The functions of deliberate self-injury: A review of the evidence

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Abstract

Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. The present article reviews the empirical research on the functions of self-injury. This literature includes self-reports of reasons for self-injuring, descriptions of the phenomenology of self-injury, and laboratory studies examining the effects of self-injury proxies on affect and physiological arousal. Results from 18 studies provide converging evidence for an affect-regulation function. Research indicates that: (a) acute negative affect precedes self-injury, (b) decreased negative affect and relief are present after self-injury, (c) self-injury is most often performed with intent to alleviate negative affect, and (d) negative affect and arousal are reduced by the performance of self-injury proxies in laboratory settings. Studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions. The conceptual and empirical relationships among the different functions remain unclear. Future research should address the measurement, co-variation, clinical correlates, and treatment implications of different functions.

Introduction

Deliberate self-injury (to be referred to as self-injury for the remainder of the paper) can be defined as the intentional and direct injuring of one's body tissue without suicidal intent (Herpertz, 1995, Muehlenkamp, 2005). Other names have also been used to refer to this behavior, including moderate self-mutilation by Favazza and Rosenthal (1993), deliberate self-harm by Pattison and Kahan (1983), self-wounding by Tantam and Whittaker (1992), and parasuicide by Ogundipe (1999). Self-injury is differentiated from stereotypic self-injurious behaviors seen in individuals with mental retardation, and from severe forms of self-mutilation such as limb amputation seen in psychotic individuals. Skin-cutting appears to be the most common type of self-injury, but other forms include burning, scratching, banging or hitting body parts, and interfering with wound healing (Briere and Gil, 1998, Favazza and Conterio, 1989, Herpertz, 1995, Langbehn and Pfohl, 1993).

The phenomenon of self-injury has concerned mental health professionals for decades. In their seminal paper, Graff and Mallin (1967) recognized self-injury as a mainstream psychiatric problem, stating that “[nonsuicidal] wrist-slashers have become the new chronic patients in mental hospitals, replacing the schizophrenics” (p. 36). Efforts to characterize the scope and nature of the problem increased in the 1970s (Carr, 1977, Lester, 1972), and by the early 1980s some were calling for self-injury to comprise its own diagnostic entity (Pattison & Kahan, 1983).

Research on self-injury has increased in recent years, and much is now known about the prevalence and risk factors for self-injury in various populations (Skegg, 2005, Gratz, 2003). However, we continue to lack a sufficient understanding of the functions of self-injury. This understanding would inform treatment, and provide a meaningful context for research on the etiology, classification, prevention, and treatment of self-injury. The goal of the present paper is to consolidate and advance knowledge about the functions of self-injury. Towards this end, I first summarize the research on the psychosocial characteristics, descriptive psychopathology, and treatment of self-injury. I then present a detailed review of the empirical literature on the functions of self-injury. I conclude by describing research endeavors that would further clarify the functions of self-injury and their implications for clinical practice.

Section snippets

Psychosocial characteristics, descriptive psychopathology, and treatment

According to the psychiatric nosology (APA, 2000), self-injury is a symptom of borderline personality disorder. Although research has documented a strong relationship between self-injury and this disorder (Klonsky et al., 2003, Simeon et al., 1992, Stanley et al., 2001, van der Kolk et al., 1991, Zlotnick et al., 1999), patients with other diagnoses may also self-injure, including those with major depression, anxiety disorders, substance abuse, eating disorders, posttraumatic stress disorder,

Empirical research on the functions of self-injury

The primary aim of this article is to review the empirical research on the functions of self-injury. Below I describe the inclusion criteria, functional theories examined, methods utilized to examine functions, and findings from the empirical literature.

Explore conceptual and empirical relationships among functions

Although the affect-regulation function of self-injury was apparent in every study reviewed, results suggest that self-injury also serves at least six other functions. Evidence of multiple functions can be interpreted in several ways, which are not mutually exclusive: (a) different functions may distinguish different subgroups of self-injurers; (b) multiple functions for self-injury may exist concurrently within-individuals; (c) functions of self-injury may evolve over time within-individuals;

Acknowledgement

I thank Thomas F. Oltmanns, Ph.D., Eric Turkheimer, Ph.D., and Alexis Black, M. A. for comments on earlier versions of this paper. This work was supported in part by Grant MH67299 from the National Institute of Mental Health and by the Office of the Vice President of Research at Stony Brook University.

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