Psychological characteristics common in self-injurers
The overall picture seems to be of people who:
· strongly dislike/invalidate themselves
· are hypersensitive to rejection
· are chronically angry, usually at themselves
· tend to suppress their anger
· have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward
· are more impulsive and more lacking in impulse control
· tend to act in accordance with their mood of the moment
· tend not to plan for the future
· are depressed and suicidal/self-destructive
· suffer chronic anxiety
· tend toward irritability
· do not see themselves as skilled at coping
· do not have a flexible repertoire of coping skills
· do not think they have much control over how/whether they cope with life
· tend to be avoidant
· do not see themselves as empowered
People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (1995). Similar findings appear in Simeon et al. (1992); they found that two major emotional states most commonly present in self-injurers at the time of injury -- anger and anxiety -- also appeared as longstanding personality traits. Linehan (1993a) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals.
In another study, Herpertz et al. (1995) found, in addition to the poor affect regulation, impulsivity, and aggression noted earlier, disordered affect, a great deal of suppressed anger, high levels of self-directed hostility, and a lack of planning among self-injurers:
We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors.
And Dulit et al. (1994) found several common characteristics in self-injuring subjects with borderline personality disorder (as opposed to non-SI BPD subjects):
· more likely to be in psychotherapy or on medications
· more likely to have additional diagnoses of depression or bulimia
· more acute and chronic suicidality
· more lifetime suicide attempts
· less sexual interest and activity
In a study of bulimics who self-injure (Favaro and Santonastaso, 1998 ) , subjects whose SIB was partially or mostly impulsive had higher scores on measures of obsession-compulsion, somatization, depression, anxiety, and hostility.
Simeon et al. (1992) found that the tendency to self-injure increased as levels of impulsivity, chronic anger, and somatic anxiety increased. The higher the level of chronic inappropriate anger, the more severe the degree of self-injury. They also found a combination of high aggression and poor impulse control. Haines and Williams (1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping. In addition, they had low self-esteem and low optimism about life.
Conterio and Favazza estimate that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000, or 1%, of Americans self-injure). In their 1986 survey, they found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported.
Types of self-injurious behavior reported were as follows:
Cutting: 72 percent
Burning: 35 percent
Self-hitting: 30 percent
Interference w/wound healing: 22 percent
Hair pulling: 10 percent
Bone breaking: 8 percent
Multiple methods: 78 percent (included in above)
On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years.
Half the sample had been hospitalized for the problem (the median number of days was 105 and the mean 240). Only 14% said the hospitalization had helped a lot (44 percent said it helped a little and 42 percent not at all). Outpatient therapy (75 sessions was the median, 60 the mean) had been tried by 64 percent of the sample, with 29 percent of those saying it helped a lot, 47 percent a little, and 24 percent not at all. Thirty-eight percent had been to a hospital emergency room for treatment of self-inflicted injuries (the median number of visits was 3, the mean 9.5).
Why so many women?
Although the results of an informal net survey and the composition of an e-mail support mailing list for self-injurers don't show quite as strong a female bias as Conterio's numbers do (the survey population turned out to be about 85/15 percent female, and the list is closer to 67/34 percent), it is clear that women tend to resort to this behavior more often than men do. Miller (1994) is undoubtedly onto something with her theories about how women are socialized to internalize anger and men to externalize it. It is also possible that because men are socialized to repress emotion, they may have less trouble keeping things inside when overwhelmed by emotion or externalizing it in seemingly unrelated violence.
As early as 1985, Barnes recognized that gender role expectations played a significant role in how self-injurious patients were treated. Her study showed only two statistically significant diagnoses among self-harmers who were seen at a general hospital in Toronto: women were much more likely to receive a diagnosis of "transient situational disturbance" and men were more likely to be diagnosed as substance abusers. Overall, about a quarter of both men and women in this study were diagnosed with personality disorder.
Barnes suggests that men who self-injure get taken more "seriously" by physicians; only 3.4 percent of the men in the study were considered to have transient and situational problems, as compared to 11.8 percent of the women.
Etiology (history and causes)
Past trauma/invalidation as an antecedent
Van der Kolk, Perry, and Herman (1991) conducted a study of patients who exhibited cutting behavior and suicidality. They found that exposure to physical or sexual abuse, physical or emotional neglect, and chaotic family conditions during childhood, latency and adolescence were reliable predictors of the amount and severity of cutting. The earlier the abuse began, the more likely the subjects were to cut and the more severe their cutting was. Sexual abuse victims were most likely of all to cut. They summarize,
...neglect [was] the most powerful predictor of self-destructive behavior. This implies that although childhood trauma contributes heavily to the initiation of self-destructive behavior, lack of secure attachments maintains it. Those ... who could not remember feeling special or loved by anyone as children were least able to ...control their self-destructive behavior.
In this same paper, van der Kolk et al. note that dissociation and frequency of dissociative experiences appear to be related to the presence of self-injurious behavior. Dissociation in adulthood has also been positively linked to abuse, neglect, or trauma as a child.
More support for the theory that physical or sexual abuse or trauma is an important antecedent to this behavior comes from a 1989 article in the American Journal of Psychiatry. Greenspan and Samuel present three cases in which women who seemed to have no prior psychopathology presented as self-cutters following a traumatic rape.
Invalidation independent of abuse
Although sexual and physical abuse and neglect can seemingly precipitate self-injurious behavior, the converse does not hold: many of those who hurt themselves have suffered no childhood abuse. A 1994 study by Zweig-Frank et al. showed no relationship at all between abuse, dissociation, and self-injury among patients diagnosed with borderline personality disorder. A followup study by Brodsky, et al. (1995) also showed that abuse as a child is not a marker for dissociation and self-injury as an adult. Because of these and other studies as well as personal observations, it's become obvious to me that there is some basic characteristic present in people who self-injure that is not present in those who don't, and that the factor is something more subtle than abuse as a child. Reading Linehan's work provides a good idea of what the factor is.
Linehan (1993a) talks about people who SI having grown up in "invalidating environments." While an abusive home certainly qualifies as invalidating, so do other, "normal," situations. She says:
An invalidating environment is one in which communication of private experiences is met by erratic, inappropriate, or extreme responses. In other words, the expression of private experiences is not validated; instead it is often punished and/or trivialized. the experience of painful emotions [is] disregarded. The individual's interpretations of her own behavior, including the experience of the intents and motivations of the behavior, are dismissed...
Invalidation has two primary characteristics. First, it tells the individual that she is wrong in both her description and her analyses of her own experiences, particularly in her views of what is causing her own emotions, beliefs, and actions. Second, it attributes her experiences to socially unacceptable characteristics or personality traits.
This invalidation can take many forms:
· "You're angry but you just won't admit it."
· "You say no but you mean yes, i know."
· "You really did do (something you in truth hadn't). Stop lying."
· "You're being hypersensitive."
· "You're just lazy."
· "I won't let you manipulate me like that."
· "Cheer up. Snap out of it. You can get over this."
· "If you'd just look on the bright side and stop being a pessimist..."
· "You're just not trying hard enough."
· "I'll give you something to cry about!"
Everyone experiences invalidations like these at some time or another, but for people brought up in invalidating environments, these messages are constantly received. Parents may mean well but be too uncomfortable with negative emotion to allow their children to express it, and the result is unintentional invalidation. Chronic invalidation can lead to almost subconscious self-invalidation and self-distrust, and to the "I never mattered" feelings van der Kolk et al. describe.
Biological Considerations and Neurochemistry
It has been demonstrated (Carlson, 1986) that reduced levels of serotonin lead to increased aggressive behavior in mice. In this study, serotonin inhibitors produced increased aggression and serotonin exciters decreased aggression in mice. Since serotonin levels have also been linked to depression, and depression has been positively identified as one of the long-term consequences of childhood physical abuse (Malinosky-Rummell and Hansen, 1993), this could explain why self-injurious behaviors are seen more frequently among those abused as children than among the general population (Malinosky-Rummel and Hansen, 1993). Apparently, the most promising line of investigation in this area is the hypothesis that self-harm may result from decreases in necessary brain neurotransmitters.
This view is supported by evidence presented in Winchel and Stanley (1991) that although the opiate and dopaminergic systems don't seem to be implicated in self-harm, the serotonin system does. Drugs that are serotonin precursors or that block the reuptake of serotonin (thus making more available to the brain) seem to have some effect on self-harming behavior. Winchel and Staley hypothesize a relationship between this fact and the clinical similarities between obsessive- compulsive disorder (known to be helped by serotonin-enhancing drugs) and self-injuring behavior. They also note that some mood-stabilizing drugs (such as Tegretol, Depakote) can stabilize this sort of behavior.
Coccaro and colleagues have done much to advance the hypothesis that a deficit in the serotonin system is implicated in self-injurious behavior. They found (1997c) that irritability is the core behavioral correlate of serotonin function, and the exact type of aggressive behavior shown in response to irritation seems to be dependent on levels of serotonin -- if they are normal, irritability may be expressed by screaming, throwing things, etc. If serotonin levels are low, aggression increases and responses to irritation escalate into self-injury, suicide, and/or attacks on others.
Simeon et al. (1992) found that self-injurious behavior was significantly negatively correlated with number of platelet imipramine binding sites (self-injurers have fewer platelet imipramine binding sites, a level of serotonin activity) and note that this "may reflect central serotonergic dysfunction with reduced presynaptic serotonin release. . . . Serotonergic dysfunction may facilitate self-mutilation."
When these results are considered in light of work such as that by Stoff et al. (1987) and Birmaher et al. (1990), which links reduced numbers of platelet imipramine binding sites to impulsivity and aggression, it appears that the most appropriate classification for self-injurious behavior might be as an impulse-control disorder similar to trichotillomania, kleptomania, or compulsive gambling.
Herpertz (Herpertz et al, 1995; Herpertz and Favazza, 1997) has investigated how blood levels of prolactin respond to doses of d-fenfluramine in self-injuring and control subjects. The prolactin response in self-injuring subjects was blunted, which is "suggestive of a deficit in overall and primarily pre-synaptic central 5-HT (serotonin) function." Stein et al. (1996) found a similar blunting of prolactin response on fenfluramine challenge in subjects with compulsive personality disorder, and Coccaro et al. (1997c) found prolactin response varied inversely with scores on the Life History of Aggression scale.
It is not clear whether these abnormalities are caused by the trauma/abuse/invalidating experiences or whether some individuals with these kinds of brain abnormalities have traumatic life experiences that prevent their learning effective ways to cope with distress and that cause them to feel they have little control over what happens in their lives and subsequently resort to self-injury as a way of coping.
Knowing when to stop -- pain doesn't seem to be a factor
Most of those who self-mutilate can't quite explain it, but they know when to stop a session. After a certain amount of injury, the need is somehow satisfied and the abuser feels peaceful, calm, soothed. Only 10% of respondents to Conterio and Favazza's 1986 survey reported feeling "great pain"; 23 percent reported moderate pain and 67% reported feeling little or no pain at all. Naloxone, a drug that reverses the effects of opiods (including endorphins, the body's natural painkillers), was given to self-mutilators in one study but did not prove effective (see Richardson and Zaleski, 1986). These findings are intriguing in light of Haines et al. (1995), a study that found that reduction of psychophysiological tension may be the primary purpose of self-injury. It may be that when a certain level of physiological calm is reached, the self-injurer no longer feels an urgent need to inflict harm on his/her body. The lack of pain may be due to dissociation in some self-injurers, and to the way in which self-injury serves as a focusing behavior for others.
NOTE: most of this applies mainly to stereotypical self-injury, such as that seen in retarded and autistic clients.
Much work has been done in behavioral psychology in an attempt to explain the etiology of self-injurious behavior. In a 1990 review, Belfiore and Dattilio examine three possible explanations. They quote Phillips and Muzaffer (1961) in describing self-injury as "measures carried out by an individual upon him/herself which tend to 'cut off, to remove, to maim, to destroy, to render imperfect' some part of the body." This study also found that frequency of self-injury was higher in females but severity tended to be more extreme in males. Belfiore and Dattilio also point out that the terms "self-injury" and "self-mutilation" are deceiving; the description given above does not speak to the intent of the behavior.
It should be noted that explanations involving operant conditioning are generally more useful when dealing with stereotypic self-injury and less useful with episodic/repetitive behavior.
Two paradigms are put forth by those who wish to explain self-injury in terms of operant conditioning. One is that individuals who self-injure are positively reinforced by getting attention and thus tend to repeat the self-harming acts. Another implication of this theory is that the sensory stimulation associated with self-harm could serve as a positive reinforcer and thus a stimulus for further self-abuse.
The other posits that individuals self-injure in order to remove some aversive stimulus or unpleasant condition (emotional, physical, whatever). This negative reinforcement paradigm is supported by research showing that intensity of self-injury can be increased by increasing the "demand" of a situation. In effect, self-harm is a way to escape otherwise intolerable emotional pain.
One hypothesis long held has been that self-injurers are attempting to mediate levels of sensory arousal. Self-injury can increase sensory arousal (many respondents to the internet survey said it made them feel more real) or decrease it by masking sensory input that is even more distressing than the self-harm. This seems related to what Haines and Williams (1997) found: self-injury provides a quick and dramatic release of physiological tension/arousal. Cataldo and Harris (1982) concluded that theories of arousal, though satisfying in their parsimony, need to take into consideration biological bases of these factors.
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
· Borderline Personality Disorder
· Mood Disorders
· Eating Disorders
· Obsessive-Compulsive Disorder
· Post-Traumatic Stress Disorder
· Dissociative Disorders
· Anxiety and/or Panic
· Impulse-control Disorder Not Otherwise Specified
· 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 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."
Unfortunately, the most popular diagnosis assigned to anyone who self-injures is 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.]
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 The Depression Resources List or Depression.com. Another good source of information about depression is the newsgroup alt.support.depression, its FAQ, and the associated web page, Diane Wilson's ASD Resources page.
To find out more about bipolar disorder, try The Pendulum Resource Page, presented by members of one of the first mailing lists created for bipolar people.
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.
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 Something Fishy and its associated site, Mirror, Mirror -- are probably the best sources for detailed information on eating disorders.
Self-injury among those diagnosed with 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.
Edited by iwalkalone, 30 November 2006 - 06:53 PM.