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#21 iwalkalone

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Posted 30 November 2006 - 06:07 PM

Who self-injures?
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.
Demographics
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.
Serotonin
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.
Behavioralist explanations
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.
Operant Conditioning
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.
Sensory Contingencies
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."
--Ani DiFranco
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.]
Mood Disorders
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.
Eating Disorders
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.
Obsessive-Compulsive Disorder
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.


#22 iwalkalone

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Posted 30 November 2006 - 06:09 PM

Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder refers to a collection of symptoms that may occur as a delayed response to a serious trauma (or series of traumas). More information on the concept is available in my quick Trauma/PTSD FAQ. It's not meant to be comprehensive, but just to give an idea of what trauma is and what PTSD is about. Herman (1992) suggests an expansion of the PTSD diagnosis for those who have been continually traumatized over a period of months or years. Based on patterns of history and symptomology in her clients, she created the concept of Complex Post-Traumatic Stress Disorder. CPTSD includes self-injury as a symptom of the disordered affect regulation severely traumatized patients often have (interestingly enough, one of the main reasons people who hurt themselves do so is in order to control seemingly uncontrollable and frightening emotions). This diagnosis, unlike BPD, centers on why patients who self-harm do so, referring to definite traumatic events in the client's past. Although CPTSD is not a one-size-fits-all diagnosis for self-injury any more than BPD is, Herman's book does help those who have a history of repeated severe trauma understand why they have so much trouble regulating and expressing emotion.
Cauwels (1992) calls PTSD "BPD's identical cousin." Herman seems to favor a view in which PTSD has been fragmented into three separate diagnoses:
Area of most prominent dysfunction Diagnosis given
Somatic/physioneurotic (Bodily dysregulation -- problems regulating or understanding messages from the body and/or expression of emotional distress in physical symptoms) Conversion Disorder(formerly Hysterical Neurosis)
Consciousness Deformation (breakdown in the ability to perceive oneself as a single entity with an uninterrupted history or to integrate body and consciousness) Dissociative Identity Disorder/ Multiple Personality Disorder
Dysregulation of identity, emotions, and relationships Borderline Personality Disorder
For an incredible amount of information on trauma and its effects, including post-trauma stress syndromes, definitely visit David Baldwin's Trauma Information Pages.
Dissociative Disorders
The dissociative disorders involve problems of consciousness -- amnesia, fragmented consciousness (as seen in DID), and deformation or alteration of consciousness (as in Depersonalization Disorder or Dissociative Disorder Not Otherwise Specified ).
Dissociation refers to a sort of turning off of consciousness. Even psychologically normal people do it all the time -- the classic example is a person who drives to a destination while "zoning out" and arrives not remembering much at all about the drive. Fauman (1994) defines it as "the splitting off of a group of mental processes from conscious awareness." In the dissociative disorders, this splitting off has become extreme and often beyond the patient's control.
Depersonalization Disorder
Depersonalization is a variety of dissociation in which one suddenly feels detached from one's own body, sometimes as if they were observing events from outside themselves. It can be a frightening feeling, and it may be accompanied by a lessening of sensory input -- sounds may be muffled, things may look strange, etc. It feels as if the body is not part of the self, although reality testing remains intact. Some describe depersonalization as feeling dreamlike or mechanical. A diagnosis of depersonalization disorder is made when a client suffers from frequent and severe episodes of depersonalization. Some people react to depersonalization episodes by inflicting physical harm on themselves in an attempt to stop the unreal feelings, hoping that pain will bring them back to awareness. This is a common reason for SI in people who dissociate frequently in other ways.
DDNOS
DDNOS is a diagnosis given to people who show some of the symptoms of other dissociative disorders but do not meet the diagnostic criteria for any of them. A person who felt she had alternate personalities but in whom those personalities were not fully developed or autonomous or who was always the personality in control might be diagnosed DDNOS, as might someone who suffered depersonalization episodes but not of the length and severity required for diagnosis. It can also be a diagnosis given to someone who dissociates frequently without feeling unreal or having alternate personalities. It's basically a way of saying "You have a problem with dissociation that affects your life negatively, but we don't have a name for exactly the sort of dissociation you do." Again, people who have DDNOS often self-injure in an attempt to cause themselves pain and thus end the dissociative episode.
Dissociative Identity Disorder
In DID, a person has at least two personalities who alternate taking full conscious control of the patients behavior, speech, etc. The DSM specifies that the two (or more) personalities must have distinctly different and relatively enduring ways of perceiving, thinking about, and relating to the outside world and to the self, and that at least two of these personalities must alternate control of the patient's actions.
DID is somewhat controversial, and some people claim that it is over-diagnosed. Therapists must be extremely careful in diagnosing DID, probing without suggesting and taking care not to mistake undeveloped personality facets for fully-developed separate personalities. Also, some people who feel as if they have "bits" of them that sometimes take over but always while they're consciously aware and able to affect their own actions may run a risk of being misdiagnosed as DID if they also dissociate.
When someone has DID, they may self-injure for any of the reasons other people do. They may have an angry alter who attempts to punish the group by damaging the body or who chooses self-injury as a way of venting his/her anger.
It's extremely important that diagnoses of DID be made only by qualified professionals after lengthy interviews and examinations. For more information on DID, check out Divided Hearts. For reliable information on all aspects of dissociation including DID, the International Society for the Study of Dissociation web site and The Sidran Foundation are good sources.
The depersonalization discussion board homepage offers information, message boards, links, and chat rooms for those seeking to understand Depersonalization Disorder.
Kirsti's essay on "bits" and "The Wonderful World of the Midcontinuum" provide reassuring and valuable information about DDNOS, the space between normal daydreaming and being DID.
Anxiety and/or Panic
The DSM groups many disorders under the heading of "Anxiety Disorders." The symptoms and diagnoses of these vary greatly, and sometimes people with them use self-injury as a self-soothing coping mechanism. They've found that it brings fast temporary relief from the incredible tension and arousal that build up as they grow progressively more anxious. For a good selection of writings and links about anxiety, try tAPir (the Anxiety-Panic internet resource).
Impulse-control Disorder Not Otherwise Specified
I include this diagnosis simply because it is becoming a preferred diagnosis for self-injurers among some clinicians. This makes excellent sense when you consider that the defining criteria of any impulse-control disorder are (APA, 1995):
· Failure to resist an impulse, drive, or temptation to perform some act that is harmful to the person or others. There may or may not be conscious resistance to the impulse. The act may or may not be planned.
· An increasing sense of tension or [physiological or psychological] arousal before committing the act.
· An experience of either pleasure, gratification, or release at the time of committing the act. The act . . . is consistent with the immediate conscious wish of the individual. Immediately following the act there may or may not be genuine regret, self-reproach, or guilt.
This describes the cycle of self-injury for many of the people I've talked to.
Self-injury as itself a diagnosis
Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome. This would be an Axis I impulse-control syndrome (similar to OCD), not an Axis II personality disorder. Favazza (1996) pursues this idea further in Bodies Under Siege. Given that it often occurs without any apparent disease and sometimes persists after other symptoms of a particular psychological disorder have subsided, it makes sense to finally recognize that self-injury can and does become a disorder in its own right. Alderman (1997) also advocates recognizing self-inflicted violence as a disease rather than a symptom.
Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome. Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles: the abuser (the one who harms), the victim, and the non-protecting bystander. Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in concert with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping.

Therapeutic approaches
A group of activists and trainers in the U.K. is working on training A&E (emergency room) personnel on ways to make what is often the self-injurer's first contact with the medical system a productive encounter. This effort is spearheaded by nurses, former self-injurers, therapists, and others. Similar efforts in the US, Canada, and Australia would be worthwhile.
Overall considerations
In order to help those who self-injure, therapists must understand what role this powerful coping mechanism plays in their clients' lives. Is it primarily a means of releasing tension? Grounding? Communicating? Reliving painful experiences? Understanding why a particular person self-injures is key to helping that person stop using self-harm as a primary coping mechanism. "[H]aving [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive," warn Solomon and Farrand (1996); "techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress."
Therapists need to examine their own motives for wanting a client to cease or stabilize his/her self-injurious behavior. Too often, care providers focus on stopping the SI as quickly as possible because they themselves are not comfortable with it -- it repulses them, makes them feel ineffective, frightens them, etc. Situations like this can easily deteriorate into a power struggle in which the therapist insists that the behavior stop and the client chooses to self-injure covertly and becomes reticent and distrustful, thus reducing the chance that a useful therapeutic alliance will be formed.
On the other hand, it is legitimate for therapists to help clients devise some sort of plan for dealing with self-injurious impulses and getting their lives (including SIV) stabilized. When a client is engaging in uncontrolled self-injury, the SI and its concomitant crises take center stage in therapy, leaving no room for dealing with core issues. In order to have a minimum of stability in treatment, therapists must walk a fine line between attempting to repress/control all self-injurious behavior and allowing the SIV to dominate the therapy.
An ideal approach would be one in which SIV is tolerated but has specific consequences. For example, a client might be invited to contact the therapist when an urge to self-harm occurs, but restricted from contact for 24 hours after an actual self-injurious act. In a system like this, the self-injurer has a chance to articulate what she is trying to communicate through her body without having to resort to self-injury, and she knows that carrying through an act of SIV will have tangible and immediate (but not permanent) negative effects. This kind of agreement between therapist and client can help stabilize the SIV and clear the road for dealing with the issues underlying the need to injure, allowing the therapist to follow Kehrberg's advice to treat self-harm within the context of underlying pathology.
Therapists should ensure that self-injuring clients have access to non-judgmental, compassionate medical care for wounds they inflict on themselves (Dallam, 1997), care that does not rob them of their dignity or autonomy. Together, client and therapist can devise a plan for getting physical wounds treated without adding additional stress to the situation. This may involve educating physicians at local emergency rooms about the nature of SIV.
Since successful treatment of SIV depends heavily on teaching the client new ways of coping with stressors so that underlying painful material can be dealt with, hospitalization should be used only as a last resort when the client is at risk for suicide or severe self-injury (Dallam, 1997). Hospitals are artificially safe environments, and the necessary tasks of learning to identify the feelings behind the act and of choosing a less-destructive method of coping need to be practiced and reinforced in the real world.
Favazza (1998 ) advocates the use of high-dose SSRIs and mood stabilizers to get self-injury under control quickly, then suggests that care be managed under a team concept, with an overseeing psychiatrist who manages meds and coordinates care, a psychotherapist, and a group therapist. He also recommends that hospitalizations be kept brief.
Several SI units have been started in U.K. hospitals, however, where self-injury is tolerated and clients are encouraged to examine their behavior after an incident. The staff accept some SI as inevitable and try to use these occasions as ways to teach about coping without SI. In cases like these, longer hospitalization may have more value.
Approaches taken by those who see self-injury as associated with BPD
· Dialectical Behavioral Therapy
· Interpersonal Group Therapy
Approaches taken by those who see self-injury as non-BPD-related
· The CPTSD approach
· Healing from TRS
· Rational-Emotive Therapy

Psychopharmacological approaches

Individual psychotherapy and how to choose a good therapist

Where to go for professional help
Hypnosis and relaxation
Hypnotic relaxation techniques have apparently been used, with some success, as an adjunct to therapy. Malon and Berardi (1987) state that treating those who self-injure requires that the therapist realize the conflicting needs of the therapist to be in charge of the relationship and of the patient to be treated like an equal; if the patient's need for being seen as an equal isn't met, no progress can be made with or without hypnosis.
The study in question reports success with three types of hypnosis:
· Breath counting: the patient is led into a trance and instructed to notice her breathing, counting each deep slow breath.
· Positive imagery: the patient is put into a trance state and instructed to visualize herself in a calm, pleasant, relaxing place doing something she enjoys. This image is held for a while.
· Affect bridge: after trance is achieved, the patient is asked to use the current unpleasant feelings to remember other times in his life when he's felt this way. Memories that are too distressing to talk about in a normal state are sometimes speakable in a trance state.
It's important to note that in all of these techniques, the therapist must remain seated close to the patient, offering encouraging words and/or touches when appropriate. Malon and Berardi go so far as to say that "simple hypnotic techniques...offered the most immediate relief when delivered with a strong communicative focus and close here-and-now contact."
In a 1998 review, Hawton et al. evaluated the effectiveness of ten different approaches to treating self-harm: problem-solving therapy, a special emergency room card getting the patient faster treatment in the ER, intensive education and outreach, and dialectical behavior therapy were compared to standard aftercare; inpatient behavior therapy was compared to inpatient insight-oriented therapy; admission to the hospital was compared to discharge after the ER visit; flupenthixol (fluanxol, an anti-psychotic drug not available in the US with severe potential side-effects) and antidepressants were each compared to placebo; followup by the initial treating therapist was contrasted to followup by a different therapist; and long-term therapy was compared with short-term therapy.
They found no significant difference in % of repeaters who were in the long-term vs short-term therapy trials, the antidepressant vs placebo trials (which used mianserin, a drug that increases serotonin in the brain, and nomifensine, a dopaminergic drug that has serious side effects and is no longer available), the intensive intervention/outreach vs standard aftercare trials, the emergency card trials, and the hospital admission vs discharge trials and the (possibly too small to yield a significant effect) inpatient behavior vs insight-oriented therapy studies.
The problem solving studies showed a distinct reduction in SI among those who got problem-solving therapy, but the results of combined studies did not reach statistical significance. The flupenthixol study showed significant reduction in repeat self-harm, but it was a very small study and there is some concern that the possible side effects of fluanxol outweighed any benefit.
The two trials showing a significant decrease in repeat self-harm among the experimental group were the DBT studies (the DBT group has fewer repeaters) and the same vs different therapist doing followup (the % of repeaters was higher in the group that saw the same therapist).

Self-Help:
Organized and otherwise
This section contains a variety of ways that you can stop yourself from making that cut or burn or bruise right now.
Am I ready to stop?
How do I start stopping?
What to do RIGHT NOW instead of SI
What if I do all this and I still want to harm?
"Fake" pain -- Understanding the urge
DBT skills
More suggestions
BCSW
S.A.F.E.
First Aid
Dealing with intrusive thoughts after stopping
How do I know if I'm ready to stop?
Deciding to stop self-injury is a very personal decision. You may have to consider it for a long time before you decide that you're ready to commit to a life without scars and bruises. Don't be discouraged if you conclude the time isn't right for you to stop yet; you can still exert more control over your self-injury by choosing when and how much you harm yourself, by setting limits for your self-harm, and by taking responsibility for it. If you choose to do this, you should take care to remain safe when harming yourself: don't share cutting implements and know basic first aid for treating your injuries.
Alderman (1997) suggests this useful checklist of things to ask yourself before you begin walking away from self-harm. It isn't necessary that you be able to answer all of the questions "yes," but the more of these things you can set up for yourself, the easier it will be to stop hurting yourself.
While it is not necessary that you meet all of these criteria before stopping SIV, the more of these statements that are true for you before you decide to stop this behavior, the better.
· I have a solid emotional support system of friends, family, and/or professionals that I can use if I feel like hurting myself.
· There are at least two people in my life that I can call if I want to hurt myself.
· I feel at least somewhat comfortable talking about SIV with three different people.
· I have a list of at least ten things I can do instead of hurting myself.
· I have a place to go if I need to leave my house so as not to hurt myself.
· I feel confident that I could get rid of all the things that I might be likely to use to hurt myself.
· I have told at least two other people that I am going to stop hurting myself.
· I am willing to feel uncomfortable, scared, and frustrated.
· I feel confident that I can endure thinking about hurting myself without having to actually do so.
· I want to stop hurting myself.



Above all.....get help...you are not alone!

Edited by iwalkalone, 30 November 2006 - 06:14 PM.


#23 iwalkalone

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Posted 30 November 2006 - 06:16 PM

Help for families and friends
Now what? Perhaps someone you care about has honored you by trusting you with information about their self-injury, or maybe you've inadvertently discovered it. Regardless of how you found out, you know about it now, and you can't pretend it away -- you have to respond in some way. Here are some guidelines for dealing with SI in a friend or family member. You might also find it helpful to post to and read the family and friends section of the bus web board. Some good conversations happen there.
Don't take it personally.
Self-injurious behavior is more about the person who does it than about the people around him/her. The person you're concerned about is not cutting, burning, hitting, or whatever just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn't intended as one. People generally do not SI to be dramatic, to annoy others, or to make a point.
Educate yourself.
Get as much information as you can about self-injury in general. This page is a good start; there are also some very informative books out there (in particular, Bodies Under Siege by Favazza, The Scarred Soul by Alderman, and A Bright Red Scream by Strong). The Favazza book is more scholarly in tone, the Alderman book is oriented toward self-help, and Strong's book presents the voice of self-injurers talking about what they do and why -- it lets you inside the mind of people who SI. All contain much valuable information and advice.
Understand your feelings.
Be honest with yourself about how this self-injury makes you feel. Don't pretend to yourself that it's okay if it's not -- many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, find a good therapist. Be careful, though, that you not try to get "surrogate therapy" for your family member/friend -- what goes on in your therapy sessions should remain between you and your therapist. Don't ask your therapist to try to diagnose or treat the person you're concerned about, and if the self-injurer seeks treatment, be sure that s/he is seeing a different therapist than you are. Don't discuss the content of your therapy sessions in any but the most general terms, and never say anything like "My therapist says you should..." Therapy is a tool for self-understanding, not for getting others to change.
Be supportive without reinforcing the behavior.
It's important that your friend, lover, child, sibling know that you can separate who they are from what they do, and that you love them independently of whether they self-injure. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what's going on with the person.
Some good ways of showing support include:
· Don't avoid the subject of self-injury. Let it be known that you're willing to talk, and then follow the other person's lead. Tell the person that if you don't bring the subject up, it's because you're respecting their space, not because of aversion.
· Make the initial approach. "I know that sometimes you hurt yourself and I'd like to understand it. People do it for so many reasons; if you could help me understand yours, I'd be grateful." Don't push it after that; if the person says they'd rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you're willing to listen if they ever do want to talk about it.
· Be available. You can't be supportive of someone if you can't be reached.
· Set reasonable limits. "I cannot handle talking to you while you are actually cutting yourself because I care about you greatly and it hurts too much to see you doing that" is a reasonable statement, for example. "I will stop loving you if you cut yourself" isn't reasonable if your goal is to keep the relationship intact.
· Make it clear from your behavior that the person doesn't need to self-injure in order to get displays of love and caring from you. Be free with loving, caring gestures, even if they aren't returned always (or even often). Don't withdraw your love from the person. The way to avoid reinforcing SIV is to be consistently caring, so that taking care of the person after they injure is nothing special or extraordinary.
· Provide distractions if necessary. Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you care about is feeling depressed, you can sometimes help by bringing something pleasant and diverting into their lives. This doesn't mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it -- it's an attempt to break a negative cycle by injecting something positive. It could be as simple as bringing the person a flower. Don't expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)
· If you live apart from the person you're concerned about, offer physical safe space: "I'm worried about you; would you come sleep over at my house tonight?" Even if the offer is declined, just knowing it's there can be comforting.
· Don't ask "Is there anything I can do?" Find things that you can do and ask "Can I ?" People who feel really bad often can't think of anything that might make them feel better; asking if you can take them to a movie or wash those (month-old) dishes (if done nonjudgmentally) can be really helpful. Spontaneous acts of kindness ("I saw this flower at the store and knew you'd love to have it") work wonders.
Take care of yourself.
It sounds like hard work, and it is. And if you try to be completely supportive to someone else 24/7, you're going to burn out (and they won't have any incentive to change). You have to find ways to be sure your needs are being met.
Take a break from it when you need to. When setting limits, remember that as much as you love someone, sometimes you're going to need to get away from them for a while. Tell the person that sometimes you need to recharge and that it doesn't affect your love for him/her. Only break into this personal time in cases of absolute life-or-death crisis.
The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don't have to be about to die to get love and attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn't going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response.
Ultimatums do NOT work. Ever.
Loving someone who injures him/herself is an exercise in knowing your limitations. No matter how much you care about someone, you cannot force them to behave as you'd prefer them to. In nearly two years of running the bodies under siege mailing list, I have yet to hear of a single case in which an ultimatum worked. Sometimes SI is suppressed for a while, but when it inevitably surfaces it's often more destructive and intense than it had been before. Sometimes the behavior is just driven underground. One person I know responded to periodic strip searches by simply finding more and more hidden places to cut. Confiscating tools used for SIV is worse than useless -- it just encourages the person to be creative in finding implements. People have managed to cut themselves with plastic eating utensils.
Punishments just feed the cycle of self-hatred and unpleasantness that leads to SIV. Guilt-tripping does the same. Both of these are incredibly common and both make things infinitely worse. The major fallacy here is in believing that SIV is about you; it almost invariably isn't (except in the most casual ways).
Accept your limitations.
Acknowledge the pain of your loved one.
Accepting and acknowledging that someone is in pain doesn't make the pain go away, but it can make it more bearable. Let them know you understand that SIV isn't an attempt to be willful or to make life hard for you or to be unpleasant; acknowledge that it's caused by genuine pain they can find no other way to handle. Be hopeful about the possibility of learning other ways to cope with pain. If they're open to it, discuss possibilities for treatment with them.
Don't force things.
If you make overtures and they're rejected, back off for a few days or weeks. Don't push it. Some people need time to decide to trust someone else, particularly if they've received a lot of negative feedback about their SI before.



Be patient.


#24 Smooth T

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Posted 05 December 2006 - 03:30 AM

The text is not actually the easiest to understand, friend. Its pretty darn technical in quite a few places. That being said, its quite the eye-opener. Thanx for starting the thread and posting such extensive articles. :flowers:

#25 iwalkalone

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Posted 13 December 2006 - 07:51 PM

somebody posted this somewhere...is about cutting:

Cutting has been described to me by my therapist as a natural drug in that it released endorphins to the brain immediately following the cutting. However, in the long run, cutting can lead to more severe depression and also can cause permanent physical damage. Cutting sometimes is accompanied by head banging, burning, or other self-destructive behaviors.
Despite some of the close minded definitions, cutting is not done only by emo kids. Although some emo kids do cut, most of the characteristics of cutters are the same as those with eating disorders. Cutters tend to be perfectionists, and often are white, middle class teenage girls, although not all cutters come from this background.
Cutting often is a result of depression, and some view it as a way to release emotional pain when it feels like you would explode otherwise. Although many people think that those with depression have experienced huge tramas in their lives, this is not necessarily the case. Depression is a disease, just like diabetes is a disease. It can strike anyone, regardless of their gender, class, or social status. I personally am attending an ivyleague college next year, was captain of my soccer team in high school, could be considered among the popular kids at my school, and have an extremely loving family. I still have the scars from my cutting, which I stopped doing 2 months ago. Although i was lucky enough to be able to stop, other people such as my older sister, became addicted. Cutting is not something to mess around with. However ,it is naive to dismiss cutting as simply a way to get attention. It is also naive to scorn those who seem to have perfect lives as being stupid for cutting. People do not choose to be depressed.

"how can you be so depressed? You're so beautiful and so good at everything." - me crying to my to my sister in an ambulance after one of her major cutting episodes

"that doesnt matter tho. being pretty doesn't change wut mood i'm in," - my sister

"how can you be so depressed? You're so beautiful and so good at everything." - me crying to my to my sister in an ambulance after one of her major cutting episodes

"that doesnt matter tho. being pretty doesn't change wut mood i'm in," - my sister

Edited by iwalkalone, 13 December 2006 - 07:54 PM.


#26 CohenGal

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Posted 04 February 2007 - 02:07 AM

I have a question, and I have no idea if this is the place to ask it or not, so I apologize in advance if this doesn't belong in this thread.

Sometimes I think I might have Obsessive Compulsive Disorder. I have some weird tendencies. I spell out words in my head and I have to group the letters in groups of three. If something I spell in my head doesn't have a number of letters that is divisible by three, I add another word to make the total number of letters divisible by three. Does that make any sense to anyone? I know it sounds really weird.
Another thing I do is that I have to take an even number of steps on one type of surface. For example, if I'm walking on pavement and then step onto grass, I have to make sure that I've taken an even number of steps on the pavement first because if I haven't it means that one foot has taken more steps on the pavement than the other foot has and it feels uneven to me.

Does it sound like I might have OCD? Or am I just weird?

#27 necrotic_cerebrum

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Posted 07 March 2007 - 11:13 PM

hi. just wanna inform you guys that there's such a thing called DSM IV criteria. i suggest you look it up. it contains the diagnostic criteria for all psychiatric disorders. if you suspect that you or some1 you know has a certain psychiatric disease, you can confirm it using the dsmIV. now if the terminologies are too technical, i can help. peace.

#28 iwalkalone

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Posted 08 March 2007 - 12:19 AM

on DSM IV criteria uh-oh...andaming disorder...andami kong disorder! :unsure: :wacko: :cry:

Avoidant personality disorder
Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
Is unwilling to get involved with people unless certain of being liked
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
Is preoccupied with being criticized or rejected in social situations
Is inhibited in new interpersonal situations because of feelings of inadequacy
Views self as socially inept, personally unappealing, or inferior to others
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
Avoidant personality disorder is often confused with antisocial personality disorder; clinically the term 'anti-social' denotes sociopathy, not social inhibitions.

Symptoms
People with avoidant personality disorder are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these individuals will choose to be lonely rather than risk trying to connect with others.

Hypersensitivity to criticism or rejection
Self-imposed social isolation
Extreme shyness in social situations, though strongly desire close relationships
Avoid interpersonal relationships
Feelings of inadequacy
Low self-esteem
Mistrust of others
Extreme shyness/timidness
Emotional distancing related to intimacy
Highly self-conscious
Self-critical about their problems relating to others
Problems in occupational functioning
Lonely self-perception
Feeling inferior to others
Chronic substance abuse/dependence
Creation of a fantasy world

Panic disorder

Panic disorder sufferers usually have a series of intense episodes of extreme anxiety, known as panic attacks. These events may last from several minutes to hours, and may vary in intensity and specific symptoms of panic over the duration (i.e. rapid heartbeat, psychological experience of uncontrollable fear, etc.). Some individuals deal with these events on a regular basis—sometimes daily or weekly. The outward symptoms of a panic attack often cause negative social experiences (i.e. embarrassment, social stigma, ostracization, etc.). As a result, as many as 35% of all individuals with panic disorder also have agoraphobia

Agoraphobia
Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape.

Agoraphobics may experience severe panic attacks in situations where they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic may be confined not only to their home, but to one or two rooms, and they may even become bed-bound, or a recluse.

Agoraphobics are often extremely sensitized to their own bodily sensations, subconsciously over-reacting to perfectly normal events. For example, the exertion involved in climbing a flight of stairs may trigger a full-blown panic attack, because it increases the heartbeat and breathing rate, which the agoraphobic interprets as the start of a panic attack instead of a normal fluctuation
--may appear as fear of being in crowds or busy places or just being outside the home.Agoraphobia can also develop as panic attacks 'spread' from one situation to another. for example, a lady we once treated had her first attack on a crowded underground train when it got stuck in a tunnel. Her mother had just died and she was already highly stressed.

At a party the following week she had another attack. She was sitting on a sofa, surrounded by people; her unconscious mind decided that this was 'the same' as the underground (where she had been sitting surrounding by people) and triggered a second occurence. It's not too hard to see how this could continue to spread to other public transport and more public situations.


recluse

is someone in isolation who hides away from the attention of the public, a person who lives in solitude, i.e. seclusion from intercourse with the world. The word is from the Latin recludere, which means "shut up" or "sequester".

A person may become a recluse for many reasons: a celebrity may seek to escape the attentions of his or her fans; a misanthrope may be unable to tolerate human society; a survivalist may be practicing self-sufficiency. It can also be due to psychological problems - such as apathy, a phobia, or other anxiety disorders. [citation needed]

It should be noted that this practice may not be voluntarily as one may become a recluse due to illness. A person may also become a recluse for religious reasons, in which case he or she is usually referred to as a hermit or an anchorite. [citation needed]

Reclusiveness does not necessarily connote geographical isolation. A recluse may live in a crowded city, but infrequently leave the security of his or her home. However, isolated and sparsely populated states (e.g., Montana, Wyoming, and Alaska) and countries (e.g., New Zealand or Australia) often harbor recluses, who are often seeking complete escape from civilization

Borderline personality disorder (BPD)
a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking, or "splitting" (believing that something is one of only two possible things, and ignoring any possible "in-betweens"), and turbulent relationships. It can also be described by mental health professionals as a serious mental illness characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior, and a disturbance in the individual's sense of self.

The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life -- including employability and relationships in work, home and social settings.

Symptoms:
disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);
liability to become involved in intense and unstable relationships, often leading to emotional crisis;
excessive efforts to avoid abandonment;
recurrent threats or acts of self-harm;
chronic feelings of emptiness.


hay dyuskoh... :cry:

parang magkakamag anak lang ang mga disorder...pag meron ka pala ng isa...andami pang iba....hay....

Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Personality Disorder Not Otherwise Specified
Mental Retardation
Attention Deficit Disorder


Susme lahat ata to meron ako eh....pwede ba yung ganun?!? :wacko:

Edited by iwalkalone, 08 March 2007 - 11:42 AM.


#29 necrotic_cerebrum

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Posted 08 March 2007 - 10:10 PM

hehe. u sure u have fulfilled the criteria to have those psych diseases?
minsan kc nagiging subjective lng tayo na na-fufulfill natin ung criteria pag akala nating may ganung sakit nga tyo. if it really concerns you, try seeing a psychiatrist. i know a few psychs from ust if u want.

#30 iwalkalone

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Posted 09 March 2007 - 01:38 PM

hehe. u sure u have fulfilled the criteria to have those psych diseases?
minsan kc nagiging subjective lng tayo na na-fufulfill natin ung criteria pag akala nating may ganung sakit nga tyo. if it really concerns you, try seeing a psychiatrist. i know a few psychs from ust if u want.




uh...pwede po home service?...ayako lumabas ng bahay eh... :blink:

yung libre lang ha? :blink: hehe...may meryenda naman eh...coke tsaka marie :D


#31 THUG

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Posted 09 March 2007 - 02:20 PM

on DSM IV criteria uh-oh...andaming disorder...andami kong disorder! :unsure: :wacko: :cry:

Avoidant personality disorder
Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
Is unwilling to get involved with people unless certain of being liked
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
Is preoccupied with being criticized or rejected in social situations
Is inhibited in new interpersonal situations because of feelings of inadequacy
Views self as socially inept, personally unappealing, or inferior to others
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
Avoidant personality disorder is often confused with antisocial personality disorder; clinically the term 'anti-social' denotes sociopathy, not social inhibitions.

Symptoms
People with avoidant personality disorder are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these individuals will choose to be lonely rather than risk trying to connect with others.

Hypersensitivity to criticism or rejection
Self-imposed social isolation
Extreme shyness in social situations, though strongly desire close relationships
Avoid interpersonal relationships
Feelings of inadequacy
Low self-esteem
Mistrust of others
Extreme shyness/timidness
Emotional distancing related to intimacy
Highly self-conscious
Self-critical about their problems relating to others
Problems in occupational functioning
Lonely self-perception
Feeling inferior to others
Chronic substance abuse/dependence
Creation of a fantasy world

Panic disorder

Panic disorder sufferers usually have a series of intense episodes of extreme anxiety, known as panic attacks. These events may last from several minutes to hours, and may vary in intensity and specific symptoms of panic over the duration (i.e. rapid heartbeat, psychological experience of uncontrollable fear, etc.). Some individuals deal with these events on a regular basis—sometimes daily or weekly. The outward symptoms of a panic attack often cause negative social experiences (i.e. embarrassment, social stigma, ostracization, etc.). As a result, as many as 35% of all individuals with panic disorder also have agoraphobia

Agoraphobia
Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape.

Agoraphobics may experience severe panic attacks in situations where they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic may be confined not only to their home, but to one or two rooms, and they may even become bed-bound, or a recluse.

Agoraphobics are often extremely sensitized to their own bodily sensations, subconsciously over-reacting to perfectly normal events. For example, the exertion involved in climbing a flight of stairs may trigger a full-blown panic attack, because it increases the heartbeat and breathing rate, which the agoraphobic interprets as the start of a panic attack instead of a normal fluctuation
--may appear as fear of being in crowds or busy places or just being outside the home.Agoraphobia can also develop as panic attacks 'spread' from one situation to another. for example, a lady we once treated had her first attack on a crowded underground train when it got stuck in a tunnel. Her mother had just died and she was already highly stressed.

At a party the following week she had another attack. She was sitting on a sofa, surrounded by people; her unconscious mind decided that this was 'the same' as the underground (where she had been sitting surrounding by people) and triggered a second occurence. It's not too hard to see how this could continue to spread to other public transport and more public situations.
recluse

is someone in isolation who hides away from the attention of the public, a person who lives in solitude, i.e. seclusion from intercourse with the world. The word is from the Latin recludere, which means "shut up" or "sequester".

A person may become a recluse for many reasons: a celebrity may seek to escape the attentions of his or her fans; a misanthrope may be unable to tolerate human society; a survivalist may be practicing self-sufficiency. It can also be due to psychological problems - such as apathy, a phobia, or other anxiety disorders. [citation needed]

It should be noted that this practice may not be voluntarily as one may become a recluse due to illness. A person may also become a recluse for religious reasons, in which case he or she is usually referred to as a hermit or an anchorite. [citation needed]

Reclusiveness does not necessarily connote geographical isolation. A recluse may live in a crowded city, but infrequently leave the security of his or her home. However, isolated and sparsely populated states (e.g., Montana, Wyoming, and Alaska) and countries (e.g., New Zealand or Australia) often harbor recluses, who are often seeking complete escape from civilization

Borderline personality disorder (BPD)
a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking, or "splitting" (believing that something is one of only two possible things, and ignoring any possible "in-betweens"), and turbulent relationships. It can also be described by mental health professionals as a serious mental illness characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior, and a disturbance in the individual's sense of self.

The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life -- including employability and relationships in work, home and social settings.

Symptoms:
disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);
liability to become involved in intense and unstable relationships, often leading to emotional crisis;
excessive efforts to avoid abandonment;
recurrent threats or acts of self-harm;
chronic feelings of emptiness.
hay dyuskoh... :cry:

parang magkakamag anak lang ang mga disorder...pag meron ka pala ng isa...andami pang iba....hay....

Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Personality Disorder Not Otherwise Specified
Mental Retardation
Attention Deficit Disorder
Susme lahat ata to meron ako eh....pwede ba yung ganun?!? :wacko:



the fact that you think you have it, would probably meant otherwise..

people who have psychological problems do not normally believe they have it..

#32 lomex32

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Posted 09 March 2007 - 02:28 PM

THUG do you belive you have it? :cool:

Peace Bro ...

Indeed they DENY having such

the fact that you think you have it, would probably meant otherwise..

people who have psychological problems do not normally believe they have it..



#33 koopahl

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Posted 09 March 2007 - 04:15 PM

there was a time i was diagnosed a schizophrenic...had dual personalities..."get away here you dumb bastard"...no, i'm the one here..."no you stupid f#&k, leave me alone"...wait, wait, i'm the one talking you get off me..."i'll k*ll you!"...you try it...(squeezing my neck, err...that damn bastard's neck!)...:lol:

seriously, i have OCD...

#34 THUG

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Posted 09 March 2007 - 04:33 PM

THUG do you belive you have it? :cool:

Peace Bro ...

Indeed they DENY having such


i actually believe i have all of it..hahaha! :D

#35 iwalkalone

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Posted 09 March 2007 - 04:42 PM

the fact that you think you have it, would probably meant otherwise..

people who have psychological problems do not normally believe they have it..



THUG do you belive you have it? :cool:

Peace Bro ...

Indeed they DENY having such


siguro yun yung mga malala na talaga...but as in my case...
...i dunno...there really must something wrong w/ me...i actually experience/ still experiencing those symptoms... and yes i'm completely aware...and it worries me alot...promise...i'm not making things up...would you be cutting yourself every now and then if you were normal???
would you?....and the rest of the other symptoms....mangyayari ba lahat sayo yun kung walang problema sa sarili mo??? talaga???....s@%t pasensya na...nag papalibre lang talaga ako sa consultation :P ...la akong pambayad sa shrink eh...haha :D ...tsaka...yun nga...ayoko lumabas ng bahay....( and this one...lumalala na talaga sya...i swear!)


there was a time i was diagnosed a schizophrenic...had dual personalities..."get away here you dumb bastard"...no, i'm the one here..."no you stupid f#&k, leave me alone"...wait, wait, i'm the one talking you get off me..."i'll k*ll you!"...you try it...(squeezing my neck, err...that damn bastard's neck!)...:lol:

seriously, i have OCD...

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#36 amoral89

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Posted 09 March 2007 - 04:47 PM

hi, sana eto yung tamang thread, balak ko sanang bumili ng anti-depressant.. tumingin ako sa internet nakita ko prozac 20. pwede ba akong bumili sa botika nun na walang prescription? Meron ba sa inyong naka-try na nun?

#37 iwalkalone

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Posted 09 March 2007 - 04:57 PM

Hello Kara,
I've been away for awhile and it has been some time since you posted anything on this topic. I hope that you have seen the silver lining around the clouds that surrounded your circumstances.

Nice avatar by the way.....artsy


no i'm not ok and i've gotten worse ...thank you. :(

hi, sana eto yung tamang thread, balak ko sanang bumili ng anti-depressant.. tumingin ako sa internet nakita ko prozac 20. pwede ba akong bumili sa botika nun na walang prescription? Meron ba sa inyong naka-try na nun?


kala ko wala sa pilipinas na ganyan...i'm sure kailangan nyan ng prescription....i think :unsure:


#38 necrotic_cerebrum

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Posted 10 March 2007 - 04:21 PM

uh...pwede po home service?...ayako lumabas ng bahay eh... :blink:

yung libre lang ha? :blink: hehe...may meryenda naman eh...coke tsaka marie :D


cge. :hypocritesmiley:

#39 necrotic_cerebrum

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Posted 10 March 2007 - 04:25 PM

THUG do you belive you have it? :cool:

Peace Bro ...

Indeed they DENY having such


thats true.. but there some psychiatric disorders wherein patients actually recognize they have "it" and tend to seek consultation themselves. :)

#40 iwalkalone

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Posted 10 March 2007 - 04:57 PM

cge. :hypocritesmiley:




:boo: Ows?!? di nga???!!! :blink:




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