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Self-Injurious Behavior (SIB) in Adolescents

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Self-Injurious Behavior (SIB) in Adolescents: an Important Consideration as a Risk Factor for Suicide

Shilpa Patel

Penn State College of Medicine

March 2003

I. Epidemiology

a. Adolescent Suicide

§ “Each year, 1 in 5 teens in the US seriously considers suicide; 5 to 8% of adolescents attempt suicide, representing approximately 1 million teenagers, of whom nearly 700,000 receive medical attention for their attempt (Grunbaum et al., 2002); and approximately 1,600 teens die by suicide (Anderson, 2002).”³

§ According to the U.S. Centers for Disease Control and Prevention (CDC), suicide is the third leading cause of death for those ages 15 to 24.

§ During 1991--2001, significant decreases occurred in the percentage of students who seriously considered suicide (29%--19%), and planned to attempt suicide (18.6%--14.8). The percentage of students who carried a weapon decreased significantly from 1991--1997 (26.1%--18.3%) and then remained constant from 1997--2001 (18.3%--17.4%). ¹

§ From 1991 to 1997, the percentage of students seriously considering suicide and the percentage that made a suicide plan showed significant linear decreases. However, the percentage of students that made an injurious suicide attempt showed a significant linear increase. ²

§ According to the recently published report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), three million American teens have thought seriously about or attempted suicide.

1. More than 13 percent of young Americans between 14 and 17 years of age considered suicide in 2000.

2. More than a third of the three million teens aged 12 to 17 thought about suicide in the past 12 months and actually tried it.

3. Girls were twice as likely as boys to say they thought about suicide, but race did not seem to make a difference.

b. Self-Injurious Behavior (SIB)

§ Lifetime prevalence rates of SIB in psychiatric adolescent inpatients have been reported as high as 61.2%, with adolescence being the most commonly reported age of onset for SIB. ⁴

§ In a review of studies done in Europe and the UK they found that the “connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is one hundred times higher than in the general population.” ⁵

II. SIB in a Group of Hospitalized Psychiatric Adolescents – Study Review ⁴

a. Definition of SIB used for study

§ SIB is deliberate self-harming behavior but without conscious suicidal ideation. The type studied was described as “injury to the body tissue that is considered superficial or moderate, and is seen in non-developmentally delayed, non-psychotic population and is nonsterotypic in nature”

b. Purpose of Study

§ To examine the features of SIB and the specific reinforcing effects because of the repetitive nature of SIB and the potential to increase in severity.

c. Subjects

§ Studied all adolescents admitted to a tertiary care inpatient psychiatric center between the ages of 12 and 18 from March to June of 2000 - N=42 (F=36, M=6). This imbalance in gender limited the studies ability to monitor for gender differences.

d. Results

§ Types of SIB seen in the study and the frequency of their occurrence.

1. > 90%, Cutting

2. > 70%, Scratching

3. > 60%, Hitting

4. > 50%, Interfering with wounds, hair pulling, biting

5. > 40%, head banging, nail biting/injuries, burning,

6. < 30%, piercing body parts, using needles, trying to break bones

7. An earlier age of onset, higher frequency of SIB, and a greater number of addictive features were noted in a subgroup of more severe repetitive self injurers.

§ This study was the first to emphasize the addictive features of SIB in adolescents.

1. > 90% “the behavior occurs more often and/or severity of self-injury has increased” and “self-injury continues despite recognizing it is harmful”

2. > 80% “tension levels reoccurs if self-injury is discontinued” and “self-injury urges are upsetting but not enough to stop”

§ This study was consistent with other similar studies that showed high rates of both suicidal behavior and depressive symptoms in inpatients with a history of SIB.

§ Almost 50% of all participants cited “stop suicidal ideation/attempt” as a reason for engaging in SIB. “Coping with feelings of depression” lead the list with 83% choosing this as their reason for engaging in SIB.

§ A small subgroup identified with “to stop feeling numb or out of touch with reality” as a reason to engage in SIB. This supports the hypothesis that for some, self-injury may act as a means to stop dissociative-like feelings.

III. Understanding Suicide and SIB in context of two models that help to explain possible theories as to why certain adolescents engage in SIB.

a. Affect regulation model

“Affect regulation is most frequently cited as the primary motivation of SIB, where the behavior may serve to express, validate, or regulate dysphoric feelings such as depression, tension, pain, or anger or it may have a role in inducing or ending dissociative symptoms.” ⁴

§ A study⁶ demonstrated this model by administering measures of affect dysregulation, number of risk-taking behaviors in past year, presence of self-mutilative behaviors in past year, and number of different types of self-mutilative behaviors in past year to adolescents admitted to an inpatient unit who were either suicide ideators (n = 25) or suicide attempters (n = 35).

§ It was noted that suicide attempters reported a greater number of self-injurious acts in the previous year than suicide ideators.

§ These data supported the contention that suicidal behavior may not be a phenomenon distinct from self-mutilative behavior and that there is a continuum of self-inflicted acts of bodily harm of increasing severity and lethality.

§ “Furthermore, the finding that a greater range of self-mutilative activities and a higher level of affect dysregulation were correlated in adolescent attempters suggests that adolescent suicide attempters may engage in a variety of self-inflicted assaults on their bodies in search of an effective method to modulate their affect. Perhaps a suicide attempt is a final attempt to adapt to intense negative emotions.”

§ Theories behind the reasons for how SIB can achieve affect regulation:

1. To create a sense of control over an overwhelming emotion

2. To have physical evidence of an emotional injury in order to feel that emotions are real, justified or able to be tolerated.

b. Anti-Suicide Model ⁷

“The anti-suicide model of self-mutilation focuses on the behavior as an active coping mechanism used to avoid suicide in direct contrast to seeing self-mutilation as an actual suicide attempt.”

§ For suicidal individuals, SIB may be viewed as an active coping mechanism to avoid suicide, consistent with the anti-suicide drive model as 50% of the subjects in the study mentioned above reported.

IV. Conclusions

a. Summary

§ SIB and Suicidal Ideation/Attempt have strong connections via the Affect Regulation Model and the Anti-Suicide Model. Both are consistent with the data presented in the Adolescent Inpatient Study looking at reasons why adolescents engage in SIB.

§ SIB is an important risk factor for suicidal ideation and attempt. Theoretically preventative interventions directed towards reducing the repeated SIB should subsequently reduce the number of suicidal attempts. The evaluation of suicidal behavior and suicide risk should not be overlooked in hospitalized adolescents with repetitive SIB.

b. Areas of Future Interest

§ Prevention and efficacy of specific prevention methods in reducing the number of suicide attempts.

§ More studies looking at specific types of SIB.

c. Websites of Interest

§ American Foundation for Suicide Prevention: www.afsp.org

§ CDC Prevention Site: www.cdc.gov/ncipc/factsheets/suifacts.htm

References:

1. Center for Disease Control and Prevention (2002), Youth Risk Behavior Surveillance — United States, 2001. MMWR Morb Mortal Wkly Rep 51(SS04);1-64.

2. Brener ND, Krug EG, Simon TR. (2000), Trends in suicide ideation and suicidal behavior among high school students in the United States, 1991-1997. Suicide and Life-Threatening Behavior. 30(4):304-12.

3. Gould MS, Greenberg T, Shaffer D (2003), Youth Suicide Risk and Preventative Interventions: A Review of the Past 10 Years. J. Am. Acad. Child Adolesc. Psychiatry, 42(4):386-405.

4. Nixon MK, Cloutier PE, Aggarwal S. (2002), Affect Regulation and Addictive Aspects of Repetitive Self-Injury in Hospitalized Patients. J. Am. Acad. Child Adolesc. Psychiatry, 41(11):1333-1341.

5. Owens D, Horrocks J, House A. (2002) Fatal and non-fatal repetition of self-harm. Systematic review. British Journal of Psychiatry, 181:193-199.

6. Zlotinik et.al (1997), Affect regulation and suicide attempts in adolescent inpatients. J. Am. Acad. Child Adolesc. Psychiat y, 36:793-798.

7. Suyemoto KL (1998), The functions of self-mutilation. Clin Psychol Rev, 18:531-554.

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