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By Gary Rich, MD
Self-harm behavior is perhaps one of the most problematic occurrences
in mental health. For a person to deliberately cut into his or her skin
and cause bleeding goes against some of our most primitive instincts
of self protection and self preservation. From the time we are children,
we learn to avoid pain and self injury. Deliberate, willful self harm
crosses a line that is commonly intuitive, and that most of us come to
take for granted. As a result, we typically react to the behavior with
shock, and the sense that something is definitely amiss.
Still deliberate self harm, along with suicidal behavior, can be thought
of as an entity with its place at one end of a spectrum of thought and
behavior. In general, it is not favorable to the self. On the other end
of that spectrum is self doubt and lack of self confidence. In the middle
is a self-critical and self-berating mindset, unnecessary risky behaviors
(such as reckless driving and sexual promiscuity), substance abuse, and
eating disorder behavior (such as bingeing and purging, and laxative
abuse).
One reason self-harm behavior is counterintuitive in the treatment setting
is because those going into health care typically have a motivation to
help victims of disease. In the case of an individual who engages in
self-harm behavior, there is the presence of an “aggressor” behavior
in the person who is primarily understood to be the victim. Therein lies
the challenge of treatment.
Self-harm behavior itself does not constitute a specific diagnosis in
the standard manual of psychiatric diagnoses (DSM-IV). However, the diagnosis
of Borderline Personality Disorder (BPD) does have intentional, nonfatal,
self-injurious behavior as a criterion of the diagnosis, and, in fact,
is the only diagnosis that does. These self- harm behaviors are considered
a “hallmark” of BPD. Rates of these self- harm behaviors
in patients diagnosed with BPD range from 69 to 80 percent.
BORDERLINE PERSONALITY DISORDER
Borderline Personality Disorder is an Axis II personality disorder characterized
by a pervasive inability to regulate emotions, especially emotions
associated with anger and loneliness. It is also characterized by an
inability to adequately control behaviors linked to these emotions.
The intensity and the inherent conflictual nature of these emotions
are depicted in the title of a book on BPD, I Hate You,
Don’t
Leave Me, by Jerold Kreisman, MD, and Hal Straus.
The serious nature of BPD emphasizes the importance of treating individuals
with the illness as effectively as possible. Suicide is among the top
ten causes of death in the United States and in the world. Suicidal behaviors
are very common among individuals with BPD. Rate of suicide among all
individuals meeting criteria is 5 to 10 percent. The rate increases to
double that when only those with a history of self-harm behavior and
nonfatal suicide attempts are included. Individuals with BPD are also
high users of mental health services. They are reported to make up 14
to 20 percent of an inpatient population at any one time and commonly
require repeated hospital admissions. Not uncommonly, individuals with
BPD will engage in self-harm behaviors while in the hospital setting,
again reflecting the paradoxical nature of the illness.
USE OF MEDICATION
Though treatment with medication cannot be expected to control self-
harm behavior specifically, it can be helpful overall to improve symptoms
associated with the behavior. In this way, medications serve in a supportive
role toward the goal of decreasing the self-harm behavior, thereby
better protecting the patient. Symptoms associated with self-harm behavior
(and concurrently BPD) can be divided into three groups.
I. Impulsivity and Aggressive Symptoms
A tendency to act before thinking things through and an angry, aggressive
frame of mind can both directly increase the risk of self-harm behavior.
II.
Affective Symptoms
The term “affective” is synonymous with mood. Symptoms such
as mood swings, depressed mood, anxiety and panic states can destabilize
one’s emotional state and increase the risk of self-harm behavior.
III.
Psychotic Symptoms
Psychotic symptoms result in perceptual distortion of reality. Auditory
hallucinations (hearing voices) and paranoid states can also be associated
with self-harm behavior. When auditory hallucinations take the form
of “command
hallucinations,” meaning the individual is hearing voices telling
him or her what to do, there is the risk of the voices telling the
person to harm him- or herself, and subsequently, self-harm behavior
occurs.
Medications can target the symptoms of each of these categories. Both “mood
stabilizers” and antidepressant medications have been shown to
have some effectiveness in decreasing impulsivity and aggression. Sertaline
(Zoloft®) and fluoxetine (Prozac®), both SSRI (selective serotonin
reuptake inhibitor) antidepressants, have specifically been shown to
be effective. Other SSRIs, including paroxetine (Paxil®), citalpram
(Celexa®), escitalopram (Lexapro®), and fluvoxamine (Luvox®),
are shown to be similarly effective. Tranylcypromine (Parnate®) and
phenelzine (Nardil®), both MAOI (monoamine oxidase inhibitor) antidepressants,
have also been shown to have some effectiveness. MAOIs do require patients
to restrict their diet to avoid foods containing tyramine.
Carbamazapine (Tegretol®), valproic acid (Depakote®), and lamotrigine
(Lamictal®) are “mood stabilizers” and have also been
found to decrease impulsivity and aggression. These medications are also
used to treat seizures. Carbamazapine and valproic acid do require lab
work from time to time to check the blood level of the medication as
well as monitor any adverse effects on the liver or blood cells. Lamotrigine
needs to be started at a low dose initially to decrease the chance of
causing a potentially serious rash that is rarely associated with the
drug.
It should be noted that antianxiety medication, such as diazepam (Valium®),
alprazolam (Xanax®), lorazepam (Ativan®), and clonazepam (Klonopin®)
have been shown at times to cause disinhibition, which may worsen impulsivity.
However, the benefits from their ability to decrease anxiety may possibly
outweigh this negative effect. These medications have the potential for
misuse and abuse due to their addictive traits.
Affective symptoms are targeted for treatment, as well. SSRIs effectively
treat depressive symptoms as well as panic attacks and other anxiety
symptoms. MAOIs and other antidepressants such as venlafaxine (Effexor®),
trazodone (Desyrel®), mirtazapine (Remeron®), bupropion (Wellbutrin®),
and tricyclic antidepressants also effectively treat depression and anxiety.
Mood stabilizers including lithium, valproic acid, carbamazapine, lamortigine,
topiramate (Topamax®), and oxcarbamazapine (Trileptal®) can decrease
mood swings and stabilize other symptoms of Bipolar Disorder.
Another category of medications is the atypical (or newer) antipsychotic
medications. Olanzapine (Zyprexa®), risperidone (Risperdal®),
quetiapine (Seroquel®), clozapine (Clozaril®), ziprasidone (Geodon®),
and aripiprazole (Abilify®) all have mood stabilizing properties
in addition to their antipsychotic properties.
Psychotic symptoms are treated with the aforementioned atypical antipsychotics
as well as the older antipsychotics, such as haloperidol and fluphenazine.
The more favorable side effect profiles of the atypical antipsychotics
make them, in general, the preferred medications.
The presence of the “aggressor” nature in individuals who
engage in self-harm behaviors needs to be considered when using medications
in treatment. Medication noncompliance tends to be very high in persons
with BPD. Misuse of medications is common and problematic. Upwards of
50 percent of patients and 87 percent of therapists have reported medication
misuse, the most problematic being overdose as a method of attempting
suicide. The potential lethality of medications should, therefore, be
considered. The relative lethality of an overdose with older tricyclic
antidepressants, and the relative proximity of the therapeutic blood
level to the toxic blood level of lithium make both of these types of
medications less than ideal.
THE NATURE OF BEHAVIOR
Inherent in the challenge of treatment for self-harm behavior is the
nature of behavior itself. As opposed to mood and thought symptoms,
behavior involves the complexity of an organized, volitional, motor
event. Because of this complexity, medications do not treat behavioral
symptoms as specifically or completely as, for example, anti-depressant
medications that treat a depressed mood or antipsychotic medications
that treat auditory hal-lucinations. This challenge is also seen in
treating substance abuse disorders and eating disorders, where specific
behaviors present primary problems in the illness. This is why it is
very important to utilize individual psychotherapy and group therapy,
in addition to consideration of psychiatric medications, in treating
people with these disorders. Dialectical Behavior Therapy (DBT) is
a treatment approach that takes into account the complexity of behavior
and has been shown to be successful.
Behavior occurs within a framework that can be divided into three aspects
(the ABCs of behavior). “A” stands for antecedents, referring
to the events, including mental events, that precede a particular behavior. “B” stands
for the behavior itself. “C” stands for the consequences
of the behavior that follow it.
Distress associated with feelings of loneliness or abandonment, and
anxiety associated with being at a loss to know what to do with unexpressed
anger, are examples of possible antecedents to self-harm behavior. Fantasies
about the possible outcomes of self harm, such as, “finally someone
will understand and attend to my emotional needs and I will no longer
be neglected” or “finally someone will know the extent of
my emotional pain” are also possible antecendents. The actual consequences
of the behavior, however, may be quite different than what was fantasized.
Understanding some of these aspects of behavior is often where therapy
starts.
HYPOTHETICAL EXAMPLE
Marsha M. Linehan, the originator of DBT treatment, talks about “emotional
vulnerability” and “invalidating environments” when
describing the backgrounds of persons with BPD. She states that the high
incidence of childhood sexual abuse within this population suggests sexual
abuse may be the prototypical invalidating experience for children.
We can hypothesize the origins of self destructiveness. A child is sexually
violated during childhood. Following the violation, there is a sense
that something wrong has occurred. The child then attempts to get help
in understanding what has happened and tries to tell a parent about it.
The parent is too preoccupied with other matters or too ignorant of sexual
abuse to address the child with an appropriate response. Inadequate attention
is paid to the matter. There is no discussion of the perpetrator being
wrong, no acknowledgement there was a failure to protect the child, and
no sense the child was psychologically injured. Without support from
an adult, the child takes on the blame for the event, and eventually
carries the guilt, shame, and anger within him- or herself. A negative
view of self is generated. Failure and disappointment in relationships
generates sensitivity to rejection and abandonment. In some cases, the
severity of the trauma and the vulnerability of the victim combine to
cause a break from reality in the form of psychotic symptoms and/or in
the form of dissociative symptoms, such as detachment from awareness
of one’s environment or awareness of one’s own personality.
Suicidal thoughts are frequent. In a desperate attempt to cope with the
problems in their life and their ongoing emotional pain, they find some
relief in self cutting. While it may not solve their problems, at least
it is better than dealing with their emotional injury completely by themselves.
The complexity of this hypothetical example illustrates the need to
use all tools available in the treatment of these illnesses. Achieving
a sense of balance in treatment likely leads to the best chance for the
patient to begin to heal from his or her emotional injuries.
RESOURCES
Borderline Personality Disorder: A Clinical Guide by John Gunderson (American
Psychiatric Association, 2001)
Stop Walking on Eggshells: Coping When Someone You Care About Has Borderline
Personality Disorder by Paul T. Mason and Randi Kreger (New Harbinger
Publications, Inc., Oakland, CA, 1998)
I Hate You, Don’t Leave Me by Jerold Kreisman, MD, and Hal Straus
(Avon Books, New York, 1989)
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