|
Article Excerpt
Public interest in self-injurious behaviors (SIB) has I increased rapidly in recent years. The media and popular literature have begun to address the issue of SIB, and counselors have had an increasing number of clients presenting with SIB. Minor forms of self-injury, such as hair twisting and fingernail biting, are common among the general population. Most cultures also have forms of culturally approved and sanctioned SIB (Favazza, 1996). For example, in Western culture, ear-piercing, tattooing, various forms of body piercing, and plastic surgery are becoming more commonplace.
In the clinical literature, there are many varied definitions indicating what constitutes SIB. For the purposes of this article, SIB is defined as a volitional act to harm one's body without any intention to die as a result of the behavior (Simeon & Favazza, 2001; Yarura-Tobias, Neziroglu, & Kaplan, 1995).
There seems to be an upward trend in the incidence of SIB. Earlier estimates indicated that 1% of the general population self-injured (Lester, 1972), and 3% to 5% of psychiatric populations engaged in SIB (Ballinger, 1971; Phillips & Muzaffer, 1961). More recent estimates indicate that approximately 4% of the general population and 21% of the clinical populations without mental retardation or a developmental disability engage in SIB (Briere & Gil, 1998). More specifically, SIB is seen in 13% to 53% of patients diagnosed with Tourette's syndrome (Robertson, 1989; Robertson, Trimble, & Lees, 1989), in 3% to 46% of the population diagnosed with mental retardation or a developmental disability (Bodfish, Crawford, & Powell, 1995; Winchel & Stanley, 1991), and in 75% of hospital patients diagnosed with borderline personality disorder (BPD; Clarkin, Widiger, & Frances, 1983).
Despite an ostensible increase in and discussion of SIB, little is known about the etiology, course, diagnosis, assessment, and appropriate treatment interventions associated with SIB. Many counselors have had little, if any, exposure in managing issues associated with client SIB.
This article focuses on forms of SIB as described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association [APA], 2000). Self-injury has long been recognized as being related to many mental disorders. The current DSM-IV-TR diagnoses that are most related to SIB are stereotypic movement disorder with self-injurious behavior, trichotillomania, impulse-control disorder not otherwise specified (NOS), and BPD.
It is important for counselors to be able to diagnose and assess SIB accurately for several reasons. First, a thorough assessment of SIB is needed to select appropriate diagnoses and to determine the severity and potential degree of danger of such behaviors. Second, the appropriate diagnosis of SIB is critical for a clear understanding of the client's SIB dynamics and the eventual selection of effective interventions.
Education on SIB has been shown to increase health care professionals' ability to assess and manage clients who self-injure (Crawford, Turnbull, & Wessely, 1997). To encourage accurate client diagnosis, this article provides an introduction to the diagnosis and assessment of SIB. A recently updated classification system that can facilitate counselor conceptualization of client SIB is discussed, along with the DSM-IV-TR diagnoses associated with SIB. Finally, questions and issues to consider in assessing SIB are addressed. After reading this article, counselors should feel more comfortable with diagnostic and assessment issues as well as special considerations when in the initial stages of working with clients who engage in SIB.
CLASSIFICATION AND DIAGNOSIS OF SIB
Classification of SIB
As stated, SIB is varied and complex and spans the DSM-IV-TR diagnostic categories. Recently, Simeon and Favazza (2001) expanded on an earlier model (Favazza & Rosenthal, 1990, 1993) and developed a classification system for organizing and categorizing SIB. Each of the four categories corresponds to, and tends to be more prevalent with, various DSM-IV-TR mental disorders. The four-category classification of SIB is as follows: Stereotypic SIB, Major SIB, Compulsive SIB, and Impulsive SIB.
Stereotypic SIB generally includes behaviors such as head banging, self-hitting and face slapping, lip and hand chewing, self-biting, and hair pulling behaviors most typically seen in individuals with organic mental disorders such as mental retardation and developmental delay. In these cases, SIB has typically been conceptualized as organically based, biologically driven behaviors. The pattern of these injurious behaviors is fixed and highly repetitive, causing a range of mild to severe tissue damage. Disorders associated with this type of SIB include Tourette's syndrome, Lesch-Nyhan syndrome, autism, temporal lobe epilepsy, mental retardation, and Cornelia de Lange.
Major SIB includes more severe or potentially life-threatening injuries such as castration, eye enucleation, and limb amputation. These extremely intrusive behaviors are obviously very isolated and generally occur when a person is suffering from a severe psychosis, intoxication, or a severe character disorder. Self-injurious behaviors of psychotic people differ from the other forms of SIB in that the person injures in response to profound disorders of perception or thought and does not recognize the irrationality of the behavior (Conn & Lion, 1983). The SIB is not of the stereotyped repetitive type but is composed of discrete acts that are often bizarre or drastic and that have personalized, symbolic meaning to the person (Conn & Lion, 1983). People who are psychotic and self-injure may do so in response to command hallucinations or delusions, particularly religiously theme-related delusions. In psychotic-related SIB, the organ system or body part that is injured is almost always associated with a delusional...
|
