Muehlenkamp JJ, Gutierrez PM. An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav 2004;34:12-23.
Data from 390 high school students were collected to examine potential differences between adolescents who had attempted suicide and those who engaged in self-injurious behavior on measures of depression, suicidal ideation, and attitudes toward life and death. Significant differences were found between controls and the self-harm groups on all dependent variables. A significant difference on attitudes toward life was found between the self-injury and suicide attempt groups. Post-hoc regression analyses showed that measures of depression, suicide ideation, and attitudes towards life predicted participants’ self-harm categorization. These findings provide preliminary evidence that self-injurious behavior is different from attempted suicide among a community sample of adolescents.

Paivio SC, McCulloch CR. Alexithymia as a mediator between childhood trauma and self-injurious behaviors. Child Abuse Negl 2004;28:339-54.
OBJECTIVE: The aim of this study was to test whether alexithymia mediates the relationship between childhood maltreatment and self-injurious behaviors (SIB) in college women. METHOD: The sample was comprised of 100 female undergraduate students. Measures were the Childhood Trauma Questionnaire [D. Bernstein, L. Fink, Manual for the Childhood Trauma Questionnaire, The Psychological Corporation, New York, 1998], the Toronto Alexithymia Scale-20 [Journal of Psychosomatic Research 38 (1994) 23; Journal of Psychosomatic Research 38 (1994) 33], and the Self-Injurious Behaviors Questionnaire which assessed the lifetime frequency of six methods of superficial self-injury (hair pulling, head banging, punching, scratching, cutting, and burning). Regression analyses were used to test the proposed mediational model. RESULTS: Forty-one percent of respondents reported having engaged in SIB; most engaged in multiple methods, and self-cutting was the most frequently endorsed method. Results of regression analyses supported the proposed mediational model for all types of maltreatment except sexual abuse. Sexual abuse, considered alone, was not significantly associated with alexithymia which precluded testing for mediational effects. CONCLUSIONS: Results support a link between a history of childhood maltreatment and SIB among college women and the hypothesis that alexithymia mediates this relationship.

Yates TM. The developmental psychopathology of self-injurious behavior: Compensatory regulation in posttraumatic adaptation. Clin Psychol Rev 2004;24:35-74.
This article utilizes a developmental psychopathology framework to explicate one pathway, originating in childhood traumatic experience, toward the development of self-injurious behavior (SIB). The descriptive psychopathology of SIB is summarized first, followed by an overview of theoretical interpretations of SIB within psychoanalytic, neo-analytic, behavioral, and biological paradigms. Building on these empirical and theoretical foundations, a developmental psychopathology framework is used to model the development of SIB in the aftermath of childhood traumatic experience, particularly maltreatment. In this model, maltreatment undermines positive adaptation at motivational, attitudinal, instrumental, emotional, and/or relational levels of competence. In turn, vulnerabilities in the child’s adaptive resources necessitate the application of alternative regulatory and relational strategies, such as self-injury, to the negotiation of contemporaneous and prospective developmental issues. The article concludes with a discussion of the empirical and clinical implications of a developmental understanding of SIB as a compensatory regulatory strategy in posttraumatic adaptation.

Ayton A, Rasool H, Cottrell D. Deliberate self-harm in children and adolescents: Association with social deprivation. Eur Child Adolesc Psychiatry 2003;12:303-7.
BACKGROUND: It has been demonstrated that adult suicidal behaviour is associated with unemployment and social deprivation. The association between self-harm and social deprivation in young people is less clear. AIMS: To examine the relationship between social deprivation and deliberate self-harm in children and adolescents in an UK district. METHOD: Computer records of patients under 18 years of age presenting with self-harm at the district casualty department were analysed in Hull and East Yorkshire. The relationship with social deprivation was examined using Townsend scores. RESULTS: 730 young people presented with self-harm during a period of two years. Socio-economic deprivation was associated with overdose, self-injury, and poisoning by illicit substances. After controlling for the proportion of single parent households, moving households with children, and adult long-term sickness in each ward, partial correlations remained significant between overdose, self-injury, and Townsend scores. CONCLUSIONS: The results highlight the importance of socio-economic deprivation in the aetiology of deliberate self-harm in young people. Primary and secondary prevention programs cannot be successful without taking this into consideration.

Horrocks J, Price S, House A, Owens D. Self-injury attendances in the accident and emergency department: Clinical database study. Br J Psychiatry 2003;183:34-9.
BACKGROUND: Self-injury is a neglected area of self-harm research and we know little about its epidemiology, hospital care and outcome. Aims To provide epidemiological data on self-injury and compare hospital management of self-injury with that for self-poisoning. METHOD: Data were collected on all self-harm attendances to the general hospitals in Leeds over an 18-month period. RESULTS: People attending hospital for self-injury or self-poisoning do not form mutually exclusive groups. There were higher proportions of self-injury episodes compared with self-poisoning, where a history of self-harm or contact with mental health services had been recorded. Fewer psychosocial assessments were carried out after episodes of self-injury compared with self-poisoning but, when they were, follow-up was recommended more often. CONCLUSIONS: The clinical importance of self-injury is not mirrored by the level of psychosocial assessment and after-care provided.

Conner KR, Langley J, Tomaszewski KJ, Conwell Y. Injury hospitalization and risks for subsequent self-injury and suicide: A national study from New Zealand. Am J Public Health 2003;93:1128-31.
OBJECTIVES: Risks for suicide and nonfatal self-injury hospitalizations associated with previous injury hospitalizations were investigated in a nationwide retrospective cohort study conducted in New Zealand. METHODS: Linked data from all New Zealand public hospitals were used to identify individuals with injury hospitalizations. Participants were followed for 12 months. RESULTS: Significantly increased age- and sex-adjusted relative risks for suicide were associated with previous hospitalization for self-injury, injuries of undetermined causes, and assault. Also, elevated risks were associated with these causes of hospitalization in the case of subsequent self-injury hospitalizations. CONCLUSIONS: Results indicate that identifiable subgroups of individuals hospitalized for injuries are at marked risk for serious suicidal behavior and suggest the potential of targeted suicide prevention for these individuals.

Wilkinson S, Taylor G, Templeton L, et al. Admissions to hospital for deliberate self-harm in England 1995-2000: An analysis of hospital episode statistics. J Public Health Med 2002;24:179-83.
BACKGROUND: Rates of deliberate self-harm (DSH) were increasing in the United Kingdom during the 1980s and early 1990s, particularly among young adult males. Self-poisoning with paracetamol was the most common means, with overdoses of anti-depressants becoming more frequent. Changes to paracetamol pack size regulations in 1997 have been followed by a reduction in overdoses, and there has been more prescription of anti-depressants less likely to necessitate hospitalization if overdosed. Improved liaison psychiatry services and increased levels of employment are among the factors that would suggest an impact on hospital admissions for self-harm. This study analysed DSH admissions to hospitals in England from 1995/96 to 1999/2000 to examine changes. METHODS: A retrospective analysis of the Hospital Episode Statistics database was carried out. RESULTS: Hospital admissions for DSH rose to 153 per 100000 in 1997/98, then declined to 143 per 100000 in 1999/2000. Paracetamol overdoses decreased from 77 to 67 per 100000. The use of anti-depressants or tranquillizers grew from 56 to 75 per 100000 during the 5 years. Self-injury, narcotics overdoses and the use of alcohol continued to increase over time. CONCLUSIONS: Yearly increases in admissions for DSH to hospitals in England reversed in 1998/99 and stabilized in 1999/ 2000. These changes were most noticeable for the 16-24 years age group. The use of paracetamol decreased, whereas other means of self-harm increased. Regional differences and the relationship between rates of DSH in the community and hospital should be explored further.

Horrocks J, House A. Self-poisoning and self-injury in adults. Clin Med 2002;2:509-12. No abstract available.

Rombach K. Self injury behavior. "The drive to hurt myself is too strong." Krankenpfl Soins Infirm 2002;95:10-3. [Article in German.] No abstract available.

McAllister M, Creedy D, Moyle W, Farrugia C. Nurses’ attitudes towards clients who self-harm. J Adv Nurs 2002;40:578-86.
BACKGROUND: Deliberate self-harm is frequently encountered by emergency department (ED) nurses. However, clients are often dissatisfied with the care provided and clinicians feel ambivalent, helpless or frustrated when working with clients who self-harm. AIM: The aim of the study was to develop and test a scale to identify relevant dimensions of ED nurses’ attitudes to clients who present with self-injury. METHODS: Items on Attitudes Towards Deliberate Self-Harm Questionnaire (ADSHQ) were drawn from a literature review and focus group discussions with ED nurses. The tool was piloted with 20 ED nurses not working in the target agencies. A survey of nurses working within 23 major public and 14 major private EDs in Queensland, Australia (n = 1008) was then undertaken. RESULTS: A total of 352 questionnaires were returned (35% response). Analysis revealed four factors that reflected nurses’ attitudes toward these clients. The factors related to nurses’ perceived confidence in their assessment and referral skills; ability to deal effectively with clients, empathic approach; and ability to cope effectively with legal and hospital regulations that guide practice. There was a generally negative attitude towards clients who self-harm. Correlations were found between years of ED experience and total score on the ADSHQ, and years of ED experience and an empathic approach towards clients who deliberately self-harm. CONCLUSION: There is a need for continuing professional development activities to address negative attitudes and provide practical strategies to inform practice and clinical protocols.

Smith SE. Perceptions of service provision for clients who self-injure in the absence of expressed suicidal intent. J Psychiatr Ment Health Nurs 2002;9:595-601.
This research involved interviewing three people who had experienced self-injury. They were accessed from the voluntary sector as I felt that if I had accessed them from the National Health Service their views might not be honest, due to their possible perceptions of threats to their care. It was not intended that the views of these people would be representative, my aim was that their views, as well as areas highlighted in the literature, would inform me of areas pertinent to the topic, when seeking staff views. The views of staff, of which there were 15 self-selecting clinicians, formed the main focus of the study. The aims of the research were designed to highlight potentially contrasting perceptions of self-injury as a means of illuminating a current clinical problem. The results showed that staff on the whole agreed with the perceptions of people who have experienced self-injury; that they are often viewed negatively, though this is changing. It was recognized that care was dependent on where the person entered the service. Staff recognized that the service is under pressure and provision may not be available in the voluntary sector for these clients.

Lewis C. A support group for self-harm patients. Nurs Times 2002;98:40-1.
Health care professionals often try to convince people who self-harm to stop, becoming caught up in a pattern of arguing with them against self-injury. Patients at the Northgate Clinic (Senior) asked for a self-harm support group to be set up so that they could talk about their behaviour and the reasons for it. Its aims were to ensure that their negative beliefs about themselves were not reinforced, that they could articulate their experiences in an empowering way and that they could take some responsibility for their behaviour.

Horrocks J, Owens D, House A. General practice based interventions to prevent repeat episodes of deliberate self harm. Pictures of self injury misrepresent published trial. BMJ 2002;325:281. No abstract available.

[No authors listed] The school nurse perspective on self-injury. School Nurse News 2002;19:18. No abstract available.

Machoian L. Cutting voices. Self-injury in three adolescent girls. J Psychosoc Nurs Ment Health Serv 2001;39:22-9.
1. Adolescent girls with a trauma history discover that violence, in the form of cutting themselves, heeds a response from others when others do not listen to their speaking voices. 2. Cutting may begin as an effort to communicate psychological distress and a plea for relationship but becomes a developmental pathway to cutting as a form of regulating unbearable affect, indicating the need for early intervention. 3. Adults actively and genuinely listening to girls is a critical component for both prevention and intervention of cutting.

Arensman E, Townsend E, Hawton K, et al. Psychosocial and pharmacological treatment of patients following deliberate self-harm: The methodological issues involved in evaluating effectiveness. Suicide Life Threat Behav 2001;31:169-80.
Development of effective treatments for patients following deliberate self-harm (self-poisoning or self-injury) is a very important element in suicide prevention. The randomized controlled trial (RCT) is the mainstay of evaluation of treatments. In a systematic review of the literature, the effectiveness of treatments based on RCTs was examined and the quality of the RCTs was assessed. Twenty trials were identified, and where possible, these were grouped on the basis of similarities among the types of treatment. In this paper, we examine the methodological aspects of the trials and consider what may be learned that will assist in the design of future studies in this field. The methodological quality of the trials was reasonable, but most trials included too few participants to detect clinically important differences in rates of repeated self-harm. In planning future trials, the following major issues should be addressed: investigators should perform power calculations to determine the number of subjects necessary to detect clinically important effects, provide information on method of randomization and interventions, use standard measures of outcome, and focus on homogeneous subgroups of patients. Improving the methodology of future studies in this field will be essential if sound evidence is to be obtained which can inform effective service provision for deliberate self-harm patients.

Mace FC, Blum NJ, Sierp BJ, et al. Differential response of operant self-injury to pharmacologic versus behavioral treatment. J Dev Behav Pediatr 2001;22:85-91.
The purpose of this study was to investigate the hypothesis that self-injurious behavior (SIB) maintained by environmental factors will be more effectively treated by behavioral treatments than by haloperidol. Fifteen subjects were enrolled in this study. The efficacy of both haloperidol and a behavioral treatment was assessed. At the onset of treatment, subjects were randomized to receive either haloperidol or a placebo. During each day of treatment, data were collected during sessions with a behavioral treatment and sessions without a behavioral treatment. Behavioral treatment resulted in a statistically significant decrease in SIB, but haloperidol did not. Eighty-three percent of subjects were classified as responders to the behavioral treatment whereas only 25% of the subjects were responders to haloperidol (p = .019). We conclude that individuals with operant SIB are more likely to respond to behavioral treatments than to haloperidol.

Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001;178:48-54.
Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide. AIMS: To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients. METHOD: A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12-16 months later. RESULTS: ICD-10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%. CONCLUSIONS: Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.

Huband N, Tantam D. Attitudes to self-injury within a group of mental health staff. Br J Med Psychol 2000;73 Pt 4:495-504.
BACKGROUND: Self-wounding is a behaviour which remains poorly understood and which can evoke strong reactions from clinical staff. Such reaction may adversely influence treatment outcome and there have been calls for changes in the attitudes of professional staff towards this client group through improved training and awareness. There has, however, been little systematic study of how clinicians perceive those who self-injure or of how their attitudes are modified by training and other factors. METHOD: This study aims to identify and explore factors governing professional attitude towards self-injury through postal survey of a large group of mental health staff. The survey assessed attitudes towards a representative case described in a vignette. RESULTS: Five key factors were identified, with perception of control being the most dominant. Attitudes of clinical staff who had obtained additional qualification in counseling or psychotherapy differed significantly from those who had not. In contrast, no effect was found for specific training in handling self-injury. Attitude to the self-wounding woman was unaffected by gender, but was affected by age and work setting. The innate potential for the sample to self-polarize was examined statistically; a line of cleavage emerged between less tolerant staff who perceived her to have more control and to be more difficult to understand and those with opposing views. CONCLUSION: Qualification in counseling or psychotherapy may modify attitude by reducing defensive attribution, allowing staff improved containment of their anxiety; alternatively, pre-existing attitudes may encourage certain staff to obtain such qualification.

Donovan S, Madeley R, Clayton A, et al. Deliberate self-harm and antidepressant drugs: Investigation of a possible link. Br J Psychiatry 2000;177:551-556.
BACKGROUND: It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs. AIMS: To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event. METHOD: This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant. RESULTS: Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P<0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline. CONCLUSIONS: Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.

Salib E, Tadros G, Cawley S. History of deliberate self harm may predict methods of fatal self harm in the elderly. Med Sci Law 2001;41:107-10.
In this study we examined the association between methods of Deliberate Self Harm (DSH) by the elderly and their subsequent methods of Fatal Self Harm (FSH). Data was collected from the files of inquests into suicide by the elderly in Birmingham and Cheshire Coroner’s Courts. All the subjects were above the age of 60, had history of deliberate self harm before the final act of fatal self harm and attracted either suicide or open verdict returned by the Coroners over a period of four years 1995-1998. We compared the methods of Deliberate Self Harm (DSH) to the methods of Fatal Self Harm (FSH) used by all the included elderly. 18 per cent of elderly victims of FSH had a previous history of DSH and in 35 per cent of the sample, the last known attempt of DSH occurred more than one year prior to the FSH. The majority of the methods that had been used in elderly DSH were used again in their final act of FSH. Nearly two thirds of all the elderly who died of an overdose had attempted suicide earlier by an overdose and one in five of those who died by hanging or drowning used the same method in an unsuccessful attempt of FSH within 12 months. A detailed history of DSH can improve the quality of risk assessment of self harm in the elderly. As more than one in three elderly victims of FSH attempted DSH more than a year prior to the final act, it is important when assessing an elderly DSH attempt that we obtain any previous case notes and question informants about the distant as well as the recent past.

Evans J, Reeves B, Platt H, et al. Impulsiveness, serotonin genes, and repetition of deliberate self-harm (DSH). Psychol Med 2000;30:1327-34.
BACKGROUND: Few studies have investigated independent associations of psychological, biological, and social variables with repeated deliberate self-harm (DSH). Serotonin function has been linked to impulsive and suicidal behaviour and genetic polymorphisms have been identified within the serotonin system that could account for this link. This study tested hypotheses linking impulsiveness, genetic polymorphisms of tryptophan hydroxylase (TPH) and the 5-HT2c receptor and repeated DSH. METHODS: Individuals presenting after DSH were interviewed, completed personality questionnaires and gave venous blood samples. Genotypes were determined for TPH intron7 and 5-HT2c (cys-ser) polymorphisms. Follow-up to identify repetition of DSH was for 1 year. RESULTS: Males with the 5-HT2c serine variant were more impulsive than those with the cysteine variant (039 standardized units, P = 0.041, 95% CI 0.017 to 0.076). There was no association between impulsiveness and the TPH intron7 polymorphism overall but a weak association with the L allele in men (0.41 standardized units, P = 0.05, 95 % CI 0.001 to 0.82). Impulsiveness, although high in the group as a whole, did not distinguish those who repeated DSH. CONCLUSIONS: The personality trait of impulsiveness may in part be related to genotypes of the 5-HT2c receptor and TPH gene in men. Impulsiveness does not differ between those who do and do not repeat DSH.

Hawton K, Harriss L, Simkin S, et al. Effect of death of Diana, Princess of Wales on suicide and deliberate self-harm. Br J Psychiatry 2000;177:463-6.
BACKGROUND: The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour. AIMS: To assess the impact of the Princess’s death on suicide and deliberate self-harm (DSH). METHOD: Analysis, using Poisson regression, of the number of suicides and open verdicts (‘suicides’) in England and Wales following the Princess’s death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital. RESULTS: Suicides increased during the month following the Princess’s funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress. CONCLUSIONS: The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

Eddleston M. Patterns and problems of deliberate self-poisoning in the developing world. QJM 2000;93:715-31.
Deliberate self-harm is a major problem in the developing world, responsible for around 600 000 deaths in 1990. The toxicity of available poisons and paucity of medical services ensure that mortality from self-poisoning is far greater in the tropics than in the industrialized world. Few data are available on the poisons most commonly used for self-harm in different parts of the world. This paper reviews the literature on poisoning, to identify the important poisons used for self-harm in these regions. Pesticides are the most important poison throughout the tropics, being both common and associated with a high mortality rate. In some regions, particular pesticides have become the most popular method of self-harm, gaining a notoriety amongst both health-care workers and public. Self-poisoning with medicines such as benzodiazepines and antidepressants is common in urban areas, but associated with few deaths. The antimalarial chloroquine appears the most significant medicine, self-poisoning being common in both Africa and the Pacific region, and often fatal. Paracetamol (acetaminophen) is used in many countries but in few has it reached the popularity typical of the UK. Domestic and industrial chemicals are responsible for significant numbers of deaths and long-term disabilities world-wide. Self-poisoning with plant parts, although uncommon globally, is locally popular in some regions. Few of these poisons have specific antidotes. This emphasizes the importance of determining whether interventions aimed at reducing poison absorption actually produce a clinical benefit, reducing death and complication rates. Future research to improve medical management and find effective ways of reducing the incidence of self-harm, together with more widespread provision of interventions proven to be effective, could rapidly reduce the number of deaths from self-poisoning in the developing world.

Deiter PJ, Nicholls SS, Pearlman LA. Self-injury and self capacities: assisting an individual in crisis. J Clin Psychol 2000;56:1173-91.
This article reports findings of a study on self-injury, childhood abuse, and self capacities that supports a theory for understanding and assisting self-injuring individuals in crisis. In the study, 233 adults from partial hospital settings and an outpatient clinic answered questions concerning self-injury, abuse history, and three self capacities (the ability to tolerate strong affect, the ability to maintain a sense of self-worth, and the ability to maintain a sense of connection to others). More than 60% reported childhood abuse. More than half reported self-injury. Individuals with a history of self-injury showed greater impairment of self capacities than individuals who did not report self-injury. Individuals with a history of childhood abuse showed greater impairment than did individuals who did not report childhood abuse. Greatest impairment was associated with both self-injury and abuse. Implications of the results are explored and the theory for assisting self-injuring individuals in crisis is presented.

Bohus M, Limberger M, Ebner U, et al. Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior. Psychiatry Res 2000;95:251-60.
Self-mutilation occurs in 70-80% of patients who meet DSM-IV criteria for borderline personality disorder. Approximately 60% of these patients report that they do not feel pain during acts of self-mutilation such as cutting or burning. Findings of recent studies measuring pain perception in patients with BPD are difficult to interpret since variables such as distress, dissociation or relevant psychotropic medication have not been controlled. The Cold Pressor Test (CPT) and the Tourniquet Pain Test (TPT) were administered to 12 female patients with BPD who reported analgesia during self-mutilation and 19 age-matched healthy female control subjects. All subjects were free of psychotropic medication. The patients were studied on two occasions: during self-reported calmness and during intensive distress (strong urge to cut or burn themselves). Even during self-reported calmness, patients with BPD showed a significantly reduced perception of pain compared to healthy control subjects in both tests. During distress, pain perception in BPD patients was further significantly reduced as compared with self-reported calmness. The present findings show that self-mutilating patients with BPD who experience analgesia during self-injury show an increased threshold for pain perception even in the absence of distress. This may reflect a state-independent increased pain threshold which is further elevated during stress. Interpretation of these findings is limited by their reliance upon self-reports.

Favaro A, Santonastaso P. Self-injurious behavior in anorexia nervosa. J Nerv Ment Dis 2000;188:537-42.
Recent reports have postulated the existence of two different types of self-injurious behavior: impulsive and compulsive. The aim of the present study is to analyze the dimensionality of self-injurious behavior and to study the link between self-injurious behavior and clinical features in anorexia nervosa. The study involved 236 consecutive patients with anorexia nervosa, diagnosed by DSM-IV criteria. Subjects were evaluated by means of a semistructured interview and self-reported questionnaires, such as the Eating Disorders Inventory and Hopkins Symptom Checklist. A principal component analysis was used to study the dimensionality of different types of self-injurious behavior, including purging. Our findings confirm the distinction between impulsive and compulsive self-injurious behavior. The dimensions appear to be represented as a continuum in both the anorexia nervosa diagnostic subgroups. A third distinct dimension emerged that included self-induced vomiting and laxative/diuretics abuse. Childhood sexual abuse and anxiety significantly predict the presence of impulsive self-injury, whereas obsessionality and age predict compulsive self-injury. The coexistence of a positive score on both dimensions of self-injurious behavior was the strongest predictor of treatment dropout. The present study highlights the importance of self-injurious behavior; it should be given due consideration in future outcome studies on anorexia nervosa.

Fowler JC, Hilsenroth MJ, Nolan E. Exploring the inner world of self-mutilating borderline patients: a Rorschach investigation. Bull Menninger Clin 2000;64:365-85.
Psychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America’s adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings.

Velazquez L, Ward-Chene L, Loosigian SR. Fluoxetine in the treatment of self-mutilating behavior. J Am Acad Child Adolesc Psychiatry 2000;39:812-4. No abstract available.

Garnis-Jones S, Collins S, Rosenthal D. Treatment of self-mutilation with olanzapine. J Cutan Med Surg 2000;4:161-3.
BACKGROUND: Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics. OBJECTIVE: The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties. CONCLUSIONS: The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its antidopamine and serotonin-blocking action.

O’Shea B. Self-harm and unemployment. Hosp Med 2000;61:495-8.
Unemployment is an important variable in both suicide and attempted suicide, acts that are themselves woven from a complex tapestry of interacting factors. The manner in which being unemployed leads to acts of self-destruction can often be better understood from detailed case histories than from the cold fruits of epidemiological research.

Low G, Jones D, MacLeod A, et al. Childhood trauma, dissociation and self-harming behaviour: A pilot study. Br J Med Psychol 2000;73(Pt 2):269-78.
OBJECTIVE: Childhood trauma is known to be an important antecedent in those who engage in deliberate self-harm (DSH). We aimed to explore the mediating mechanisms between childhood trauma and subsequent DSH in a sample of women detained in a high secure setting. METHOD: From a previous incidence study into DSH, we subdivided a group of 50 women as follows: non-harmers (N = 13), infrequent harmers (N = 22) and frequent harmers (N = 15). These three groups were then compared on several measures believed to be associated with DSH. RESULTS: The frequency of DSH was related to low self-esteem, increased dissociation, anger (both inwardly and outwardly directed), impulsivity, and a history of sexual and physical abuse. When these variables were entered into a path analytic model exploring the relationship between childhood trauma and subsequent DSH, two paths emerged: one major path which linked childhood sexual abuse to DSH via increased dissociation and another, more minor association, linking childhood sexual abuse via reduced self-esteem. CONCLUSION: This study shows a strong association between high levels of dissociation and an increased frequency of self-harming behaviour. This association is theoretically plausible and has therapeutic implications.

Sansone RA, Wiederman MW, Sansone LA, et al. Patterns of self-harm behavior among women with borderline personality symptomatology: psychiatric versus primary care samples. Gen Hosp Psychiatry 2000;22:174-8.
The current study investigated differences in self-harm behavior among individuals with borderline personality symptomatology from two different clinical settings. Participants were women, between the ages of 18 and 45, from an outpatient mental health setting or a primary care setting. Each participant completed the Self-Harm Inventory (SHI) and the borderline personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R). Using a predetermined cut-off for substantial borderline personality symptomatology on the SHI, group comparisons with chi(2) analyses indicated that “overdosed” and “hit self” were significantly more common in the mental health subsample whereas “abused laxatives” was significantly more common in the primary care subsample. Using a predetermined cut-off for borderline personality on the PDQ-R, chi-square analyses indicated that “overdosed” and “hit self” remained significantly more common in the mental health subsample. Despite these differences, there was remarkable similarity of symptoms between groups. The implications of these findings are discussed.

Morgan JF, Lacey JH. Blood-letting in anorexia nervosa: a case study. Int J Eat Disord 2000;27:483-5.
BACKGROUND: Deliberate blood-letting has been characterized as an alternative to purging behavior in bulimia. METHOD: We describe a female healthcare worker with an 8-year history of restrictive anorexia nervosa, who initially presented with anemia, using blood-letting, cold baths, and starvation to control her mental state. RESULTS: In contrast with the previous cases of bulimia, the aim of blood-letting in this case of anorexia nervosa was to achieve anemia. She compared the psychic correlates of anemia to emaciation, rather than to deliberate self-harm or purging. DISCUSSION: We note that mainstream 19th century psychiatry prescribed “baths, blood-letting and diet” as a treatment of “madness.”

Bailey AM. Assessment and discharge following self-harm. Br J Psychiatry 2000;176:495.

Nadkarni A, Parkin A, Dogra N, et al. Characteristics of children and adolescents presenting to accident and emergency departments with deliberate self harm. J Accid Emerg Med 2000;17:98-102.

OBJECTIVES: The aim of this study was to provide a description of the characteristics of children and adolescents presenting to the accident and emergency (A&E) department with deliberate self harm. METHODS: Descriptive analysis of data collected by reviewing the notes of all children and adolescents aged 16 years and under, presenting during the period of study (1 January to 31 December) with a history of deliberate self harm. RESULTS: A total of 100 children (18 boys, 82 girls) were responsible for 117 episodes of deliberate self harm. Nine repeaters were responsible for 22% of the attendances; 38% had made use of emergency ambulance service and 6% were referred by their general practitioner (GP). Sixty nine per cent were accompanied by immediate family and 21% children presented alone. Seventy four per cent presented within three hours of the attempt and 37% presented between 6 pm and midnight; 77% presented during weekdays and 30% of attempts had occurred during spring. Ninety two per cent had used a pharmaceutical drug. Sixty five per cent had made the attempt at home and 12% in a public place. Twenty five per cent had prior or current contact with the child psychiatric services and a similar proportion had prior or current contact with social services. CONCLUSIONS: Few of the children and adolescents presenting with deliberate self harm to the A&E department have been referred by their GP. They frequently present alone or are accompanied by people who are not family members making assessment and treatment difficult. Many already have other services involved in their care and thus the gathering and dissemination of information can become quite lengthy. The time of presentation is usually out of hours, further complicating this process. A small number of young people present with repeated self harm, who are known to be most vulnerable for completing suicide.

Harris J. Self-harm: cutting the bad out of me. Qual Health Res 2000;10:164-73.
The practice of self-harm is increasing in the United Kingdom, accounting for the highest number of acute medical admissions for women. The medical and nursing response to repeaters, set within a climate of dwindling emergency and accident resources, has been one of impatience, frustration, and hostile care. The author undertook a correspondence study with 6 women who regularly self-harmed. The women claimed that medical and nursing professionals viewed their self-harm as irrational and illogical. However, a qualitative examination of the motivations and interests of all parties reveals that self-harm acts possess situated internal logic, whereas professionals tend to use rational logic in attempting to understand them.

Turell SC, Armsworth MW. Differentiating incest survivors who self-mutilate. Child Abuse Negl 2000;24:237-49.
OBJECTIVE: This study was an exploratory analysis of the variables which differentiated incest survivors who self-mutilate from those who do not. METHOD: A sample of women incest survivors (N = 84) were divided into two groups based on the presence or absence of self-mutilation. Participants included both community and clinical populations. A packet consisting of a demographic questionnaire, Sexual Attitudes Survey, Diagnostic Inventory of Personality and Symptoms, Dissociative Events Scale and the Beck Depression Inventory was completed by each participant. RESULTS: Demographic, incest, and family of origin variables distinguished the self-mutilating women from those who did not. These include ethnicity and educational experiences; duration, frequency, and perpetrator characteristics regarding the incest; and multiple abuses, instability, birth order, and loss of mother in one’s family of origin. Psychological and physical health concerns also differentiated between the two groups. CONCLUSIONS: Many variables may differentiate between women incest survivors who self-mutilate from those who do not. A rudimentary checklist to describe the lives of incest survivors who self-mutilate resulted from these findings. The importance of the concept of embodiment is also discussed.

Hurry J, Storey P. Assessing young people who deliberately harm themselves. Br J Psychiatry 2000;176:126-31.
BACKGROUND: Many young people who harm themselves have chronic mental health or social problems or are at risk of future self-harm or even suicide. The accident and emergency (A&E) clinic is an important gateway to treatment. AIMS: To describe the psychosocial assessment of 12- to 24-year-old patients attending A&E clinics following deliberate self-harm (DSH) and to identify features of service management and provision which maximise specialist assessment. METHOD: A postal questionnaire was sent to a sample of one in three A&E departments in England. In a representative sample of 18 of these hospitals, staff were interviewed and 50 case notes per hospital were examined. RESULTS: Psychosocial assessment by non-specialist doctors in A&E departments tended to be of variable quality, focused on short-term risk. Around 43% of patients aged 12-24 were assessed by a specialist; specialist assessment was associated with high admission rates and the presence of on-site psychiatric departments and DSH teams. CONCLUSIONS: Young DSH patients at risk often go unidentified; as a result their psychological problems may not be treated. Hospitals are frequently unaware of the proportion of patients discharged without adequate assessment.

Lawlor M, Corcoran P, Chambers D. Suicide attempts v. deliberate self-harm: a response. Br J Psychiatry 2000;176:91-2. No abstract available

Darely M. Crisis telephone consultation for deliberate self-harm patients. Br J Psychiatry 2000;176:91. No abstract available.

Hawton K, Townsend E, Arensman E, et al. Psychosocial versus pharmacological treatments for deliberate self harm. Cochrane Database Syst Rev 2000;CD001764. Review.
OBJECTIVES: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. SEARCH STRATEGY: Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted. SELECTION CRITERIA: All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm. DATA COLLECTION AND ANALYSIS: Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution). MAIN RESULTS: A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0. 47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0. 09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93). REVIEWER’S CONCLUSIONS: There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

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