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Self-Injurious Behavior

Nurses can help prevent and reduce harm through early recognition

Vol. 9 • Issue 25 • Page 19
The Learning Scope

This offering expires in 2 years: November 24, 2010

The goal of this continuing education offering is to provide nurses current information about self-injurious behavior presented in a healthcare setting that nurses can apply to practice. After reading this article, you will be able to:

1. Define self-injurious behaviors.

2. Identify the most common forms of self-injurious behaviors.

3. Describe the treatment plan for a patient on a medical unit who practices self-injurious behaviors.

You can earn 1 contact hour of continuing education credit in three ways: 1) For im­mediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

RN Joan goes into meet her new patient, a young female admitted to the medicine specialty unit due to appendicitis. On completion of the nursing assessment, Joan notices scars on the patient's stomach and inner aspect of the patient's arms. Joan is shocked by the multiple burn marks and asks how the patient received them. The patient is reluctant and evasive in her responses, but says she is not suicidal. Concerned for her patient's well-being, Joan is unsure how to approach what appear to be self-inflicted injuries.

When presented with a patient who appears to have self-injuries, most professionals don't know how to proceed. Some will show shock and ask punitive questions: "How could you do that to yourself?" Others may see it as attention- seeking and state, "You must be really desperate for attention to cut yourself." Staff often assign labels to patients, e.g., "borderline" or "manipulator," which only reinforces frustration of not knowing how to effectively engage and treat patients who exhibit self-injurious behavior (SIB).1Like many social phenomena, SIBs are difficult to comprehend and explain. This is almost certainly because they confront and challenge some of our most fundamental values and beliefs.

Defining SIB

SIB (self-harm or self-mutilation) is the intentional injuring of one's own body without apparent suicidal intent.2SIB may include cutting, head-banging, burning, needle-sticking, severe scratching/biting, interfering with wound healing, ingestion of sharp objects or toxic substances, or bone breaking.

Cutting often is considered one of the most common methods of self-harm; one study cites it occurs among 70 percent of people who deliberately harm themselves.2The prevalence of head-banging or hitting among those who exhibit SIB ranges from 21 to 44 percent, and up to 35 percent burn their skin.2The CDC's Poisoning in the United States: Fact Sheet states, "Self-harm poisoning was the second-leading cause of ED visits for intentional injury in 2006, and among the ED visits, 75 percent of the cases resulted in hospitalization."3

So what does an RN who encounters a situation similar to Joan's do? Important steps to ensure a "culture of safety" for the patient include assessing risk; engaging the individual in a supportive, accessible, problem-solving manner; recognizing there may be an addictive and rewarding nature of self-harm to the patient; limiting the length of hospital admission; and maximizing patient responsibility.

Nurses have a key role to play in preventing and reducing self-harm through early recognition of such behaviors. Nurses should adopt an index of suspicion of self-harm during the daily assessment of all patients. By being alert to risk factors during routine assessments, nurses may be able to detect patients at risk of self-harm early.

When working with patients who are at risk for SIB, nurses need to carefully take into account precipitating events; accompanying emotions and cognitions; factors potentiating or delaying cutting; description of the actual act; the client's goals, benefits and negative results; and aggravating factors that might be controllable.

Understanding Risk Factors

People who present with SIB are not a homogenous group; therefore, the behaviors that arise are associated with a broad range of mental states.4While there is the assumption SIB is more prevalent with females, current findings show SIB is equally prevalent among male and females and age of onset typically ranges between 14 and 24.2While most researchers view SIBs as distinct from suicidal attempts, the risk of suicide increases 50 percent within the first 12 months after an episode of SIB, compared to the general population risk.5The proportion rate for those who return to medical services with repeated SIB within a year of the initial incident ranges from 13 to 18 percent.4This same study suggested most people who have entered emergency hospitals for SIB met diagnostic criteria for mental disorders.

Other studies have identified SIB occurs within the framework of other mental states such as borderline personality disorder, posttraumatic stress disorder, eating disorders and substance abuse. The risk for SIB is higher in those with a history of physical, emotional or sexual abuse.6SIB occurs in nonclinical populations as well, representing approximately 4 percent of the general population. Thirty-five percent of college students report using one form of self-harm in their lifetime.2A recent study of more than 3,000 college-age participants with at least one episode of SIB reported a low level of engagement with health providers and a tendency to avoid professional help. This was related to the shame and isolation that people with SIB experience.7Individuals practicing SIB report it as a way to self-soothe and way to manage overwhelming thoughts and feelings.8It is described as a sense of rising tension before the act and preoccupation with persistent urges to hurt the self. Individuals who perform SIB tend to report increased anxiety and somatic symptoms that become intolerable.9SIB also is perceived as a "short-circuiting" strategy for diverting painful emotions, and behaviors associated with it are most often a silent, hidden practice.10As a result, a sense of shame and repulsion is reported along with alienation, powerlessness and hopelessness.

Implications for SIB range from physical injuries leading to other health consequences that may be mild or serious and require inpatient medical treatment. SIB initially used to self-soothe or escape painful emotions can become a problem rather than a solution since it creates patterns of dependency versus mature coping mechanisms. Since SIB provides physical tension release and physical calming, it can become a physical addiction as well as a compulsive behavior.

Engaging SIB in Treatment

Treatment considerations for patients presenting with SIB in a medical hospital setting should include risk assessments to evaluate the patient's use of SIB, current practices and number of times engaged in SIB over the past 12 months. For many, SIB is a crucial coping mechanism in response to childhood abuse when the individual had no one to teach self-soothing skills.

This pattern of self-injury behavior is well ingrained by the time it gains clinical attention. The nurse's skill to evaluate current stressors, the individual's degree of control of the behavior and the patient's degree of emotional regulation will help shape treatment considerations. Questions about what has supported them in the past to tolerate the intensities of their feelings will help create an alliance.

For a nurse caring for a patient with SIB, it is important to focus on the environmental stressors that trigger the behaviors. Understanding the patterns and what can be used as an alternative when a patient's urges become increasingly high and persistent creates the opportunity for a safer outcome.

It is critical for the nurse to assess whether the behavior is escalating and compulsive, or whether the patient can stop. An increased capacity to recognize distress in the patient with SIB can lead to intervening in more appropriate manners. Because patients presenting with SIB can be taxing on the staff, it is helpful to maintain a calm demeanor, display respect and respond by not presenting a rescuing approach when care is delivered.

Most important is the ability of the staff to refrain from shock or judgment when assessing the patient. Empathetic listening encourages patients to use their "voice" rather than their body and creates an environment of compassion for healing.

Staff Considerations

Most nurses do not receive educational resources on caring for patients who present with SIB.11Recognition of these behaviors as self-injurious is essential to mitigate adverse health outcomes for these patients. Nurses' engagement and empathic approach to building an alliance with patients who demonstrate SIB is important. In addition, familiarity and appropriate use of assessment instruments can assist the nurse in identifying those who are at high risk of practicing SIB.

Given the complexity in understanding SIB, along with frequently associated emotions of being frightened, frustrated, repulsed and angry toward people exhibiting these behaviors, it is a requisite for RNs to assess their own reactions and behaviors. As part of professional development, supervision and/or inservicing may be necessary. Further research is needed on implementing practice guidelines and risk assessments for inpatient care of patients with SIB.

As in our example, Joan would benefit from clinical guidelines, resources and supervisor support to ensure patient safety and quality care. Being empathic and using assessment tools will help Joan clarify her patient's needs. Being able to process case information with other staff members will allow Joan to be more in tune to her reactions and behaviors, therefore setting the stage for a more balanced approach to the delivery of healthcare services. n


1. Cook, S., Clancy, C., & Sanderson, S. (2004). Self-harm and suicide: Care, interventions and policy. Nursing Standard, 18(43), 43-52.

2. Klonsky, M.A., Oltmanns, T.F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160(8), 1501-1508.

3. CDC. (2008). Poisoning in the United States: Fact sheet. Retrieved Aug. 26, 2008 from the World Wide Web:

4. Crawford, M., & Kumar, P. (2007). Intervention following deliberate self-harm: Enough evidence to act? Evidence-Based Mental Health, 10(2), 37-39.

5. Cooper, J., et al. (2005). Suicide after deliberate self-harm: A 4-year cohort study. American Journal of Psychiatry, 162(2), 297-303.

6. Trepal, H., & Wester, K. (2007). Self-injurious behaviors, diagnoses, and treatment methods: What mental health professionals are reporting. Journal of Mental Health Counseling, 29(4), 363-376.

7. Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117(6), 1939-1948.

8. Froeschle, J., & Moyer, M. (2004). Just cut it out: Legal and ethical challenges in counseling students who self-mutilate. Professional School Counseling, 7(4), 231-236.

9. Ferentz, L.R. (2002). Understanding self-injurious behavior: Teenagers who find themselves overwhelmed by depression or anxious feelings may seek tension relief by engaging in self-injurious behaviors. Student Assistance Journal. Retrieved Aug. 20, 2008 from the World Wide Web: (subscription required)

10. Gladstone, G., et al. (2004). Implications of childhood trauma for depressed women: An analysis of pathways from childhood sexual abuse to deliberate self-harm and revictimization. American Journal of Psychiatry, 161(8), 1417-1425.

11. McCann, et al. (2007). Deliberate self harm: Emergency department nurses' attitudes, triage and care intentions. Journal of Clinical Nursing, 16(9), 1704-1711.

Carol Boylan is director of the psychiatric medical unit, Hahnemann University Hospital, and Roberta Waite is an assistant professor at the Drexel University College of Nursing and Health Professions, both in Philadelphia.

Online Resources

To learn more about this topic, visit the following Web sites for resources.

The American Self-Harm Information Clearinghouse provides simple and clear definitions of what self-injury is, along with myths and information about why people injure themselves.

The Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults provides links and resources for information on SIB.

Site offers expert information, self-injury support groups, self-injury chat, journals and self-injury support lists.

Healing Self-Injury features selected articles, commentaries, written contributions from the readership and reviews of various resources for those who live with SIB.

David Baldwin's Trauma Information Pages focuses primarily on emotional trauma and traumatic stress, including posttraumatic stress disorder, for clinicians and researchers in the traumatic-stress field.

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