Essay: Seven functions of self-injury

A review of literature shows that seven functions of self-injury have been consistently identified. These include affect-regulation, anti-dissociation, anti-suicide, interpersonal boundaries, interpersonal-influence, self-punishment, and sensation-seeking(Klonsky, 2007). It is imperative to note that these functions are not mutually exclusive and there might be considerable overlap between these functions with each act of self-harm. The affect-regulation model of self-injury suggests that self-injury is a strategy to alleviate acute negative affect or affective arousal (Gratz, 2003). Linehan had theorized that early invalidation environments lead to poor coping skills and such individuals with biological dispositions for emotional instability were less effective in managing their emotions and are therefore prone to use self-injury as a maladaptive strategy for affect-regulation (Marsha M. Linehan, 1993). The anti-dissociation model posits self-injury as a response to episodes of dissociation or depersonalization that individuals might feel at the peak of their emotional state. The self injurious act might be used to terminate the periods of dissociation or depersonalization and feel real again (Klonsky, 2007). The anti-suicide model views self-injury as a mechanism to resist suicidal urges. It may be used to express suicidal desires without actually attempting a fatal act.The interpersonal-influence model stipulates that self-injury is used to influence the self- injurer’s environment (Klonsky, 2007). The acts may be a cry for help or to avoid abandonment. Alternatively, the self- injurer may not have any desire to manipulate the environment, but the environment may be affected and reactive to the behavior (Gerson & Stanley, 2002). The interpersonal boundaries model is based on the object relation’s theory. Gunderson viewed self-harm as an attempt to reestablish contact with a lost object and to create an illusion of control over new objects (Gunderson, 2009). The self-punishment model suggests that self-injury is an expression of anger towards oneself. Linehan (1993) hypothesizes that self-injurers have learned from their environments to punish or invalidate themselves (Marsha M. Linehan, 1993). Self-injury therefore would be ego-syntonic and soothing in the face of emotional distress. The sensation-seeking model regards self-injury as a mode of providing excitement or stimulation. This model caries the least evidence compared to others (Laye-Gindhu & Schonert-Reichl, 2005).
ACUTE VERSUS CHRONIC SUICIDALITY
Though it would be somewhat clinically artificial to dichotomize suicidal ideation into acute and chronic states, however it has pragmatic values in terms of assessment and management. Acute suicidal ideation is characteristically an exceptional event in the life of an individual—typically abrupt or very recent in onset. (Sansone, 2004). It usually manifests after an overwhelming stressor and can cause distress to manifest an axis I disorders like depression. It is usually assumed to be a response to a profound sense of despair and desire for death, which, if unsuccessful, usually results in a persistence of the depressed mood state. While acute suicidal ideation usually occurs in the face of stressors or axis I disorder like depression and psychosis, chronic suicidal ideation is an ongoing, protracted process usually associated with axis II disorders specially borderline personality disorder. Chronic suicidal ideation seems to be more episodic, transient and a regulator of the emotional state. Persons with borderline personality disorder often report that there is a gradual build-up of suicidal ideation, which, when acted on, result in improvement in the affective state and a release of pent-up emotions. Suicidal ideation in borderline personality disorder varies in intensity over time. Findings from the Collaborative Longitudinal Study of Personality Disorders showed that borderline personality symptoms tend to wax and wane, depending on life events (Grilo, McGlashan, & Skodol, 2000). Therefore a person with borderline personality disorders during a good phase may not elicit any suicidal ideation, while during a crisis phase may have exacerbation of borderline pathology and heightened suicidal ideation. While comorbidity of major depressive episode and borderline personality disorder is common (Yen et al., 2003), it does not account for chronic suicidality. Long-term affective instability with a high level of sensitivity to the environment is a key feature of borderline personality disorder, which is posited to be a key element in maintaining the chronic suicidality in such patients. It can be hypothesized that chronic suicidality has three functions. The first involves dealing with painful affects (Marsha M. Linehan, 1993). A second function of chronic suicidality in borderline personality disorder can be to communicate distress (Paris, 2002). The third function of chronic suicidality could be to gain a sense of control. Borderline patients characteristically complain a sense of emptiness along with a fear of abandonment. This internal state may result in suicidal behaviors in an attempt to gain control over one’s own life. Thus while chronic suicidal ideation might be a hallmark of borderline personality disorder and other severe personality disorders, it becomes imperative to continue assessing for acute risk of suicide in these patients. There is no clear cut distinction between the two and this clinical judgment depends as much on the therapist’s anxiety as on objective risk (Paris, 2002).
PERSONALITY DIMENSIONS AND SUICIDALITY
Although a direct causal relation between personality traits and/or disorder with suicidal behaviour is complex, however research since 1990s has suggested that certain personality features and/or disorders are related to suicidal behavior and are independent of other known risk factors (Oldham, Skodol, & Bender, 2007). Research has shown that patients at risk of suicide have specific temperaments as well as personality and defense mechanism profiles (Pompili et al., 2008). Three sets of personality constellations have been consistently found in studies that are related with increased suicidality. Impulsive aggressiveness has been shown to have a strong association to a history of suicidal behavior (Arie et al., 2005; Oldham et al., 2007; Pompili et al., 2008; Zouk, Tousignant, Seguin, Lesage, & Turecki, 2006). Biological studies have also supported the association between impulsivity and suicidality. Oquendo and Mann conducted a comprehensive review of animal and human studies evaluating the biology of impulsivity and suicidality (M. A. Oquendo & Mann, 2000). They noted that impulsive aggression was associated with lower serotonin levels. Gerson et al summarized that self-injurious behavior involved lower serotonin and abnormal dopamine levels while suicidal behaviors involve lower serotonin and enhanced dopamine and norepinephrine levels (Gerson & Stanley, 2002). On the other hand, individual who are perfectionists and vulnerable to narcissistic injury might also be at increased risk of suicide. Suicide attempts in narcissistic patients can arise because of their very fragile self-esteem and in response to perceived narcissistic injury (Oldham et al., 2007). The theoretical and empirical literature on adolescent suicide also point towards an association between depression, perfectionism, narcissism and suicidal behavior (Arie et al., 2005). A third category of individual with consistently elevated risk of suicidal behaviors is those with emotional dysregulation. Linehan hypothesized that emotional dysregulation in conjunction with an invalidating environment explained the suicidal behavior characteristic of individuals with borderline personality disorder (Marsha M. Linehan, 1993). Emotional or affective dysregulation and impulsive aggression are considered as the two most relevant factors for suicidal or self-injurious behavior in patients with borderline personality disorder (Oldham, 2006). Other traits that have been useful in predicting history of suicidal attempts are aggression, anxiety, neuroticism, extroversion, impulsivity, hostility, and psychoticism (Brezo, Paris, & Turecki, 2006). Temperament has also been studied in the context of suicidality. In one study, irritable temperament and social introversion were the strongest predictors of suicide risk while hyperthymic temperament was found to be a protective factor both for hopelessness and suicide risk (Pompili et al., 2008). Specific affective temperament types (depressive, cyclothymic, hyperthymic, irritable, and anxious) have also been found to have a strong relationship with suicidal behavior (Kochman et al., 2005).
ASSESSMENT FOR SUICIDE RISK
The assessment and management of suicidality in patients with borderline personality disorder can be challenging and frustrating for even the most experienced clinicians, yet it is possible to identify acutely increased risk and use interventions to establish a therapeutic alliance and de-escalate the crisis situation. A detailed psychiatric evaluation is the first and foremost step in assessment of risk of suicide. The purpose of this evaluation is to obtain information regarding patient’s psychiatric and other medical history and current mental state about suicidal thinking and behaviour as well as through collateral source of information. This information enables the psychiatrist to identify specific factors influencing the risk for suicide or other suicidal behaviours and potential targets for interventions and in determining the setting for treatment of the patient. The use of suicide risk assessment scales can be used to assist the assessment but should not be used as a replacement to a thorough clinical assessment.
Many studies have identified risk factors at the population level, which are associated with an increased risk of suicidal behaviors. So extrapolation of these factors to an individual will allow categorization of the risk, but will be of less use in predicting suicide. The goal of a suicide assessment is therefore not to predict suicide, but rather to place a person along a putative risk continuum, to appreciate the basis of suicidality, and to allow for a more informed intervention (Jacobs, Brewer, & Klein-Benheim, 1999). Personality disorder may be a determinant of suicidal behavior in many ways; by predisposing to major psychiatric disorders such as depression or alcoholism, by leading to difficulties in relationship and social adjustment, by precipitating undesirable life events, by impairing the ability to cope with a psychiatric or physical disorder and also by drawing a person into conflicts with family members and others (Kulkarni, Rao, & Begum, 2013). Persons with personality disorders have been associated with a subset of specific risk factors associated with increased suicidal behavior. Some of these may be modifiable and therefore amenable to interventions. These are as follows:
1. Comorbid Disorders
Empirical evidence shows that comorbid psychiatric and personality disorders in suicide attempters pose greater estimated risk of suicide than psychiatric disorders alone (Kulkarni et al., 2013). The estimated risk of suicide can be six times greater in persons with comorbid psychiatric and personality disorders than in person with psychiatric disorders alone (Foster, Gillespie, & McClelland, 1997). Most of the research in the field of comorbidity in personality disorders and suicidality has been done in the field on borderline personality disorder. Soloff et al. found a higher level of lethality of suicide attempts in patients with comorbidity, compared to patients with borderline personality disorder alone (Paul H. Soloff, Fabio, Kelly, Malone, & Mann, 2005). In another study on inpatients with borderline personality disorder, Soloff and colleagues reported that the comorbidity of borderline personality disorder and major depressive episode increased the number and seriousness of suicide attempts (P. H. Soloff, Lynch, Kelly, Malone, & Mann, 2000). After using regression analysis on these patients, they identified impulsivity and hopelessness as independent risk factors for suicidal behaviors. Substance use has also been associated to be co-morbid with personality disorders especially borderline personality disorder. This well-documented comorbidity of substance abuse with borderline personality disorder (Oldham, 2006; Oldham et al., 2007; Torgersen, Kringlen, & Cramer, 2001) increases patients’ risk for impulsive suicidal behavior and for impaired judgment. The impairment of judgment with substance use can lead to a low intent but high lethality suicidal attempt.
2. Recent life events
Adverse life events can be a tumultuous phase in any person’s lifetime and these may push a vulnerable person towards suicide. In the stress diathesis model, suicidal behaviors occur when an individual with the diathesis is exposed to stress, which determines the behavior’s timing (Maria A. Oquendo et al., 2004). In a study of persons with personality disorders attempting suicide, it was found that negative life events, particularly those pertaining to love, marriage or crime–legal matters, were significant predictors of suicide attempts, even after controlling for baseline diagnoses of borderline personality disorder, major depressive disorders, substance use disorders, and a history of childhood sexual abuse (Yen et al., 2005). There has however been contradictory evidence wherein life events after adjusting for borderline personality disorders and major depressive episode have not been predictive of suicidal attempt (Kelly, Soloff, Lynch, Haas, & Mann, 2000).
3. History of childhood abuse
A childhood history of sexual or physical abuse is common in borderline personality disorder and is linked with self-injurious behavior in both clinical and nonclinical data. The history and severity of childhood sexual abuse but not physical abuse is also posited to predict adult suicidal behavior independent of other known risk factors (Paul H. Soloff, Lynch, & Kelly, 2002). These findings were further replicated recently wherein high levels of hostility and childhood history of sexual abuse led to an increased risk for suicidal behavior in patients with borderline personality disorder (Ferraz et al., 2013).
In summary, patients with personality disorders especially borderline and anti-social personality disorders in the presence of the above mentioned risk factor show increased suicidal behaviors. The presence of co-morbidity especially when acutely evident, may catapult these patients into acute suicidality.
When assessing suicidal behavior in the emergency department in a patient with chronic suicidality, it is useful to consider a model that describes ‘‘acute- on-chronic’’ risk (Oldham, 2006). This model suggest that acute stressors can increase a person with personality disorders’ suicidal risk. Comorbidities such as a past or current major depressive episode, substance use disorders, and history of sexual abuse can provide important information about a patient’s chronic level of risk, whereas a current major depressive episode or increasing substance use can indicate acute-on-chronic risk (Zaheer, Links, & Liu, 2008). A detailed history of previous suicidal attempts including the mode, lethality, circumstances of attempt and access to means should be necessarily done. This helps in assessing the clinical risk of suicidal behavior. Additional risk for suicide should be considered in patients with Cluster B personality disorder, schizotypal features, lifetime post-traumatic stress disorder and cognitive-perceptual symptoms which may further heighten the suicide risk (McGirr, Paris, Lesage, Renaud, & Turecki, 2007). This rigorous approach to assessment should also ensure that the known risk factors for suicide like other axis I diagnosis, age, social support be also assessed in persons with personality disorders. In patients who present with the ‘acute-on-chronic’ suicide risk, it is important to evaluate for the factors that are specific for the current prevailing emotional state as they may suggest as a proximal risk factor for suicidality. Rudd et al gave the concept of suicide warning signs which they described as the earliest detectable sign that indicates heightened risk for suicide in the near-term (Rudd et al., 2006). Similarly Hendin and his colleagues described three signs that immediately precede the suicide of a patient: a precipitating event, intense affective state other than depression like severe anxiety or extreme agitation, and recognizable changes in behaviour patterns including speech or actions that suggest suicide along with deterioration in occupational or social functioning, and increased substance abuse (Hendin, Maltsberger, Lipschitz, Haas, & Kyle, 2001). It is equally important to enquire into other personality profiles associated with increased suicidal risk like affective instability, impulsivity, and aggression particularly in borderline patients. One should keep in mind that although patients with borderline personality disorder are usually chronically suicidal, it is good practice to always assess for acute risk of suicide and manage it accordingly. Once a detailed evaluation of the suicide risk is made, clinicians should progress onto de-escalate the patient, establish a plan of safety, prepare a management plan and hospitalize the patient if necessary.
Setting
Treatment settings and conditions include a continuum of possible levels of care, from an inpatient setting to partial hospitalisation and intensive outpatient programs to occasional ambulatory visits. The choice of specific treatment setting depends not only on the psychiatrist’s estimate of the patient’s current suicide risk and potential for dangerousness to others, but also on other aspects of the patient’s current status. In addition, the benefits of intensive interventions such as hospitalization must be weighed against their possible negative effects (e.g., disruption of employment, financial and other psychosocial stress, social stigma).
A history of past suicide attempts is one of the most significant risk factors for suicide, even in patients of personality disorders and this risk may be increased by more serious, more frequent, or more recent attempts. Thus, it is very important to ask about past suicide attempts and self-destructive behaviors, including specific questioning about aborted suicide attempts.
A review of past history of treatment including the pharmacological and psychological treatments is also important and should include information on co-morbid diagnoses, prior hospitalizations, suicidal ideation, or previous suicide attempts.
A family history of suicide, mental illness, and dysfunction should be obtained as well which must include suicide and suicide attempts as well as a family history of any psychiatric hospitalizations or mental illness, including substance use disorders. Also one should enquire about family organization and structure. The probing should include a history of family conflict or separation, parental legal trouble, family substance use, domestic violence, and physical and/or sexual abuse.
The current psychosocial adversities or crisis faced by patient can also increase the risk of suicide viz financial or legal stressors, interpersonal conflicts or losses; homelessness; loss of job; failure in exams.
In persons with personality disorders significant contribution is made by hopelessness, aggression, and impulsivity, all or none thinking, perfectionism with very high expectations from oneself. It is also helpful to determine the patient’s tendency to engage in risk-taking behaviours as well as the patient’s past responses to stress, including the capacity for reality testing and the ability to tolerate rejection, subjective loneliness, or psychological pain when his or her unique psychological needs are not met.
As part of the suicide assessment it is essential to inquire specifically about the patient’s grading of suicidal thoughts, plans, behaviours, and intent.
Another important part of assessment is the direct enquiry regarding suicidal ideation. Also the assessor should probe about the presence of suicide plan and any steps that have been taken toward enacting those plans. The persons with personality disorder always do not engage in only deliberate self harm but some of the attempts are actually steps taken to end life. A clinician should take into account of this fact and a high degree of sensitivity should be exercised.
The relevance of scales in risk assessment.
A number of suicide assessment scales have been developed by researchers for use in suicidal patients. Self-report rating scales may sometimes assist in opening communication with the patient about particular feelings or experiences. In addition, the content of suicide rating scales, such as the Scale for Suicide Ideation (Beck et al, 1979) and the Suicide Intent Scale (Beck et al, 1974), may be helpful to psychiatrists in developing a thorough line of questioning about suicide and suicidal behaviours. However, existing suicide assessment scales suffer from high false positive and false negative rates and have very low positive predictive values (Brown et al, 2002).As a result, such rating scales should not be used as substitutes for a detailed clinical evaluation for clinical estimations of suicide risk.