Eating Disorders and Self-Harm: A Chaotic

Intersection
By Randy A. Sansone, MD, John L. Levitt, PhD & Lori A. Sansone, MD
Reprinted from Eating Disorders Review
May/June 2003 Volume 14, Number 3
2003 Grze Books

There is clear empirical evidence that a subgroup of individuals with eating disorders (ED) engage in
self-harm behavior (SHB). Individually these disorders are difficult to treat; in combination they
represent a chaotic intersection. SHB ranges from various non-lethal forms of self-injury to genuine
suicide attempts. Some examples of non-lethal self-injury include hitting, burning, scratching, or
cutting oneself; pulling out one's hair and eyelashes; purposefully precipitating harmful "accidents,"
and participating in physically abusive relationships.

SHB may also manifest as overt eating disorder symptoms, such as

abusing laxatives, inducing vomiting, or exercising excessively with the
expressed or primary intent to experience pain or cause self-injury.
Therefore, when assessing ED symptoms, it is essential to determine the
intent or function of the symptoms (i.e., food, body, and weight issues vs.
purposeful self-harm).

The Prevalence of SHB Among Eating Disorders Patients

The prevalence of non-lethal self-injury among ED patients is approximately 25%, regardless of the
type of eating disorder or the treatment setting (Eating Disorders2002; 10:205). As for suicide
attempts, the prevalence rates appear to vary, depending on the ED diagnostic subgroup and study
setting. The prevalence of suicide attempts is lowest among outpatients with anorexia nervosa (16%).
Prevalence rates are higher for bulimic individuals treated as outpatients (23%) and inpatients (39%).
The highest rates of suicide attempts are reported among bulimic individuals who have comorbid
alcohol abuse (54%) (Eating Disorders 2002; 10:205).

Causes of SHB Among Those with ED

The precise etiology of self-harm behavior among those with ED is unknown, but it is suspected to be
complex, with many underlying causes. It is also known to vary between individuals. About 25% of
self-harming individuals with ED appear to meet the criteria for borderline personality disorder (BPD).

Variables that contribute to BPD include temperament, traumatic triggering events, family-of-origin
dysfunction (e.g., inconsistent treatment by a caretaker, a negative family environment, or "biparental
failure"), and various biological abnormalities, including possible aberrations in serotonin levels.
Because BPD is frequently associated with a history of abuse during childhood (e.g., sexual, physical,
and emotional abuse and witnessing violence), it is difficult to ascertain if associated biological findings
are the causes of and/or outcomes of early developmental trauma. However, early violation of body
boundaries appears to foster dissociative defenses in young victims, as well as a separation of body
self and psychological self ("You can hurt my body, but not me"). These processes appear to
subsequently lower the threshold for SHB in adulthood.

Multi-Impulsive Bulimia
A related construct, multi-impulsive bulimia, also involves impulsive SHB (e.g., suicide attempts), in
addition to other forms of impulsivity such as substance abuse and sexual promiscuity. Compared with
BPD, considerably less is known about multi-impulsive bulimia in terms of etiology. It may be that this
syndrome is actually made up of a subset of individuals with BPD.

Assessment
When assessing an individual with suspected SHB and an eating disorder, it is crucial to explore in
depth not only ED symptoms, but also the presence of concomitant SHB. These may include: (1) past
suicide attempts; (2) repetitive, ongoing, non-lethal self-harm behavior; and (3) ED symptoms that do
not appear to be related to concerns about food, body, and/or weight. An example of the latter could
include self-injury equivalents such as inducing vomiting without food in one's stomach.
Although proven thresholds for various symptoms have not been established, an ongoing pattern of
SHB is the conceptual benchmark. Several instruments to help detect and measure self-harm are now
available to clinicians, including the Self-Harm Inventory (J Clin Psychol 1998; 54:973), the Self-Injury
Survey (1994; Providence, RI), and the Impulsive and Self-Harm Questionnaire (Dissert Abstr
Int 1997; 58:4469).

Treatment Strategies
There is no consistent, empirically proven treatment strategy for SHB in those with ED. However, a
variety of interventions, used in assorted combinations, appear to offer promise.
Psychotherapy. Many psychotherapeutic techniques for SHB have been described for years in the
literature on borderline personality disorder. Here are some of the approaches:

(a) Cognitive restructuring (eliciting and restructuring faulty cognitions that promote SHB).
(b) Dynamic approaches (e.g., uncovering the deeper dynamic themes around SHB, such as selfpunishment or eliciting caring responses from others, and bringing these themes into the patient's
conscious awareness).
(c) Sublimation (defined as rechanneling SHB into more socially acceptable alternatives, such as
drawing or writing out self-destructive urges in detail).
(d) Interpersonal restructuring (using a consistent verbal phraseology at the time of a crisis that
restructures the meaning and function of self-harm behavior in an interpersonal relationship).
(e) Family intervention (i.e., uncovering and translating what the patient may be trying to
communicate though SHB).
(f) Various forms of contracting (i.e., encouraging personal control, establishing limits around the
treatment).
(g) Group therapy.
Again, none of these approaches alone is effective, whereas combinations appear to promote some
degree of stabilization in most patients.
Dialectical Behavior Therapy is a formal approach that includes a combination of techniques, including
individual and group intervention, cognitive and dynamic therapy, and psychoeducation. Like other
forms of combination treatment, this systematized approach holds promise for the treatment of these
complex patients.
Psychotropic medication. Three clinical issues are relevant when considering whether to use
psychotropic medications in this population: (1) the meaningful reduction of SHB; (2) selection of
medications that are reasonably weight-neutral; and (3) avoidance of medications that are dangerous
in overdose.
Most prescribing clinicians initially choose treatment with a weight-neutral selective serotonergic
reuptake inhibitor (SSRI). As caveats, both sertraline (Zoloft) and fluoxetine (Prozac) appear to be
relatively weight-neutral, whereas paroxetine (Paxil) is frequently associated with weight gain. In
addition, citalopram (Celexa) overdose is associated with cardiac conduction changes that may
foreshadow an arrhythmia, which can be lethal.

When there is no meaningful response with an SSRI, a second medication may be added. We typically
choose an anticonvulsant. Gabapentin (Neurontin; 100-600 mg per day) is seemingly weight-neutral
at lower doses, and is safe in overdose. Topiramate (Topamax) is associated with weight loss, and
may be particularly helpful among those with binge eating disorder. Safety in overdose with
topiramate is not well studied, but reports indicate no adverse effects.
Low-dose, atypical antipsychotic drugs may also be used as an augmentation strategy, either with the
SSRI alone, or with the combination of an SSRI and anticonvulsant. Ziprasidone (Geodon) is weightneutral at all doses (e.g., 20 mg once or twice daily) and low-dose risperidone (Risperdal; e.g.,
0.25-0.5 mg per day) also appears to be reasonably weight-neutral. In contrast, olanzapine
(Zyprexa), quetiapine (Seroquel), and clozapine (Clozaril) are noted for producing weight gain in
susceptible patients. These latter three atypical antipsychotics may also cause metabolic abnormalities
such as elevated serum glucose, cholesterol, and triglyceride levels.
Finally, several studies indicate that eicosapentaenoic acid (EPA), an omega-3 fatty acid found in fish
oil, may reduce depressive and aggressive symptoms as well as suicidal ideation (Am J
Psychiatry 2003; 160:167; Am J Psychiatry 2002; 159:477). In the empirical literature, the suggested
dosage of EPA has been 1000 mg/day, although this explicit formulation is not seemingly available
over-the-counter (e.g., a 432- mg softgel capsule is available). EPA appears to be weight-neutral and
safe, even in overdoses.
Given the preceding pharmacologic suggestions, medications appear to offer modest yet meaningful
reductions in SHB (an estimated 30% reduction in symptoms). As is the case with any trauma-based
syndrome, including post-traumatic stress disorder, full remission is unlikely with the use of
medications alone. The outcome data for the combination of psychotherapy strategies and medications
varies, of course, from moderate remissions to refractory courses.

Conclusions
Patients with SHB constitute a substantial minority of individuals with eating disorders. While our
understanding of the causes for SHB in this population remain somewhat elusive, it is likely that this
phenomenon has many causes. Assessment of all ED patients should include clinical inquiry into the
presence of SHB. In addition, formal measures of SHB are available.
Treatment approaches need to be individualized, and consist of a combination of psychotherapeutic
strategies and medications. A reduction in SHB is a reasonable expectation, but a full and sustained
remission is less likely to occur in the short term. Whether full remission occurs with longer follow-up
periods is unknown. Clearly, these patients remain complex enigmas in our clinical realms.

About the Authors

Randy A. Sansone, MD is a Professor at Wright State University School of Medicine, Dayton, OH.
John L. Levitt, PhD is Clinical Director of the Eating Disorders Program at Alexian Brothers Behavioral
Health Hospital, Rolling Meadows, IL.
Lori A. Sansone, MD is in private practice with Alliance Physicians, Dayton, OH.

Suggested Reading
1.

Wonderlich S, Myers T, Norton M, et al. Self-harm and bulimia nervosa: A complex

connection. Eating Disord 2002; 10:257.

2.

Sansone RA, Levitt JL. Self-harm behaviors among those with eating disorders: An overview. Eating
Disord 2002; 10:205.

3.

Sansone RA, Sansone LA. Assessment tools for self-harm behavior among those with eating
disorders. Eating Disord 2002; 10: 193.

4.

Sansone RA, Levitt JL, Sansone LA. Self-harm behavior and eating disorders. J Prof Counselor (in
press).

5.

Levitt JL, Sansone RA, Cohn LS. Self-Harm Behavior and Eating Disorders. New York: BrunnerRoutledge (in press).

Bipolar disorder self injury

Bipolar disorder self injury is very misunderstood.

Often, even the best resources on bipolar disorder neglect this important bipolar
symptom.

Accurate information on bipolar disorder would make it clear that bipolar is about
extreme moods and that the tell-tale symptoms of bipolar disorder revolve around
these mood swings into mania and depression.

Often people confuse bipolar disorder (manic-depressive illness) with other

conditions such as Borderline Personality Disorder (BPD) and even psychosis.

The current trend towards labeling any teen with conduct issues as "bipolar", and
the publicity and mixed messages around "cutting" and other forms of self injury,
lead many people to equate these things. In fact they are often unrelated.

In particular, the contemporary forms of self injury that currently garner so much
publicity - I am thinking in particular of cutting - DO NOT APPEAR ANYWHERE in the
official DSM diagnosis of bipolar disorder.

Clinically, bipolar is all about mania and depression. Self injury per se is not part of
the diagnostic criteria for bipolar disorder and there is no necessary relationship
between the two.

However, many people search the Internet for information on bipolar disorder and
write to me about bipolar disorder self injury, assuming that cutting is always
bipolar symptom. This is simply not true.

Bipolar disorder self injury does not mean cutting.

According to experts:

"[Self injury] is listed in the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR) as a symptom of borderline personality disorder and depressive
disorders. It is sometimes associated with mental illness, a history of trauma and
abuse including emotional abuse, sexual abuse, eating disorders, or mental traits
such as low self-esteem or perfectionism".

Learn about the difference between self injury in Bipolar vs Borderline Personality
Disorder.

This is not to say there is not good reason for the confusion, or that it is true to say
that bipolar disorder and self injury NEVER go together. For example, self-mutilation
is significantly correlated with impulsiveness, chronic anger, and anxiety. Bipolar is
also strongly correlated with impulsiveness, anger, and anxiety. Learn more about
self injury and bipolar.

Interestingly, self injury is often treated with SSRI type antidepressants such as
Zoloft or Prozac. These are generally unsuitable medications for treating bipolar as
they may trigger manic episodes. This is all part of the confusion around bipolar
disorder self injury.

Types of self harm in bipolar disorder

Despite the remarks above, I do believe there is a lot to say about bipolar disorder
self injury.

There are are many types of self harm that manifest in bipolar symptoms. The most
dangerous is bipolar suicides.

Many studies indicate a 15% rate of suicide amongst individuals with bipolar
disorder. This rate is about 30 times higher than than that of the general population.

Some studies have come up with rates as high as 30%-50%.

More recent studies, however, have been finding lower rates. There are two reasons
for this. The first reason is that now studies tend to take in a wider range of bipolar
people, whereas earlier studies focused on patients who were already hospitalized.
The second reason is the increase in the use of lithium and other medications that
effectively treat bipolar.

The absolute most conservative figure suggested for patients diagnosed today is AT
LEAST a 5% lifetime suicide risk.

There are other statistics that illustrate how bipolar disorder can effect every aspect
of a person's life and the many types of self harm in bipolar disorder.

Problem gambling is a common bipolar disorder self injury.

For example:

1. Bipolar people are TWICE as likely to have gambling problems.

2. Bipolar people are THREE times as likely to smoke.

3. A recent study of bipolar teens found a significantly higher risk of drug or alcohol
abuse or addiction - 31% compared with just 4% in the non-bipolar control group.

4. People with mental health problems are THREE times more likely to accumulate
huge debts than the general population, and amongst those with bipolar disorder
the number is more likely to be higher. This is because over-spending is part of the
condition.

5. Preventable cardiovascular disease is the number one killer of people with bipolar
disease. Bipolar people also have a lower physical quality of life. This could be due
to some of the types of self harm already mentioned - a higher consumption of
addictive substances such as alcohol and tobacco, the long-term secondary effects
of the pharmacological treatment and a more sedentary way of life.

6. Bipolar people have higher rates of divorce and relationship breakdown. In

important research, hypersexuality was reported in 57% of manic individuals, based
on averages across seven studies, with a range of values from 25% to 80%!

Types of self harm include substance abuse.

7. Research has also identified what is called "downward drift" amongst people with
bipolar disorder (Goodwin and Jamison, 2007). This is where, compared to nonbipolar family members, bipolar people eventually end up with lower levels of
wealth and income.

Why are people with bipolar disorder prone to so many types of self harm? We have
looked at some specific types of bipolar disorder self injury. Anger, recklessness,
impulsiveness and poor judgment are common in bipolar.

These bipolar signs and symptoms are a dangerous cocktail when mixed with the
low self-esteem, shame, and frustration that many people living with manicdepressive illness constantly torment themselves with.

Nonsuicidal self-injury: How categorization guides treatment

Understanding how and why patients engage in NSSI leads to optimal care
Vol. 11, No. 03 / March 2012
Armando R. Favazza, MD
Emeritus Professor of Psychiatry, University of Missouri-Columbia, Columbia, MO
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Formerly called self-mutilation, self-injury, or self-harm, nonsuicidal self-injury (NSSI)
is the deliberate and direct alteration or destruction of healthy body tissue without
suicidal intent; these behaviors range from skin cutting or burning to eye
enucleation or amputation of body parts. NSSI must be deliberate, as opposed to
accidental or indirect behaviorssuch as overdoses or ingesting harmful substances

that cause injury that is uncertain, ambiguous as to course, or invisible (the

injuries do not disfigure observable body tissue).1 NSSI acts are done without an
intent to die, although persons who self-harm may have suicidal ideation and
passive thoughts of dying.2 Persons who repeatedly engage in NSSI and are
demoralized over their inability to control it are at risk for suicide attempts.3
NSSI can be classified as nonpathological or pathological.4 Culturally sanctioned,
nonpathological NSSI consists of body modification practices such as tattoos or
piercing. Body modification practices may be a sublimation of pathological NSSI. For
a description of nonpathological NSSI, see the Box.5 Pathological NSSI typically is a
method of emotional regulation. Understanding why patients engage in pathological
NSSI and how it is categorized can help guide assessment and treatment.
Box
Body modification: When self-injury is not pathological
Body modification practices and rituals are culturally sanctioned forms of
nonsuicidal self-injury (NSSI). Body modification practices include tattooing and
piercing earlobes, nipples, and other body parts to accommodate jewelry. Most
practices are harmless but when carried to extremes, they may point to underlying
neuroses. For some patients, a tattoo or piercing may be psychologically beneficial
eg, to reclaim ones body after an attack or rape.5

Body modification rituals, such as head gashing by Sufi healers, penis cutting during
aboriginal coming-of-age ceremonies, and Hindu body piercing to attain spiritual
goals, are meaningful activities that reflect the tradition, symbolism, and beliefs of a
society. These rituals serve an elemental purpose by correcting or preventing
destabilizing conditions that threaten people and communities, such as mental and
physical diseases; angry gods, spirits, or ancestors; failure of children to accept
adult responsibilities; conflicts (eg, male-female, intergenerational, interclass,
intertribal); loosening of clear social role distinctions; loss of group identity; immoral
or sinful behaviors; and ecological disasters.
These rituals are effective because participants believe they promote healing,
spirituality, and social order. Knowledge about body modification practices and
rituals in which NSSI is perceived to be therapeutic opens the door to an
understanding of pathological NSSI as a form of self-help behavior and allows
clinicians to have a more empathic interaction with patients who self-injure.
Why people engage in NSSI
NSSI is best regarded as a pathological approach to emotional regulation and
distress tolerance that provides rapid but temporary relief from disturbing thoughts,
feelings, and emotions. For approximately 90% of patients, NSSI decreases

symptoms, most commonly untenable anxiety (Its like popping a balloon),

depressed mood, racing thoughts, swirling emotions, anger, hallucinations, and
flashbacks.6,7 In some instances, NSSI generates desired feelings and selfstimulation during periods of dissociation, depersonalization, grief, insecurity,
loneliness, extreme boredom, self-pity, and alienation.8,9 NSSI also may signal
distress to elicit a caring response from others or provide a means of escape from
intolerable social situations.10 Table 1 lists factors associated with NSSI.
Table 1
Factors associated with NSSI
High levels of negative and unpleasant thoughts and feelingsa
Poor communication skills and problem-solving abilitiesb
Abuse, maltreatment, hostility, and marked criticism during childhoodc,d
Under- or over-arousal responses to stressb
High valuation of NSSI to achieve a desired responsee
Need for self-punishmenta
Modeling behaviors based on exposure to NSSI among peers, on the Internetie,
postings on YouTubeand in the mediaf
NSSI: nonsuicidal self-injury Source:
References
Deliberto TL, Nock MK. An exploratory study of correlates, onset, and offset of nonsuicidal self-injury. Arch Suicide Res. 2008;12(3):219-231.
Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problemsolving deficits among adolescent self-injurers. J Consult Clin Psychol.
2008;76(1):28-38.
Weierich MR, Nock MK. Posttraumatic stress symptoms mediate the relation
between childhood sexual abuse and nonsuicidal self-injury. J Consult Clin Psychol.
2008;76(1):39-44.
Yates TM. The developmental psychopathology of self-injurious behavior:
compensatory regulation in posttraumatic adaptation. Clin Psychol Rev.
2004;24(1):35-74.
Whitlock JL, Powers JL, Eckenrode J. The virtual cutting edge: the Internet and
adolescent self-injury. Dev Psychol. 2006;42(3):407-417.

Lewis SP, Heath NL, St Denis JM, et al. The scope of nonsuicidal self-injury on
YouTube. Pediatrics. 2011;127(3):e552-e557.
The functional approach
One model of classifying NSSI focuses on the behavioral functions it serves.11,12 In
this model, the most common function of NSSI is removal or escape from an
aversive affective or cognitive state (automatic positive reinforcement). Automatic
negative reinforcement explains using NSSI to generate feelingseg, by patients
with anhedonia or numbness. NSSI also may be used as a signal of distress to gain
attention, access helpful environmental resources (social positive reinforcement), or
remove distressing interpersonal demands (social negative reinforcement).
The functional model is key to providing thorough clinical evaluations that should
include understanding the antecedent and consequent thoughts, feelings,
situations, triggers, and vulnerabilities related to NSSI acts.
The medical approach
Clinical Point
NSSI may fall within 4 descriptive categories: major, stereotypic, compulsive, or
impulsive
A descriptive, phenomenological model of NSSI classification uses concepts and
terminology with which most psychiatrists are familiar, takes into account patients
who have comorbid psychiatric disorders, is based on atheoretical, descriptive
observations, and fits into what might be regarded as a medical model. In this
classification, NSSI usually is regarded as a symptom or associated feature of a
specific psychiatric disorder, although it may occur in persons who do not meet
diagnostic criteria of a mental illnesseg, copycat cutting in high school
students.13,14 NSSI may fall within 4 descriptive categories: major, stereotypic,
compulsive, or impulsive. For psychiatric disorders associated with these types of
pathological NSSI, see Table 2.
Major NSSI includes infrequent acts that destroy significant body tissue, such as eye
enucleation and amputation of body parts. They are sudden, messy, and often
bloody acts. Seventy-five percent occur during a psychotic state, mainly
schizophrenia; of these, approximately one-half occur during a first psychotic
episode.15 The reasons patients typically offer for such behavior often defy logical
understandingeg, to enhance general well-beingbut most center on religion,
such as a concrete interpretation of biblical texts about removing an offending eye
or hand or becoming an eunuch,16,17 or on sexuality, such as controlling troubling
hypersexuality or fear of giving in to homosexual urges.18
Stereotypic NSSI acts, most commonly associated with severe and profound mental
retardation, include repetitive head banging; eye gouging; biting lips, the tongue,

cheeks, or fingers; and face or head slapping. The behaviors may be monotonously
repetitive, have a rhythmic pattern, and be performed without shame or guilt in the
presence of onlookers.
Compulsive NSSI encompasses repetitive behaviors such as severe skin scratching
and nail biting, hair pulling (trichotillomania), and skin digging (delusional
parasitosis).
Impulsive NSSI consists of acts such as skin cutting, burning, and carving; sticking
pins or other objects under the skin or into the chest or abdomen; interfering with
wound healing; and smashing hand or foot bones. These behaviors usually are
episodic and occur more frequently in females. The average age of onset in patients
who engage in impulsive NSSI is 12 to 14, although it may occur throughout the life
cycle.
Clinical Point
One or 2 impulsive NSSI acts do not have prognostic importance unless they are
serious enough to warrant an ED visit
One or 2 isolated instances of impulsive NSSI do not have much prognostic
importance unless they are serious enough to warrant an emergency department
visit. The real danger is when the behavior becomes repetitive and addictive. The
crossover from episodic to repetitive usually varies from 5 to 10 episodes.
Persons who engage in repetitive NSSI may use multiple methods, but skin cutting
predominates. Such persons often develop a self-identity as a cutter, are
preoccupied with their NSSI, may carve words into their skin, and may perform acts
of self-harm with other self-injurers. Some may cut themselves hundreds or even
thousands of times, creating scars that result in social morbidity. They often seek
professional help avidly, but may become so demoralized over their inability to stop
their NSSI that they are at risk for suicide.3 In some repetitive self-injurers, other
impulsive behaviors such as bulimia or substance abuse may alternate or coexist
with NSSI. This pattern often runs its course in 5 to 15 years and may end abruptly,
especially in patients with borderline personality disorder.
Table 2
Psychiatric disorders associated with pathological NSSI
Type of NSSI
Related psychiatric disorders
Major
Alcohol/drug intoxication, body integrity identity disordera

Stereotypic
Autism,b Tourettes syndrome,c Lesch-Nyhan syndrome,d hereditary neuropathies,e
mental retardation
Compulsive
Trichotillomania, delusional parasitosis
Impulsive
Anxiety disorders (generalized, acute stress, posttraumatic stress, obsessivecompulsive, substance-inducedf-h); borderline, histrionic, and antisocial personality
disordersi,j; somatoform and factitious disordersk,l; dissociative identity and
depersonalization disordersm,n; anorexia and bulimia nervosao,p; depressive
disordersq,r; bipolar disorders; schizophreniat,u; alcohol use disorderv;
kleptomaniaw
NSSI: nonsuicidal self-injury Source:
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identity disorder. Psychol Med. 2005;35(6):919-928.
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new neurobiology. Nat Rev Genet. 2008;9(5):341-355.
Robertson MM, Trimble MR, Lees AJ. Self-injurious behaviour and the Gilles de la
Tourette syndrome: a clinical study and review of the literature. Psychol Med.
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Baumeister AA, Frye GD. The biochemical basis of the behavioral disorder in the
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Gadoth N, Mass E. Hereditary neuropathies with self-mutilation. J Pediatr Neurol.
2004;2(4):205-211.
Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative
behavior. J Consult Clin Psychol. 2004;72(5):885-890.
Pitman RK. Self-mutilation in combat-related PTSD. Am J Psychiatry.
1990;147(1):123-124.
Primeau F, Fontaine R. Obsessive disorder with self-mutilation: a subgroup
responsive to pharmacotherapy. Can J Psychiatry. 1987;32(8):699-701.
Stone MH. Borderline personality disorder. Primary Psychiatry. 2006;13(5):36-39.

Coid J, Wilkins J, Coid B, et al. Self-mutilation in female remanded prisoners II: a

cluster analytic approach towards identification of a behavioral syndrome. Crim
Behav Ment Health. 1992;2:1-14.
Rogers T. Self-inflicted eye-injuries. Br J Psychiatry. 1987;151:691-693.
Nielsen K, Jeppesen M, Simmelsgaard L, et al. Self-inflicted skin diseases. A
retrospective analysis of 57 patients with dermatitis artefacta seen in a dermatology
department. Acta Derm Venereol. 2005;85(6):512-515.
Bliss EL. Multiple personalities. A report of 14 cases with implications for
schizophrenia and hysteria. Arch Gen Psychiatry. 1980;37(12):1388-1397.
Miller F, Bashkin EA. Depersonalization and self-mutilation. Psychoanal Q.
1974;43(4):638-649.
Paul T, Schroeter K, Dahme B, et al. Self-injurious behavior in women with eating
disorders. Am J Psychiatry. 2002;159(3):408-411.
Favazza AR, DeRosear L, Conterio K. Self-mutilation and eating disorders. Suicide
Life Threat Behav. 1989;19(4):352-361.
Nixon MK, Cloutier PF, Aggarwal S. Affect regulation and addictive aspects of
repetitive self-injury in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry.
2002;41(11):1333-1341.
Nock MK, Joiner TE Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents:
diagnostic correlates and relation to suicide attempts. Psychiatry Res.
2006;144(1):65-72.
Esposito-Smythers C, Goldstein T, Birmaher B, et al. Clinical and psychosocial
correlates of non-suicidal self-injury within a sample of children and adolescents
with bipolar disorder. J Affect Disord. 2010;125(1-3):89-97.
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1971;127(10):1345-1349.
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1967;17(2):234-244.
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First-line treatment: Psychotherapy
Clinical Point

No medications are FDA-approved for NSSI but clinical experience suggests

pharmacotherapy may help some NSSI patients
Many studies have demonstrated the efficacy of psychotherapy as the primary
treatment for NSSI.19-21 Except for patients with Lesch-Nyhan syndrome or other
rare neurologic syndromes, the biologic causes of NSSI, including the role of
endogenous opioids, are unclear. No medications are FDA-approved for NSSI.
Pharmacotherapy may help NSSI patients, but such treatment recommendations are
based on clinical experience, and polypharmacy is common.22 Studies have not
demonstrated specific benefits or consistent efficacy of pharmacotherapy for
NSSI.23
Major NSSI. Prevention is key to addressing major NSSI. Consider atypical
antipsychotics for psychotic patients who are preoccupied with religion, the Bible, or
sexuality, as well as those who dramatically and suddenly change their appearance
by cutting off their hair, engaging in extreme body modification practices, or
wearing bizarre clothes.24 In my clinical experience, agitated patients who have
committed major NSSI are at high risk for a second episode and should receive
pharmacotherapy based on treatment guidelines and hospitalized until the agitation
is controlled.
Stereotypic NSSI. Patients with this form of NSSI often cannot articulate what is
bothering them. With input from caretakers, assess the likelihood that a patient is
reacting to pain. Analgesics may be effective. Also check for infections such as otitis
media. Selecting a medication can be challenging. Start with a moderate dose of a
selective serotonin reuptake inhibitor (SSRI), then slowly add an atypical
antipsychotic, followed by a mood stabilizer, then clonidine, and then a beta
blocker; a trial of naltrexone also is an option.23 Behavior therapy is the primary
treatment.
Compulsive NSSI. Compulsive NSSI patients typically seek help from dermatologists
or family physicians. Literature on psychiatric treatment is limited, but SSRIs,
lithium, benzodiazepines, and atypical antipsychotics (for delusional parasitosis)
may be effective. N-acetylcysteine, 600 mg twice a day, may relieve
trichotillomania.25 Treatment should include psychotherapy.
Clinical Point

Psychotherapy, especially dialectical behavior therapy, is vital for impulsive NSSI

patients
Impulsive NSSI. Patients who engage in episodic impulsive NSSI should receive
pharmacotherapy for underlying psychiatric illnesses such as generalized anxiety
disorder, posttraumatic stress disorder, or depression. Do not automatically

diagnose borderline personality disorder. Patients whose NSSI behavior is

uncontrollable initially should receive high doses of SSRIs that can be lowered when
impulsivity decreases, atypical antipsychotics, and a mood stabilizer such as
lamotrigine. Psychotherapy is vital, especially dialectical behavior therapy.
Cognitive-behavioral and interpersonal therapies also are effective, as is
psychodynamic therapy.19-21
NSSI patients and their families may benefit from Web sites that provide
information, advice, monitored blogs, and support groups (see Related Resources).
Related Resources
Favazza A. Bodies under siege: self-mutilation, nonsuicidal self-injury, and body
modification in culture and psychiatry. 3rd ed. Baltimore, MD: Johns Hopkins
University Press; 2011.
Nock MK. Understanding nonsuicidal self-injury: origins, assessment, and treatment.
Washington, DC: American Psychological Association; 2009.
Cornell University Family Life Development Center. About self-injury.
www.crpsib.com/whatissi.asp.
Drug Brand Names
Clonidine Catapres, Kapvay
Lamotrigine Lamictal
Lithium Eskalith, Lithobid
Naltrexone ReVia
Disclosure
Dr. Favazza reports no financial relationship with any company whose products are
mentioned in this article or with manufacturers of competing products.
Previous Page 1 2
REFERENCES
1. Walsh BW, Rosen PM. Self-mutilation: theory research, and treatment. New York,
NY: Guilford Press; 2008:32.
2. Nock MK, Favazza AR. Nonsuicidal self-injury: definition and classification. In: Nock
MK ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment.
Washington, DC: American Psychological Association; 2009:9-18.

3. Favazza AR, Conterio K. Female habitual self-mutilators. Acta Psychiatr Scand.

1989;79(3):283-289.
4. Favazza A. Bodies under siege: self-mutilation nonsuicidal self-injury, and body
modification in culture and psychiatry. 3rd ed. Baltimore, MD: Johns Hopkins
University Press; 2011.
5. Gallina R. Tattoos and body piercing. In: Vale V Juno A, eds. Modern primitives.
San Francisco, CA: Re/Search Publications; 1989:101-105.
6. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: the
experiential avoidance model. Behav Res Ther. 2006;44(3):371-394.
7. Nock MK, Prinstein MJ. Contextual features and behavioral functions of selfmutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.
8. Miller F, Bashkin EA. Depersonalization and self-mutilation. Psychoanal Q.
1974;43(4):638-649.
9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin
Psychol Rev. 2007;27(2):226-239.
10. Nock MK. Actions speak louder than words: an elaborated theoretical model of
the social functions of self-injury and other harmful behaviors. Appl Prev Psychol.
2008;12(4):159-168.
11. Nock MK, Prinstein MJ. A functional approach to the assessment of selfmutilative behavior. J Consult Clin Psychol. 2004;72(5):885-890.
12. Nock MK, Prinstein MJ. Contextual features and behavioral functions of selfmutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.
13. Favazza AR, Rosenthal RJ. Diagnostic issues in self-mutilation. Hosp Community
Psychiatry. 1993;44(2):134-140.
14. Rosen PM, Walsh BW. Patterns of contagion in self-mutilation epidemics. Am J
Psychiatry. 1989;146(5):656-658.
15. Large M, Babidge N, Andrews D, et al. Major self-mutilation in the first episode of
psychosis. Schizophr Bull. 2009;35(5):1012-1021.
16. Kushner AW. Two cases of auto-castration due to religious delusions. Br J Med
Psychol. 1967;40(3):293-298.
17. Moskovitz RA, Byrd T. Rescuing the angel within: PCP-related self-enucleation.
Psychosomatics. 1983;24(4):402-403,406.
18. Cleveland SE. Three cases of self-castration. J Nerv Ment Dis. 1956;123(4):386391.

19. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial
and follow-up of dialectical behavior therapy vs therapy by experts for suicidal
behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757766.
20. Kahng S, Iwata BA, Lewin AB. Behavioral treatment of self-injury 1964 to 2000.
Am J Ment Retard. 2002;107(3):212-221.
21. Levy KN, Yeomans FE, Diamond D. Psychodynamic treatments of self-injury. J
Clin Psychol. 2007;63(11):1105-1120.
22. Lott IT, McGregor M, Engelman L, et al. Longitudinal prescribing patterns for
psychoactive medications in community-based individuals with developmental
disabilities: utilization of pharmacy records. J Intellect Disabil Res. 2004;48(Pt
6):563-571.
23. Sandman CA. Psychopharmacologic treatment of nonsuicidal self-injury. In: Nock
MK ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment.
Washington, DC: American Psychological Association; 2009:291-322.
24. Sweeny S, Zamecnik K. Predictors of self-mutilation in patients with
schizophrenia. Am J Psychiatry. 1981;138(8):1086-1089.
25. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine a glutamate modulator, in the
treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen
Psychiatry. 2009;66(7):756-763.
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