Psychiatric Times.
No. 7
Adolescent Nonsuicidal Self-Injury: Evaluation and Treatment
Why Do Adolescents Self-Injure and What Are the Therapeutic Options for Treating Them?
By Brian D. Smith, MD |
June 1, 2008
Dr Smith is assistant professor in the department of psychiatry at Michigan State University, Lansing. He reports no conflicts of interest concerning the subject matter of this article.
Pharmacotherapy for self-injury
There is evidence, albeit limited, for pharmacotherapy. It should be noted that there are no medications currently labeled for the treatment of self-injury or BPD. Medications are used to target the neurotransmitter systems most likely to contribute to self-injury. Opioid, serotonin, and dopamine(Drug information on dopamine) receptors are commonly implicated.
The opioid system is implicated because of higher pain thresholds and stress-induced analgesia in BPD, likely mediated by increased activity of the dorsal prefrontal cortex with deactivation of the anterior cingulate and amygdala.34 NSSI may also involve addictive qualities, including postcessation withdrawal dysphoria.14 Open-label studies of the opioid antagonist naltrexone(Drug information on naltrexone) have shown reduced self-injury.35,36
Decreased serotonin levels have been linked to impulsive, aggressive, and suicidal behaviors.37 Self-injury is usually an impulsive act, with half of cutters thinking of the behavior less than an hour before committing the act.22 Fluoxetine(Drug information on fluoxetine) is the serotonergic medication with the most evidence for use in NSSI, with at least 2 controlled trials showing reductions in impulsive aggression.38,39 In an open-label trial, venlafaxine was also beneficial.40Self-injury may also present in syndromes that involve the dopamine system, such as Lesch-Nyhan syndrome and Tourette syndrome.41 Self-biting behaviors may be elicited by stimulants that primarily work through a dopaminergic mechanism of action. The use of dopamine antagonists has been studied for NSSI. Although there is some evidence for the efficacy of all of the atypical antipsychotics for reducing aggression and/or impulsivity, olanzapine(Drug information on olanzapine) has had the best results in the most rigorous trial designs.39,42-46
There is a paucity of literature regarding combination therapy. Surprisingly, adding fluoxetine to DBT was not found to give any additional benefit.47 A trial of olanzapine plus DBT reduced the frequency of impulsivity/aggressive behavior more than placebo plus DBT, although self-injurious behavior did not decrease significantly.48In addition to serotonergic, dopaminergic, and opioid medications there are other drug categories being studied for NSSI. There are promising case reports for glutamate-decreasing agents, including riluzole(Drug information on riluzole), N-acetylcysteine, and topiramate.49 Similarly, the glutamate-modulating agent lamotrigine(Drug information on lamotrigine) was found to decrease behavioral dyscontrol, impulsivity, and anger in open-label trials, retrospective trials, and controlled trials.50-52 There have been controlled studies of lithium(Drug information on lithium), divalproex, carbamazepine(Drug information on carbamazepine), and omega-3 fatty acids, which have all demonstrated decreases in impulsive aggression, but not NSSI specifically, in individuals with BPD.53-56 There was also an open-label study of oxcarbazepine(Drug information on oxcarbazepine) that demonstrated statistically significant decreases in impulsivity, affective instability, and outbursts of anger in small sample populations with BPD.57 Clonidine(Drug information on clonidine), an a2-agonist, decreased the urge to commit self-injurious behavior in an open study.58
Conclusions
NSSI is common and its prevalence may be increasing in adolescents. There are a number of known risk factors for NSSI, and NSSI may be a risk factor for later suicide attempts and completion. NSSI has a number of psychological functions and may be contagious and/or addictive. DBT, when available, can be considered the standard treatment for cases of NSSI that do not respond to initial interventions.
Medications should be considered the second line of treatment in most instances. The serotonin, opioid, and dopamine systems have been implicated, so medications that target these systems have potential benefit. Before pharmacological treatment is initiated for NSSI, preexisting medications for other mental health concerns should be optimized. In the absence of an existing psychotropic regimen or clear indications for pharmacotherapy of comorbid mental health conditions, fluoxetine, currently the best-studied antidepressant for NSSI, is a good first option. If fluoxetine is poorly tolerated or of insufficient benefit, consider switching to olanzapine, which appears to be the most effective atypical antipsychotic for NSSI.
The suggestion of first initiating a trial of an SSRI, as opposed to an atypical antipsychotic, has more to do with side-effect profile than potential efficacy. In fact, a recent meta-analysis of randomized controlled trials of pharmacotherapy against core traits of BPD found that antidepressants and mood stabilizers did not produce significant benefits against impulsivity and aggression or suicidality (although they were effective against affective instability and anger).59 On the other hand, antipsychotics, as a class, had a positive effect in reducing impulsivity and aggression. For severe and/or refractory cases, consider other SSRIs, serotonin-norepinephrine reuptake inhibitors, other atypical antipsychotics, naltrexone, clonidine, mood stabilizers, or glutamate-modulating agents (Table 2).
Given our growing awareness of the magnitude of the NSSI problem and the limited evidence base for its treatment, there are many future directions for research. Studies that specifically target the symptom of self-injury, especially in individuals without BPD, are sorely needed. We must also construct new studies that overcome limitations of past studies including small sample sizes, with a predominance of female, white, and adult participants, lack of controls, over reliance on self-report, low dosing of medications, and short trial durations. There needs to be further investigation of new generation antidepressants, naltrexone, clonidine, omega-3 fatty acids, atypical antipsychotics, mood stabilizers, glutamate-modulating agents, and polypharmacy to target NSSI. Finally, there must be further investigation of the potential efficacy of combined medication and psychotherapy, especially DBT.
References
1. Simeon D, Stanley B, Frances A, et al. Self-mutilation in personality disorders: psychological and biological correlates. Am J Psychiatry. 1992;149:221-226.
2. Favazza AR, Conterio K. Female habitual self-mutilators. Acta Psychiatr Scand. 1989;79:
283-289.
3. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates,
and functions. Am J Orthopsychiatry. 1998;68:
609-620.
4. Klonsky ED. The functions of deliberate self-injury:
A review of the evidence. Clin Psychol Rev. 2007;
27:226-239.
5. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117:1939-1948.
6. Muehlenkamp JJ, Gutierrez PM. An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav. 2004;34:12-23.
7. Hawton K, Fagg J, Simkin S, et al. Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. Br J Psychiatry. 1997;171:556-560.
8. Zanarini MC, Frankenburg FR, Ridolfi ME, et al. Reported childhood onset of self-mutilation among borderline patients. J Personal Disord. 2006;20:9-15.
9. Volkow ND. What do we know about drug addiction? Am J Psychiatry. 2005;162:1401-1402.
10. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114:140-146.
11. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL. Discriminating borderline personality from other axis II disorders. Am J Psychiatry. 1990;
147:161-167.
12. Guertin T, Lloyd-Richardson E, Spirito A, et al. Self-mutilative behavior in adolescents who attempt suicide by overdose. J Am Acad Child Adolesc Psychiatry. 2001;40:1062-1069.
13. Sansone RA, Levitt JL. Self-harm behaviors among those with eating disorders: an overview. Eating Disord. 2002;10:205-213.
14. Favazza AR. Self-injurious behavior in college students. Pediatrics. 2006;117:2283-2284.
15. Young R, Sweeting H, West P. Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study. BMJ. 2006;332:1058-1061.
16. Jones MB, Jones DR. Testing for behavioral contagion in a case-control design. J Psychiatr Res. 1994;28:35-55.
17. Taiminen TJ, Kallio-Soukaninen K, Nokso-
Koivisto H, et al. Contagion of deliberate self-harm among adolescent inpatients. J Am Acad Child
Adolesc Psychiatry. 1998;37:211-217.
18. Whitlock JL, Powers JL, Eckenrode J. The virtual cutting edge: the internet and adolescent self-injury. Dev Psychol. 2006;42:407-417.
19. Nock MK, Prinstein M. A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72:885-890.
20. Gutierrez P, Osman A, Barrios F, Kopper B. Development and initial validation of the Self-harm Behavior Questionnaire. J Pers Assess. 2001;77:475-490.
21. Sansone R, Wiederman M, Sansone L. The Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. J Clin Psychol. 1998;54:973-983.
22. Rodham K, Hawton K, Evans E. Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43:80-87.
23. Cooper J, Kapur N, Webb R, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry. 2005;162:297-303.
24. Nock MK, Joiner TE Jr, Gordon KH, et al. Nonsuicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144:65-72.
25. Zimmerman GL, Olsen CG, Bosworth MF. A "stages of change" approach to helping patients change behavior. Am Fam Physician. 2000;61:1409-1416.
26. Suyemoto KL, MacDonald ML. Self-cutting in female adolescents. Psychotherapy. 1995;32:162-171.
27. Walsh BW. Treating Self-Injury. New York: Guilford Press; 2006.
28. Conterio K, Lader W. Bodily Harm. New York: Hyperion Press; 1998.
29. van den Bosch LM, Koeter MW, Stijnen T, et al. Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behav Res Ther. 2005;43:1231-1241.
30. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757-766.
31. Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet. 2004;364:453-461.
32. Weinberg I, Gunderson JG, Hennen J, Cutter CJ Jr. Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients. J Personal Disord. 2006;20:482-492.
33. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry. 2001;158:36-42.
34. Schmahl C, Bohus M, Esposito F, et al. Neural correlates of antinociception in borderline personality disorder. Arch Gen Psych. 2006;63:659-667.
35. Roth AS, Ostroff RB, Hoffman RE. Naltrexone as a treatment for repetitive self-injurious behavior: an open-label trial. J Clin Psychiatry. 1996;57:233-237.
36. Sonne S, Rubey R, Brady K, et al. Naltrexone treatment of self-injurious thoughts and behaviors. J Nerv Ment Dis. 1996;184:192-194.
37. Coccaro EF, Siever LJ, Klar HM, et al. Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior. Arch Gen Psychiatry. 1989;46:587-599.
38. Rinne T, van den Brink W, Wouters L, van Dyck R. SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder. Am J Psychiatry. 2002;159:2048-2054.
39. Zanarini MC, Frankenburg FR, Parachini EA. A
preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry. 2004;65:903-907.
40. Markovitz PJ, Wagner SC. Venlafaxine in the treatment of borderline personality disorder. Psychopharmacol Bull. 1995;31:773-777.
41. Winchel RM, Stanley M. Self-injurious behavior: a review of the behavior and biology of self-mutilation. Am J Psychiatry. 1991;148:306-317.
42. Bogenschutz MP, Nurnberg HG. Olanzapine versus placebo in the treatment of borderline personality disorder. J Clin Psychiatry. 2004;65:104-109.
43. Zanarini MC, Frankenburg FR. Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study. J Clin Psychiatry. 2001;62:849-854.
44. Bellino S, Paradiso E, Bogetto F. Efficacy and tolerability of quetiapine in the treatment of borderline
personality disorder: a pilot study. J Clin Psychiatry. 2006;67:1042-1046.
45. Pascual JC, Oller S, Soler J, et al. Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. J Clin Psychiatry. 2004;65:1281-1283.
46. Nickel MK, Muehlbacher M, Nickel C, et al. Aripiprazole in the treatment of patients with borderline personality disorder: a double-blind, placebo-controlled study. Am J Psychiatry. 2006;163:833-838.
47. Simpson EB, Yen S, Costello E, et al. Combined dialectical behavior therapy and fluoxetine in the treatment of borderline personality disorder. J Clin Psychiatry. 2004;65:379-385.
48. Soler J, Pascual JC, Campins J, et al. Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am J Psychiatry. 2005;162:1221-1224.
49. Pittenger C, Krystal JH, Coric V. Initial evidence of the beneficial effects of glutamate-modulating agents in the treatment of self-injurious behavior associated with borderline personality disorder. J Clin Psychiatry. 2005;66:1492-1493.
50. Pinto OC, Akiskal HS. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder. J Affect Disord. 1998;51:333-343.
51. Tritt K, Nickel C, Lahmann C, et al. Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study. J Psychopharmacol. 2005;19:287-291.
52. Preston GA, Marchant BK, Reimherr FW, et al. Borderline personality disorder in patients with bipolar disorder and response to lamotrigine. J Affect Disord. 2004;79:297-303.
53. Links PS, Steiner M, Boiago I, et al. Lithium therapy for borderline patients: preliminary findings. J Clin Psychopharmacol. 1990;4:173-181.
54. Hollander E, Tracy KA, Swann AC, et al. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology. 2003;28:1186-1197.
55. Gardner DL, Cowdry RW. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psychiatry. 1986;143:519-522.
56. Zanarini MC, Frankenburg FR. Omega-3 fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry. 2003;160:167-169.
57. Bellino S, Paradiso E, Bogetto F. Oxcarbazepine in the treatment of borderline personality disorder: a pilot study. J Clin Psychiatry. 2005;66:1111-1115.
58. Philipsen A, Richter H, Schmahl C, et al. Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. J Clin Psychiatry. 2004;65:1414-1419.
59. Nose M, Cipriani A, Biancosino B, et al. Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials. Int Clin Psychopharmacol. 2006;21: 345-353.
