Addressing issues related to addictive behaviors and diagnoses
Disorders that are thought to have an addictive component other than substance use disorders (SUDs) include those involving self-injury. Self-injury–related diagnoses include nonsuicidal self-injury (NSSI), excoriation disorder, and trichotillomania. Types of self-harm include cutting with a sharp object (e.g., razor blade, knife), burning, pulling out hair, or picking at wounds to prevent healing (National Alliance on Mental Illness, 2020). Prevalence rates are hard to determine because often self-injury may go unreported or undetected. Estimated rates are higher in teenagers, with a rate of up to 30% in this population (Monto et al., 2018) and 6% in adults (Westers et al., 2016). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5; American Psychiatric Association [APA], 2013) lists NSSI as a condition for further study. Proposed criteria include self-inflicted injury for more than 5 days in the past 1 year with the expectation of obtaining relief from a negative feeling or cognitive state, to resolve an interpersonal difficulty, or to induce a state of positive feeling (APA, 2013). Other self-injurious behaviors include excoriation disorder, picking at skin that is experienced as pleasurable, and trichotillomania, pulling hair on the body, which can lead to gratification or pleasure. These behaviors are also considered anxiety-related disorders (APA, 2013). Results of a meta-analysis included an association between self-injury and other anxiety and mood disorders (Bentley et al., 2015).
Self-injury has been described as having an addictive component (Blasco-Fontecilla et al., 2016). Addiction can be described as a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and life experiences in which people engage in behaviors that become compulsive and often continue despite harmful consequences (American Society of Addiction Medicine, 2019). Harmful consequences of self-injuring behavior include disfigurement, which can lead to stigma, potential for infection, and unintended death. In addition, self-harm has been associated with an increased risk of future suicide attempts (Castellví et al., 2017). Dissociation has also been linked to the act of self-injury. Dissociation can be described as an altered state of consciousness that results in diminished awareness of the environment, which may explain the incongruence of inflicting pain to feel better (Kiliç et al., 2017).
Neurobiology of Self-Injury and the Pleasure Reward System
The underlying neurobiology of self-injury is thought to be similar to substance use disorders (SUDs), in which a physiological response of increased dopamine is triggered by a compulsive behavior that leads to chronically decreased dopamine levels (Volkow et al., 2016). People with NSSI have been found to have low levels of endogenous opioids (Groschwitz & Plener, 2012). In self-injury, pain activates opioid receptors in the pleasure reward system of the brain, which increases dopamine levels (Bresin & Gordon, 2013). In some cases, people induce pain, which increases dopamine, to self-medicate (Bresin & Gordon, 2013). However, the body responds to repeated activation of the brain reward system and higher dopamine production by attempting to maintain homeostasis, resulting in altered dopamine regulation and a decrease in dopamine production (Volkow et al., 2016). Low dopamine levels are associated with a decreased feeling of well-being, difficulty responding to stress, and craving to engage in addictive behaviors (Volkow et al., 2016). In addition, low dopamine levels are thought to result from chronic stress or exposure to trauma in people who self-injure (Stanley et al., 2010). It is also thought that pain leading to increased endogenous opioids serves as a function to regulate negative affect (Bresin & Gordon, 2013). Furthermore, neurobiological changes noted on brain scans in people with self-injury include hyperarousal in limbic structures, such as the amygdala and anterior cingulate cortex, as well as decreased cortisol levels (Groschwitz & Plener, 2012).
Perspectives from People Who Engage in Self-Injury
Individuals who engage in self-injury do so for a variety of reasons, including to feel pain because they feel emotional numbness; to experience physical pain rather than emotional pain; and also for the physical pain to take away the emotional pain, and to experience a pleasurable response (Mayo Clinic, 2020). Results from qualitative studies with people who engage in self-injury often reveal an addictive component. In one open-ended survey study of 88 participants recruited from an online NSSI support group, many participants used addiction-related terms such as “tolerance” and “progression” in describing their experience (Wester & McKibben, 2016). Moreover, many described an immediate emotional relief from NSSI followed by guilt and shame (Wester & McKibben, 2016). In another content analysis study of 500 online forum postings, researchers identified addictive themes, including those related to urges and obsessions, relapse, not wanting to or being able to stop, self-injuring as a coping mechanism, and hiding and shame (Davis & Lewis, 2019). In addition, a quality caring approach from health care professionals has been identified as important to recovery in people who self-injure (Lindgren et al., 2018). Unfortunately, negative attitudes of nurses toward patients who self-injure have been identified (Hodgson, 2016).
Screening and Identification of Patients Who Self-Injure
Questions about self-injury, including if individuals have ever cut or hurt themselves for reasons other than suicide, should be asked within the course of a mental health assessment. For individuals who have self-injured, follow-up questions including how often, where the injuries were, and what was used should be asked. Asking to see any scars is useful to determine severity. Physical examination, when conducted, may show evidence of self-injury, although individuals may take steps to self-injure in places that are not readily visible.
Several screening instruments have been developed to identify self-harm. The Ottowa Self-Injury Inventory is a 26-item self-report questionnaire for assessing functions and addictive features of self-injury and has been validated and used in numerous studies (Cloutier & Nixon, 2003; Guérin-Marion et al., 2018; Martin et al., 2013). Other self-harm instruments include the 17-item self-report Deliberate Self-Harm Inventory (Gratz, 2001) and the Self-Harm Inventory, which is a 22-item self-report questionnaire (Sansone & Sansone, 2010). In addition, a model has been developed to assess suicidal ideation, onset, aftercare, reasons, and stage of change (SOARS), which includes a guide to responding to self-injury (Westers et al., 2016).
Nonpharmacological Treatment for Self-Harm
Identifying triggers and developing coping skills are important components of therapy strategies for treating self-injury. Dialectical behavioral therapy (DBT) is the most common nonpharmacological treatment for self-injury, which focuses on emotional regulation. Strategies in DBT include accepting reality as it is and changing behaviors that need to be changed through individual and group therapy, mindfulness training, and telephone coaching (Prada et al., 2018). DBT has been shown to be an effective treatment for self-injury in numerous high-level evidence research studies (Cook & Gorraiz, 2016; McCauley et al., 2018).
Cognitive-behavioral therapy (CBT) is another form of therapy used to treat self-injury that focuses on skills to change thinking and behavior to improve mood, functioning, and well-being (Beck Institute for Cognitive Behavior Therapy, 2019). Researchers who conducted a systematic review and meta-analysis of psychosocial interventions for self-injury found evidence that CBT was associated with a reduction in self-harm. Harm reduction strategies offer safer substitutes for self-injury, including placing ice on the skin, which causes a painful burning sensation without breaking the skin, or placing a rubber band on wrists or ankles and snapping it instead of cutting the skin (HelpGuide, 2019).
Pharmacological Treatment for Self-Injury
Individuals who engage in self-harm should be screened and treated for other co-occurring mental health disorders, such as anxiety and mood disorders, with U.S. Food and Drug Administration (FDA)–approved medications such as serotonin reuptake inhibitors, norepinephrine reuptake inhibitors, and mood stabilizers. Naltrexone, an off-label, non-FDA–approved medication has been studied and is useful in treating self-injury by targeting the addictive process. Naltrexone is an opioid antagonist currently approved for opioid and alcohol use disorder and has an action as an antagonist that attaches to opioid receptors in the brain, which blocks the effect of opioids and alcohol as well as reduces cravings (Substance Abuse and Mental Health Services Administration, 2019). Off-label naltrexone has been extensively studied, including in randomized controlled trials and systematic reviews, for treatment of a variety of mental health disorders that are associated with an addictive component, including other substances as well as self-injury (Worley, 2017). Naltrexone was found to be an effective medication for self-injury in a systematic review of pharmacological interventions for self-injury (Turner et al., 2014). In another study, a retrospective analysis of 161 patients treated with naltrexone for self-injury showed a highly significant reduction of self-harm (Meiser et al., 2015). In addition, results of older studies have shown a decrease in self-injury with the use of naltrexone (Griengl et al., 2001; Guerdjikova et al., 2014; Roth et al., 1996).
Patients with anxiety and mood disorders have higher rates of self-injury. It is important to identify and address self-injury because it can lead to adverse results, including infection; disfigurement, which can lead to stigma; unintended death; and a higher risk of suicide. Nurses can educate patients on the addictive component to self-injury, which can be useful for prevention as well as to help people develop coping skills and alternatives to self-injury. Nurses can play an important role in screening patients who engage in self-injury and referring them for treatment and should approach patients with support and without judgment. Questions and screening instruments are useful in identifying individuals who self-injure. Once identified, individuals should be referred for treatment, which can include nonpharmacological treatment, such as DBT and CBT, as well as pharmacological management with off-label use of naltrexone. With knowledge of the underlying neurobiology and treatment strategies, nurses can help improve the quality of life for individuals who engage in self-injury.
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