Following are some academic references on self-injury. These are far more
clinical than the rest of the resources that will appear on this page when it
is through. But if you are wondering what the psychiatrists are saying about
self-injury these days, these journal articles reveal a lot. This list is just
a small sampling; more references can be obtained from the National
Library of Medicine’s website. I omitted articles dealing with self-injury
in the mentally disabled, focusing instead on self-injury in the general population.
Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm:
The experiential avoidance model. Behav Res Ther 2006;44:371-94.
Despite increasing attention to the phenomenon of deliberate self-harm (DSH),
the literature currently lacks a unifying, evidence-based, theoretical framework
within which to understand the factors that control this behavior. The purpose
of the present paper is to outline such a framework-the Experiential Avoidance
Model (EAM) of DSH. The EAM poses that DSH is primarily maintained by negative
reinforcement in the form of escape from, or avoidance of, unwanted emotional
experiences. Literature on factors that may lead to experiential avoidance is
reviewed, along with the mounting empirical evidence that DSH functions to help
the individual escape from unwanted emotional experiences. The EAM integrates
a variety of research on emotions, experiential avoidance, and DSH within a
clinically useful framework that sparks novel research directions.
Lovell A. Daniel’s story: self-injury and the case study as method. Br J
Nurs 2006 Feb 9-22;15:166-70.
This article explores the value of case study methodology as a means of investigating
the relationship between people with learning disabilities and self-injury.
One life story might appear to be of limited value in this regard; however,
it is argued that it might not only be of use in demonstrating the development
of an isolated self-injuring career, but there may also be insights into its
entrenchment in the lives of others. The telling of one story might serve as
a filter, through which the interventions of medication, mechanical restraint
and behaviourism can be observed over time. Furthermore, studying one life in
some detail might be used to illustrate broader concerns about the context of
the transition from institutional to community care. The restrictions of such
an approach are acknowledged, particularly in the telling of a story where the
main character’s words cannot be heard, but maybe that is also the point of
undertaking research about those at the margins of society.
Csorba J, Szelesne EF, Steiner P, et al. [Symptom specificity of adolescents
with self-injurious actions.] Psychiatr Hung 2005;20:456-462. [Article in Hungarian]
As an introductory part of the paper, authors give a short overview of existing
results in te literature related to self-injurious behaviour and adolescents’
deliberate self-harm. In their own random sample study, authors organized a
self-report screen (provincial town, 3 educational facilities, 470 pupils aged
between 14 and 18 years) by means of the translated version of Ottawa Self Injury
Inventory (OSI) used widely in community-based studies in Canada. The Beck Depression
Inventory was introduced to measure the key symptoms of depression among youngsters.
26 youngsters were found to have had at least one self-injurious action in their
life-time. The authors describe the characteristics of these subjects on the
basis of symptom occurrence statistics. Although the depressive symptoms have
an expected correlation with the self-injurious ideas, depression does not seem
to have the same relationships with the actual self-harm action. The authors
attempt to give an explanation of this contradiction.
Woldorf GM. Clinical implications of the paradox of deliberate self-injury.
J Spec Pediatr Nurs 2005;10:196-200. No abstract available.
Reece J. The language of cutting: Initial reflections on a study of the
experiences of self-injury in a group of women and nurses. Issues Ment Health
Nurs 2005;26:561-74.
Non-suicidal self-injury is a distressing act, which can arouse dissent and
negative comment in service users and providers. The purpose of the study was
to describe how women who self-injure and nurses assign meaning to shared discourses
about self-injury. The wider study is framed in a grounded theory methodology.
Fourteen qualified nurses and 11 women who have self-injured were interviewed
using unstructured and initially open-ended interviews, lasting 45-90 minutes.
Initially a thematic analysis was used to code data. In this report, three of
the early themes are reported with some comparative interpretations. Nurses
lack understanding of the meanings of cutting behaviour. A common language is
needed if nurses are to be effective in helping women who have self-injured
to express distress in less damaging ways.
Muehlenkamp JJ. Self-injurious behavior as a separate clinical syndrome.
Am J Orthopsychiatry 2005;75:324-33.
The field of clinical psychology may benefit from adopting a deliberate self-injury
syndrome as a distinct disorder for representation in the Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association,
2000). The phenomenological and empirical data supporting a deliberate self-injury
syndrome are reviewed, and arguments for and against the adoption of a distinct
syndrome are explored.
Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the
assessment of people attending hospital following self-poisoning or self-injury.
Br J Psychiatry. 2005;186:60-6.
BACKGROUND: Self-harm is associated with a high risk of suicide. It is unclear
whether suicidal intent at the time of self-harm is a risk factor for future
suicidal behaviour. AIMS: To investigate the relationship between suicidal intent
and patient characteristics, repetition of self-harm, and suicide. METHOD: Clinical
and demographic data on 4415 patients presenting to hospital following self-harm
between 1993 and 2000 were analysed. Suicidal intent was measured using the
Beck Suicide Intent Scale (SIS). Follow-up information on repetition of self-harm
and suicide was investigated for 2489 patients presenting between 1993 and 1997.
RESULTS: Suicidal intent at the time of self-harm was associated with risk of
subsequent suicide, especially within the first year and among female patients.
Suicide was more strongly associated with scores on the circumstances section
of the SIS than the self-report section. The association between repetition
of self-harm and SIS scores was different for male and female patients. CONCLUSIONS:
The measurement of suicidal intent in the assessment of self-harm patients is
beneficial for the evaluation of future suicide risk. A shortened measuring
scale might be useful in clinical practice.
Rashid A, Brennen MD. Psychiatric assessment of patients with self-inflicted
lacerations to the wrist and forearm admitted to a nonpsychiatric ward: The
experience of a regional plastic surgery unit. Br J Plast Surg 2005.
In 1984, the Department of Health (DoH) recommended that all patients with deliberate
self-harm (DSH) must have a mental assessment before discharge. DSH patients,
especially those with lacerations to wrist and forearm, are a regular source
of admission to plastic surgery units. In Northern Ireland, the regional plastic
surgery service is provided at the Ulster Hospital, which does not have an on-site
psychiatric department. Consequently, it was often difficult to arrange a psychiatrist
assessment for these patients on the ward even when the assessment was required
urgently. The objective of this study was to develop and validate a protocol
that would ensure that these patients were assessed and followed up for their
mental health as recommended by the DoH. In the absence of clear guidelines
from the DoH and utilising the existing arrangement between Accident and Emergency
(A&E) and the psychiatric services, all referring A&E departments were
instructed at the time of referring patients with DSH to wrist and forearm to
arrange a psychiatric examination before transferring the patient to the plastic
surgery unit. Data were collected retrospectively (August 2002-October 2002)
and prospectively (November 2002-October 2003) and comprised demographic features,
previous history of self-harm, conduct of the patient in A&E and the ward,
length of stay in the hospital and various aspects of psychiatric assessment
and follow-up. In total, 42 referrals were made during the period studied. The
average age was 28 years with a male to female ratio of 2:1. The average hospital
stay was two days. Despite difficulties, our practice was found effective in
ensuring psychiatry assessment and follow-up without risking the patient’s physical
health. The study also highlighted the need for collaboration between plastic
surgeons and psychiatrists to improve services in regards to DSH patients.
Adams J, Rodham K, Gavin J. Investigating the self in deliberate self-harm.
Qual Health Res 2005;15:1293-309.
In this study, the authors explored how a group of young people aged 16 to 26
years (who identified themselves as having engaged in deliberate self-harm)
made sense of the self by conducting two online focus groups and four e-mail
interviews. They analyzed data using interpretive phenomenological analysis.
The concept of validation was the primary means of making sense of the self
and concerned the desire to be considered legitimate and of worth. This desire
was clearly evident across three realms of conflict: (a) the intrinsic or extrinsic
self, which marked the distinction between objective fact and subjective opinion;
(b) the accepted or denied self; and (c) the notion of normality. It is possible
that having one’s denied self validated online might lead to an exacerbation
of an individual’s self-harming behavior. Further work is needed to explore
the effects of online discussion forums on such taboo forms of behavior.
Lamprecht HC, Pakrasi S, Gash A, Swann AG. Deliberate self-harm in older
people revisited. Int J Geriatr Psychiatry 2005;20:1090-6.
BACKGROUND: Deliberate self harm (DSH) in later life is under researched
and is believed to be related to both mental illness and suicide. AIMS: The
aim of the study was to examine deliberate self-harm (DSH) in older people presenting
to acute hospital services over three years. METHOD: This was a retrospective
observational study. We reviewed 97 episodes of DSH involving 82 patients aged
65 and over referred to the Liaison Psychiatric Service of the Tees and North
East Yorkshire NHS Trust South Locality from 2000 to 2002. RESULTS: There was
a year on year increase in the number of older people presenting with DSH, especially
in men. Twenty-one percent of older men had no discernible psychiatric diagnosis.
There were a small number of people who repeated DSH within a year and males
were as likely to be repeaters as females. Twenty-three percent of all patients
saw a General Practitioner (GP) in the 7 days before the episode of DSH and
this increased to 58% in the 4 weeks preceding the episode of DSH. More males
(56%) than females (26%) who presented with DSH were married. The most common
method of DSH (93%) was medication overdose of which 66% used prescribed medication.
There was no difference in the methods used to self-harm between men or women.
CONCLUSION: DSH in the elderly may start to mirror some of the characteristics
seen in younger adults with DSH. While the numbers of DSH per year are small
among the elderly compared to younger adults, the observations suggest an increase
in DSH in men. Marriage may no longer be a protective factor in prevention of
DSH among older men. Longer-term observational studies of DSH in older people
are required to confirm these changing patterns. GPs may have an important role
to play in prevention of DSH in later life.
Haavisto A, Sourander A, Multimaki P, et al. Factors associated with ideation
and acts of deliberate self-harm among 18-year-old boys. A prospective 10-year
follow-up study. Soc Psychiatry Psychiatr Epidemiol 2005;40:912-21.
BACKGROUND: The aims of the study were: (1) to identify the prevalence of
ideation and acts of deliberate self-harm in 18-year-old boys; (2) to report
the use of mental health services among these boys; (3) to identify risk factors
assessed at age 8 and (4) to identify associated cross-sectional factors at
age 18 of self-reported ideation and acts of deliberate self-harm. METHODS:
The participants in this community-based 10-year follow-up study consisted of
2,348 boys born during 1981. At baseline, three informant sources were used:
parents, teachers and the children themselves. The questionnaires used were
the Rutter Parents Scale, the Rutter Teacher Scale and the Children’s Depressive
Inventory. At follow-up, boys' psychopathology, adaptive functioning and substance
use were studied using the Young Adult Self-Report questionnaire. Further questions
about demographic factors and life events were added at both stages. RESULTS:
The prevalence of ideation of deliberate self-harm was 4.0%, and of acts 2.2%,
during the preceding 6 months. Of the subjects who reported ideation, 9.7%,
and of those who reported acts, 16.0%, had used mental health services during
the previous year. Self-reported depressive symptoms at age 8 predicted ideation
and acts of deliberate self-harm 10 years later. Suicidal boys’ problems in
many life areas were linked with suicidal tendency through psychiatric symptoms,
especially anxious/depressed symptoms and aggressive behaviour. CONCLUSIONS:
The connection between self-reported depressive symptoms at age 8 and ideation
and acts of deliberate self-harm at age 18 is a good reason to already pay special
attention to children’s own intimations of distress in elementary school. It
is likely that an effective way to prevent suicidality among adolescents is
to search for and treat psychiatric problems among young people. Self-reported
screening questionnaires used, e.g. in school healthcare, may provide an opportunity
to recognize these problems.
Skegg K. Self-harm. Lancet. 2005;366:1471-83.
The term self-harm is commonly used to describe a wide range of behaviours and
intentions including attempted hanging, impulsive self-poisoning, and superficial
cutting in response to intolerable tension. As with suicide, rates of self-harm
vary greatly between countries. 5-9% of adolescents in western countries report
having self-harmed within the previous year. Risk factors include socioeconomic
disadvantage, and psychiatric illness--particularly depression, substance abuse,
and anxiety disorders. Cultural aspects of some societies may protect against
suicide and self-harm and explain some of the international variation in rates
of these events. Risk of repetition of self-harm and of later suicide is high.
More than 5% of people who have been seen at a hospital after self-harm will
have committed suicide within 9 years. Assessment after self-harm includes careful
consideration of the patient’s intent and beliefs about the lethality of the
method used. Strong suicidal intent, high lethality, precautions against being
discovered, and psychiatric illness are indicators of high suicide risk. Management
after self-harm includes forming a trusting relationship with the patient, jointly
identifying problems, ensuring support is available in a crisis, and treating
psychiatric illness vigorously. Family and friends may also provide support.
Large-scale studies of treatments for specific subgroups of people who self-harm
might help to identify more effective treatments than are currently available.
Although risk factors for self-harm are well established, aspects that protect
people from engaging in self-harm need to be further explored.
Parker G, Malhi G, Mitchell P, et al. Self-harming in depressed patients:
Pattern analysis. Aust N Z J Psychiatry 2005;39:899-906.
OBJECTIVE: As deliberate self-harm (DSH) is a common concomitant of depressive
disorders, we undertook a study examining the relevance of possible determinants
and correlates of DSH. METHOD: Three separate samples of depressed outpatients
were studied to determine consistency of identified factors across samples,
with principal analyses involving gender, age and diagnosis-matched DSH and
non-DSH subjects. RESULTS: Across the samples, some 20% of subjects admitted
to episodes of DSH. Women reported higher rates and there was a consistent trend
for higher rates in bipolar patients. Univariate analyses examined the relevance
of several sociodemographic variables, illicit drug and alcohol use, past deprivational
and abusive experiences, past suicidal attempts and disordered personality functioning.
Multivariate analyses consistently identified previous suicide attempts and
high acting out behaviours across the three samples, suggesting the relevance
of an externalizing response to stress and poor impulse control. CONCLUSIONS:
Results assist the identification and management of depressed patients who are
at greater risk of DSH behaviours.
Konradsen F, Hoek W, Peiris P. Reaching for the bottle of pesticide—A cry
for help. Self-inflicted poisonings in Sri Lanka. Soc Sci Med 2006;62:1710-9.
This long-term study in Sri Lanka explored the complexities behind self-inflicted
pesticide poisonings by 166 Sri Lankans. Using or threatening to use pesticides
for self-harm has become a response to stressful events and a powerful message
towards a specific individual, or to the outside world in general, conveying
misgiving, anger, sadness, hopelessness, frustration, or simply a way to manipulate
a situation to one’s own advantage. The effects of alcohol misuse are especially
important in understanding self-harm at the community level in terms of the
impact they have on the domestic environment. Also, issues around "love
affairs," arranged marriages and domestic physical, sexual or psychological
abuse in the domestic environment are referred to by many self-harmers or their
relatives as a reason for ingesting poison. Clearly, easy access to lethal pesticides
by impulsive individuals often living under economically or psychosocially stressful
conditions, combined with insufficient treatment facilities and limited outreach
programs, can be a deadly blend. A strategy aimed at reducing the availability
of the most toxic pesticides and improving case management should be implemented,
as it is likely to reduce death from pesticides although unlikely to impact
on the number of episodes. Support to families plagued by domestic violence
and male alcohol misuse is essential to improve the quality of life for the
most vulnerable and to reduce the number of self-harm episodes in the long-term.
Evans E, Hawton K, Rodham K. In what ways are adolescents who engage in
self-harm or experience thoughts of self-harm different in terms of help-seeking,
communication and coping strategies? J Adolesc 2005;28:573-87.
The purpose of this study was to ascertain whether adolescents who deliberately
harmed themselves or had thoughts of self-harm differed from other adolescents
in terms of help-seeking, communication and coping strategies. The participants
were 6020 15-16 year-old school pupils who were surveyed using an anonymous
self-report questionnaire. Adolescents with one or more episodes of deliberate
self-harm (DSH) in the previous year were more likely to identify themselves
as having serious problems than other adolescents. However, a substantial proportion
of adolescents with either DSH or thoughts of self-harm did not identify themselves
as having serious problems. Adolescents with DSH were most likely to feel the
need for help but not try to get any; they were less able to talk to family
members and teachers and had fewer categories of people who they were able to
talk to. Like other adolescents, those with DSH or thoughts of self-harm were
more likely to seek and receive help from their friends than from other sources.
They differed from other adolescents in terms of coping strategies they reported
employing when faced with difficulties, showing less focus on problems and more
avoidant behaviours. The findings have important implications for preventive
strategies, including educational programmes on emotional health and coping,
and for the clinical care of adolescents identified as at risk or having self-harmed.
Dennis M, Wakefield P, Molloy C, et al. Self-harm in older people with depression:
Comparison of social factors, life events and symptoms. Br J Psychiatry 2005;186:538-9.
Studying non-fatal self-harm in older adults may provide insight into suicidal
behaviour in this age group. The objectives of the study were to determine clinical
factors that might help to differentiate those older adults with depression
who are most at risk of self-harm and suicide. We examined social factors, life
events, hopelessness and other depression symptoms in a group of 48 older people
with depression referred following an episode of self-harm compared with 50
similarly aged people with depression who had no history of self-harm. The groups
were similar in many respects, although those in the self-harm group were more
likely to have a poorly integrated social network and were more hopeless.
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