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Repeated self-injury: perspectives from general psychiatry

  • Leonard Fagin

Patients who repeatedly injure themselves present particular management problems for general psychiatric teams. This article, the first of a series of four, examines the characteristics of those that present to adult mental health services, and the possible underlying background and trigger factors that lead to these anxiety-raising events. Suggestions are made on preventive and assessment procedures, staff reactions and management strategies aimed at helping patients deal with the overwhelming feelings that underlie self-injury.

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American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). Washington, DC: APA.
Arnold, L. & Magill, A. (1997) What's the harm? A Book for Young People Who Self-harm or Self-injure. Abergavenny: Basement Project.
Arnold, L. & Magill, A. (1998) The Self-Harm Help Book. Abergavenny: Basement Project.
Barker, P. & Buchanan-Barker, P. (2004) Guidelines miss the reality of self-harm. Mental Health Nursing, 24 (6), 46.
Bohus, M., Haaf, B., Stiglmayr, C. et al (2000a) Evaluation of in-patient dialectical behaviour therapy for borderline personality disorder – a prospective study. Behaviour Research and Therapy, 38, 875887.
Bohus, M., Limberger, M., Ebner, U. et al (2000b) Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior. Psychiatry Research, 95, 251260.
Bowers, L., Gournay, K. & Duffy, D. (2000) Suicide and self-harm in inpatient psychiatric units. A national survey of observation policies. Journal of Advanced Nursing, 32, 437444.
Brown, M., Comtois, K. & Linehan, M. (2002) Reasons for suicide attempts and non-suicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, 198202.
Byford, S., Knapp, M., Greenshields, J. et al (2003) Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach. Psychological Medicine, 33, 977986.
Claes, L., Vandereycken, W. & Vertommen, H. (2001) Self-injurious behaviors in eating-disordered patients. Eating Behaviors, 2, 263272.
Collins, D. (1997) Attacks on the body: how can we understand self-harm? Psychodynamic Counselling, 2, 463475.
Crowe, M. & Bunclark, J. (2000) Repeated self-injury and its management. International Review of Psychiatry. Special Issue: Suicide and Attempted Suicide, 12, 4853.
Cullberg, J., Wasserman, D. & Stefansson, C. (1988) Who commits suicide after a suicide attempt? An 8 to 10 year follow-up in a suburban catchment area. Acta Psychiatrica Scandinavica, 77, 598603.
D'Alessandro, M. & Lester, D. (2000) Self destructiveness and manic depressive tendencies. Psychological Reports, 87, 466.
Department of Health (1999a) Safer Services: Report of the National Confidential Enquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health.
Drew, B. L. H. (2000) Suicidal behaviour and no-suicide contracting in inpatient settings. Dissertation Abstracts International: Section B: The Sciences and and Engineering, 60 (11-B), 5428.
Favaro, A. & Santonastaso, P. (2002) The spectrum of self-injurious behaviour in eating disorders. Eating Disorders, 10, 215225.
Favazza, A., DeRosear, L. & Conterio, K. (1989) Self mutilation and eating disorders. Suicide and Life-Threatening Behavior, 19, 352361.
Ferreri, M., Loze, J., Rouillon, F. et al (2004) Clozapine treatment of a borderline personality disorder with severe self-mutilating behaviours. European Psychiatry, 19, 177178.
Gladstone, G., Parker, G., Mitchell, P. et al (2004) Implications of childhood trauma for depressed women. An analysis of pathways from childhood sexual abuse to deliberate self-harm and revictimization. American Journal of Psychiatry, 161, 14171425.
Gough, K. (2005) Guidelines for managing self-harm in a forensic setting. British Journal of Forensic Practice, 7 (2), 1014.
Gournay, K. & Bowers, L. (2000) Suicide and self-harm in inpatient psychiatric units: a study of nursing issues in 31 cases. Journal of Advanced Nursing, 32, 124131.
Griengl, H., Sendera, A. & Dantendorfer, K. (2001) Naltrexone as a treatment of self-injurious behaviour. A case report. Acta Psychiatrica Scandinavica, 103, 234236.
Haw, C., Houston, K., Townsend, E. et al (2001) Deliberate self-harm patients with alcohol disorders. Characteristics, treatment and outcome. Crisis, 22, 93101.
Haw, C., Hawton, K., Sutton, L. et al (2005) Schizophrenia and deliberate self-harm: a systematic review of risk factors. Suicide and Life-Threatening Behavior, 35, 5062.
Hawton, K., Rodham, K., Evans, E. et al (2002) Deliberate self harm in adolescents: self report survey in schools in England. BMJ, 325, 12071211.
Hawton, K., Harriss, L., Simkin, S. et al (2004) Self-cutting: patient characteristics compared with self-poisoners. Suicide and Life-Threatening Behavior, 34, 199208.
Horrocks, J., Price, S., House, A. et al (2003) Self-injury attendances in the accident and emergency department. Clinical database study. British Journal of Psychiatry, 183, 3439.
Huband, N. & Tantam, D. (2000) Attitudes to self-injury within a group of mental health staff. British Journal of Medical Psychology, 73, 495504.
Jeffery, D. & Warm, A. (2002) A study of service providers' understanding of self harm. Journal of Mental Health, 11, 295304.
Kahan, J. & Pattison, E. M. (1984) Proposal for a distinctive diagnosis: the deliberate self-harm syndrome (DSH). Suicide and Life-Threatening Behavior, 14, 1735.
Langbehn, D. & Pfohl, B. (1993) Clinical correlates of self-mutilation among psychiatric inpatients. Annals of Clinical Psychiatry, 5, 4551.
Low, G., Jones, D., Duggan, C. et al (2001) The treatment of deliberate self-harm in borderline personality disorder using dialectical behaviour therapy. A pilot study in a high security hospital. Behavioural and Cognitive Psychotherapy, 29, 8592.
Meltzer, H., Lader, D., Corbin, T. et al (2002) Non-fatal suicidal behaviour among adults aged 16 to 74. London: TSO (The Stationery Office).
Milligan, R. & Andrews, B. (2005) Suicidal and other self-harming behaviour in offender women. The role of shame, anger and childhood abuse. Legal and Criminology Psychology, 10, 1325.
Muehlenkamp, J. (2005) Self injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 324333.
Muehlenkamp, J., Swanson, J. & Brausch, A. (2005) Self-objectification, risk-taking and self-harm in college women. Psychology of Women Quarterly, 29, 2432.
National Collaborating Centre for Mental Health (2004) Self-Harm: Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. London: National Institute for Clinical Excellence.
Nijman, H. & Campo, J. (2002) Situational determinants of inpatient self-harm. Suicide and Life, 32, 167176.
Paton, J. & Jenkins, R. (eds) (2002) Understanding self injury. In Mental Health Primary Care in Prison. Adapted for Prisons and Youth Offenders Institutions from the WHO Guide to Mental Health in Primary Care. Disk 2. London: Royal Society of Medicine.
Potter, M., Vitale, N. & Dawson, A. (2005) Implementation of safety agreements in the acute psychiatric facility. Journal of the American Psychiatric Nurses Association, 11, 144155.
Prasad, V. & Owens, D. (2001) Using the internet as a source of self-help for people who self-harm. Psychiatric Bulletin, 25, 222225.
Reece, J. (2005) The language of cutting. Initial reflections on a study of the experiences of self-injury in a group of women and nurses. Issues in Mental Health Nursing, 26, 561574.
Richardson, A., Bergen, H., Martin, G. et al (2005) Perceived academic performance as an indicator of risk of attempted suicide in young adolescents. Archives of Suicide Research, 9, 163176.
Robertson, M. M., Trimble, M. R. & Lees, A. (1989) Self-injurious behaviour and the Gilles de la Tourette syndrome: a clinical study and review of the literature. Psychological Medicine, 19, 611625.
Rodham, K., Hawton, K. & Evans, E. (2004) Reasons for deliberate self harm. Comparison of self poisoners and self cutters in a community sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 8087.
Rogers, P., Watt, A., Gray, N. et al (2002) Content of command hallucinations predicts self-harm but not violence in a medium secure unit. Journal of Forensic Psychiatry, 13, 251262.
Roth, A., Ostroff, R. & Hoffman, R. (1996) Naltrexone as a treatment for repetitive self-injurious behaviour: an open label trial. Journal of Clinical Psychiatry, 57, 233237.
Royal College of Psychiatrists (2004) Assessment Following Self-harm in Adults (Council Report CR122). London: Royal College of Psychiatrists.
Sansone, R., Wiederman, M. & Sansone, L. (2000) Medically self-harming behaviour and its relationship to borderline personality symptoms and somatic preoccupation among internal medicine patients. Journal of Nervous and Mental Disease, 188, 4547.
Sansone, R., Gaither, G. & Songer, D. (2002) The relationships among childhood abuse, borderline personality and self-harm behaviour in psychiatric inpatients. Violence and Victims, 17, 4956.
Saxe, G., Chawla, N. & Van der Volk, B. (2002) Self-destructive behaviour in patients with dissociative disorders. Suicide and Life, 32, 313320.
Selby and York Primary Care Trust (2003) Finding Alternatives to Self-harm. Service-user Handbook. York: Selby and York Primary Care Trust.
Shearer, S. (1994) Phenomenology of self-injury among inpatient women with borderline personality disorder. Journal of Nervous and Mental Disease, 182, 524526.
Shepperd, C. & McAllister, M. (2003) CARE: A framework for responding therapeutically to the client who self-harms. Journal of Psychiatric and Mental Health Nursing, 10, 442447.
Sheth, H., Dziewulski, P. & Settle, A. D. (1994) Self-inflicted burns: a common way of suicide in the Asian population. A ten-year retrospective study. Burns, 20, 334335.
Simeon, D. & Hollander, E. (2001) (eds) Self-injurious Behaviors: Assessment and Treatment. Washington, DC: American Psychiatric Publishing.
Slinn, R., King, A. & Evans, J. (2001) A national survey of the hospital services for the management of adult deliberate self-harm. Psychiatric Bulletin, 25, 5355.
Stanley, B., Gameroff, M., Michalsen, V. et al (2001) Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, 158, 427432.
Swinton, M. & Smith, S. (1997) Costs of physical health care for self-injuring patients. Psychiatric Bulletin, 21, 538541.
Taylor, D. & Cameron, P. (1998) Deliberate self-inflicted trauma: population demographics, the nature of injury and a comparison with patients who overdose. Australian and New Zealand Journal of Public Health, 22, 120125.
Turp, M. (2002) The many faces of self-harm. Psychodynamic Practice: Individuals, Groups and Organizations, 8, 197217.
Tyrer, P., Thompson, S., Schmidt, U. et al (2003) Randomised controlled trial of brief cognitive therapy versus treatment as usual in recurrent deliberate self-harm: the POMACT Study. Psychological Medicine, 33, 969976.
Tyrer, P., Tom, B., Byford, S. et al (2004) Differential effects of manual assisted cognitive–behavioural therapy in the treatment of recurrent deliberate self-harm and personality disturbance. The POPMACT Study. Journal of Personality Disorders, 18, 102116.
Van Heeringen, C. & De Volder, V. (2002) Trends in attempted suicide in adolescents and young adults in Gent, 1986–1995. Archives of Suicide Research, 6, 135141.
Way, B. B. & Banks, S. (2001) Clinical factors related to admission and release decisions to psychiatric emergency services. Psychiatric Services, 52, 214218.
Weaver, T., Chard, K., Mechanic, M. et al (2004) Self-injurious behaviours, PTSD arousal, and general health complaints within a treatment-seeking sample of sexually abused women. Journal of Interpersonal Violence, 19, 558575.
Zlotnick, C., Shea, M., Pearlstein, T. et al (1996) The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive Psychiatry, 37, 1216.
Zlotnick, C., Mattia, J. I. & Zimmerman, M. (1999) Clinical correlates of self-mutilation in a sample of general psychiatric patients. Journal of Nervous and Mental Disease, 187, 296301.
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Repeated self-injury: perspectives from general psychiatry

  • Leonard Fagin
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On being non-judgemental

Ovais Wadoo, SHO
17 October 2006

I read the article “Repeated Self Injury” by Dr Leonard Fagin. It wasinteresting to read the response by Dr Md Ali Jaha wh argued whether we are really non-judgemental when dealing with certain patients who present repeatedly (for example people with borderline personality disorder or alcohol misuse).

The response of staff dealing with self harm depends as much on theirexperience as any other factors. A junior psychiatrist answering a desperate call on a Friday evening about a young man threatening to cut his wrist may give different advice than a senior clinician who knows this patient well (as stated in the article). So to know a patient well, especially when the patient has difficult and complex problems becomes all the more important. We know that information gathering is key to making any diagnosis or management plans. So the information passed by our colleagues proves to bevery important as it gives us the background of the patient, his past riskissues and previous interventions.

As doctors we must use our skills and competencies to make judgements(clinical not moral) to ensure that patient receives best possible care and that is not being judgemental. Being non-judgemental means "relating to or having an open attitude without implicit moral judgement".
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Adopting a non-judgemental attitude

Dr Md Ali Jahan, SHO, Psychiatry
23 June 2006

My thanks must go to Dr Leonard Fagin for his excellent article on "Repeated self-injury".

I have read many timesin relation to managing a self harming patient who is presenting very frequently to the ward or A&E - please be non-judgemental. But, are we really non-judgemental when seeing people who self harm especially with borderlinepersonality or alcohol misue problems? How can we be non-judgemtnal when dealing with such complex and difficult patients?

In many junior doctors' rooms, I have seen advanced notices regarding patients who present themselves very often to services, giving instructions from community mental health or crisis teams saying - In this situation, how can I be non-judgemental about the patient who is going to be seen by me? Is it not the case that we are blocking the emergence of new ways of dealing with apparently the same situation in future?

I understand that we should not have any set ideas about any person before seeing him or her, but if we deal with same patients over and over again with the same pattern of behaviour, then, what are the ways that can help us become non-judgmental? Is it a basic instinct that at the end of the day we really cannot be non-judgemental?
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