabled individuals, and in several studies, repetitive self injurious behavior has been decreased with treatment with naltrexone. (For a review of the evidence, see Symons FJ et al, Ment Retard Dev Disabil Res Rev 2004;10(3):193–200.)
Data on individuals who are not autistic is sparse, with just a few case reports and open label studies. NSSI is a disorder that can be both frightening and infuriating to parents, teachers, and people who work with adolescents, but ultimately it seems to be just a symptom of distress. Helping the adults who surround the patient understand and recognize the distress may be the most healing thing you can do.