Introduction
Self-injurious thoughts and behaviors (SITB) encompass a range of actions where individuals intentionally harm themselves, often reflecting complex psychological struggles. These behaviors include suicide attempts and non-suicidal self-injury (NSSI), distinguished primarily by the intent to die. Understanding these behaviors, their underlying theories, risk factors, assessments, and interventions is crucial for effective clinical management and prevention.
Definitions and Distinctions
Self-injurious behavior (SIB) or self-directed violence refers to deliberate attempts to harm oneself, without necessarily intending death (Centers for Disease Control and Prevention [CDC], as cited in Nock, 2017). In contrast, risky behaviors like rough driving or excessive drinking, though harmful, do not qualify as SIB unless intent to harm oneself is present. The intent to die separates suicidal behavior from NSSI, where the latter serves other functions such as emotional regulation.
Earlier classifications like the DSM-IV-TR and ICD-10 subsumed suicide under disorders like major depressive disorder or emotionally unstable personality disorder. The DSM-5, however, emphasizes the importance of considering NSSI as a distinct diagnosis, a view supported by suicidologists advocating for nuanced understanding (Nock, 2017).
Risk and Protective Factors
Risk factors include genetic predispositions, psychiatric disorders, childhood trauma, emotional dysregulation, and stressful life events. Conversely, protective factors such as strong social support, effective coping skills, and access to mental health care can buffer against SITB.
Theories of Suicidal Behavior
Several theoretical models attempt to explain suicidal behavior:
- Hopelessness Theory (Beck et al., 1985) posits that pervasive hopelessness drives suicidality.
- Psychache Theory (Shneidman, 1996) highlights unbearable psychological pain as the central cause.
- Escape Theory (Baumeister, 1990) suggests suicide as an escape from aversive self-awareness.
- Emotional Dysregulation Theory (Linehan, 1993) frames suicide as an extreme attempt to regulate intense negative emotions.
- Interpersonal Psychological Theory (Joiner, 2005) emphasizes the interaction between perceived burdensomeness, thwarted belongingness, and acquired capability for suicide.
Theories of Non-Suicidal Self-Injury
Various models explain the emergence and maintenance of NSSI:
- Biological theories propose that endorphin release during NSSI produces rewarding sensations.
- Social and communication models suggest NSSI serves to express emotions, avoid unpleasant tasks, or seek attention (Walsh, 2014).
- Psychodynamic models view NSSI as a way to establish boundaries between self and others.
- Anti-suicide model interprets NSSI as a compromise to manage suicidal urges without ending life.
- Affect Regulation Theory considers NSSI a strategy to reduce negative affect and generate positive feelings.
- Experiential Avoidance Model (Chapman et al., 2006) describes NSSI as a way to escape from intolerable internal experiences.
- Emotional Cascade Model (Selby et al., 2008) suggests that rumination fuels negative affect, leading individuals to engage in NSSI to disrupt the cycle.
Additionally, social learning and cognitive models point to learned associations and efforts to suppress unwanted thoughts as contributors to NSSI.
Assessment of SITB
Comprehensive assessment tools are essential:
- Suicide-specific scales include the Beck Suicide Intent Scale, Beck Scale for Suicide Ideation, and Suicide Behavior Questionnaire-Revised.
- NSSI assessments include the Self-Injury Questionnaire, Self-Harm Inventory, and Inventory of Statements About Self-Injury.
Risk assessment must consider contextual factors (e.g., triggers, motivations, outcomes) and employ a hierarchical exploration of thoughts and intent (Rudd, 2006; Rudd, 2012).
Prevention and Treatment
Prevention Strategies
- Raising awareness through helplines and public education.
- Promoting emotional regulation, healthy coping, and communication skills.
- Reducing self-derogation and enhancing self-esteem.
Treatment Approaches
Suicide Treatment
- Pharmacological interventions and hospitalization when necessary.
- Ensuring environmental safety.
- Brief problem-focused therapies to address crisis points.
- Involving significant others in care planning (Walsh, 2014).
NSSI Treatment
- Ensuring safety through after-care planning and first aid education.
- Evidence-based psychotherapies like Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Cognitive Analytic Therapy (CAT), and Acceptance and Commitment Therapy (ACT).
- Replacement skill training: teaching alternatives like mindful breathing, artistic expression, and physical activity.
- Negative replacement behaviors: using safe methods to simulate self-injury sensations without tissue damage (e.g., snapping a rubber band, holding ice cubes).
Mindful Breathing Techniques
Mindfulness exercises such as "I Am Here... I Am Calm", exhale counting, and "letting go" breathing help individuals remain present, reduce judgmental thinking, and manage emotional surges associated with self-injurious urges (Walsh, 2014).
Conclusion
Understanding and addressing SITB requires a nuanced appreciation of underlying emotional, cognitive, biological, and social factors. Integrating thorough assessment, preventive efforts, and evidence-based interventions can significantly reduce the burden of suicide and NSSI, offering individuals pathways toward recovery and resilience.
References
- Beck, A. T., Brown, G. K., Berchick, R. J., Stewart, B. L., & Steer, R. A. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142(5), 559–563.
- Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97(1), 90–113.
- Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44(3), 371–394.
- Joiner, T. E. (2005). Why people die by suicide. Harvard University Press.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
- Nock, M. K. (2017). The Oxford handbook of suicide and self-injury. Oxford University Press.
- Rudd, M. D. (2006). The assessment and management of suicidality. Professional Resource Press.
- Rudd, M. D. (2012). Brief cognitive-behavioral therapy for suicidal patients. Guilford Press.
- Selby, E. A., Anestis, M. D., & Joiner, T. E. (2008). Understanding the relationship between emotional and behavioral dysregulation: Emotional cascades. Behaviour Research and Therapy, 46(5), 593–611.
- Shneidman, E. S. (1996). The suicidal mind. Oxford University Press.
- Walsh, B. W. (2014). Treating self-injury: A practical guide (2nd ed.). Guilford Press.