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A STAGGERING NUMBER of self-injury and attempted suicide cases have been reported in EDs. According to the CDC, in 2008 self-injurious behavior (SIB) and suicide attempts accounted for at least 666,000 ED visits.1 About 12% of U.S. teenagers engage in SIB.2 Of those who engage in SIB, 75% are White, middle-class females.3
Regardless of where you work, you're likely to care for some patients who engage in SIB. As a nurse, you must provide fair and ethical care to all patients, including those who harm themselves. But trying to help these patients modify their behavior can be frustrating for nurses and other caregivers. This article addresses how to identify signs and symptoms of SIB and how to intervene effectively.
For this article, SIB is defined as self-harming behaviors used to cope with intense, uncomfortable emotions.4 This nonsuicidal, deliberate self-infliction of a wound is an attempt to seek expression.2 These behaviors don't include responses to psychotic delusions or hallucinations. For example, SIB doesn't include an auditory hallucination commanding someone to "cut it off if it offends you" or a delusion, which is a thought not founded in reality, such as the notion that God wants someone to be punished. SIB also doesn't include body adornments such as tattooing or body piercing.
Although people may engage in SIB for any combination of reasons, the primary one is to cope with their emotions and to feel better. These emotions may occur individually or in combination, or one may follow another. The emotion may be different from episode to episode.
A research study by Huband and Tantum found that the primary themes precipitating self-injuring are powerlessness, shame, anger, and feelings of not being cared for.5 Nurses must assess each patient to determine what actually drives these behaviors.
In one study that explored adolescent females' self-injury by cutting, several themes were revealed related to this behavior. These included experiencing trauma in childhood, feeling abandoned, being an outsider, self-loathing, silently screaming, releasing the pressure, feeling alive, being ashamed, and being hopeful.6
According to other literature, about 50% of people who engage in SIB were sexually abused or were deprived, neglected, or abused in childhood. As many as 90% were restrained from self-expression.7,8 For example, after an upsetting life experience in childhood, this person may have been told, "Don't be a baby-don't cry." He or she may have been forbidden to talk about what happened. SIB is seen more often in those who suffer from affective disorders, such as bipolar disorder or depression, and those with personality disorders, specifically borderline personality disorder.7 (See How the pattern develops.)
Unlike a person who commits suicide, who intends to die, someone engaged in SIB primarily seeks to find relief from overwhelming stress. While it's important to assess for suicidality, most who engage in self-injury behaviors aren't suicidal. The behavior is often performed to release pain and stress and to feel better. SIB may even be a way to prevent suicide because it relieves emotional distress.2 However, some patients who didn't intend to kill themselves have died as a result of their wounds.
No one knows how many ED or healthcare provider visits for "accidental" injuries are self-injury cases in disguise, or how many cases aren't reported. SIB may result in more severe effects than the person intended, sometimes requiring medical treatment, including surgical repair. Possible complications from SIB include wound infections, scarring, being shunned, and difficulty focusing on school or employment tasks.
The methods of inflicting self-injury vary as widely as the imagination. Although cutting tends to be the most frequently noted form of SIB, people may also hurt themselves by burning, pinching, stabbing, beating, inserting objects, hitting or punching hard objects, head banging, and pouring chemicals on themselves. In adolescents, cutting, burning, biting, hair pulling, or picking of skin or hair are reported forms of SIB.2,9
Areas of the body may be chosen to injure because they're easily accessible, easily hidden, or considered offensive or deserving of harm. With regard to cutting, the arms and legs are the areas where injuries are most often inflicted.6 In my experience, people sometimes choose the area to injure based on their own thoughts, ideas, or needs. For example, people may cut their hand because it was used in a sexual act, or they may chose to cut their arm because doing so provides a quick and easy way to relieve internal anxiety. Or they may choose to cut their torso because they can hide the wound.
Communicating with those who engage in SIB is extremely difficult and challenging for caregivers. When you're planning approaches and care, always consider that your patient with SIB may have been abused or neglected in childhood.
Many healthcare professionals have misconceptions about SIB, the most common being that people engage in SIB primarily to gain attention. Although this may be true at times, this reason is less likely than others.10 For example, many patients who self-injure have difficulty articulating their thoughts and emotions and use SIB to physically express their emotional pain and turmoil. They may give any number of reasons for self-injury including these:
* They may be having feelings of self-hatred or self-loathing. SIB is more likely to occur in response to frustration and rage.11
* They may believe that they deserve punishment because they feel guilty for something or believe that somehow they're to blame for past experiences.4,12 Any new feelings of guilt may exacerbate feelings from the past, including the feeling that they deserve punishment.
* They may want to exert control over their bodies or a situation because they feel a lack of control.
* They may attempt to cause self-harm to receive nurturing missing from their past. For example, people who received little attention from their primary caregiver when they were children may gain a feeling of satisfaction from nurturing a wound.
* They may injure themselves because SIB has become habit-forming and addictive.5
For people who engage in SIB, certain triggers may lead to SIB. Triggers can be anything-for example, a smell, clothing, or the sound of a person's voice-that reminds them of upsetting events in their past or causes stress. Lacking effective coping skills, they turn to SIB to relieve emotional pain.
The trigger may spur memories or exacerbate self-hatred or the need for control. A person may try to resist SIB for hours or days before finally giving in to the desire and engaging in self-harm. Others may respond to a trigger immediately and engage in SIB with little or no warning. (See Two pathways to SIB.)
Some triggers may be part of routine nursing care. For example, we remove patients' street clothes and put them in a flimsy gown, or we might knock quickly, then walk in on patients while they're in bed or in the bathroom. Although we can't completely avoid these actions, we can be more sensitive to the likely effects on these patients and prepare them in advance. For example, explain tests and procedures and ask what these patients need to feel prepared and supported.
How should you assess and care for these patients? First, let go of assumptions. For example, don't assume that an apparent self-injury was a suicide attempt, or that you know what a patient hoped to gain by a self-injury.
Because SIB and suicide attempts aren't one and the same, closely assess these patients for intention. The best way to assess is to ask open-ended questions and talk openly in a nonjudgmental way.13 Use active listening to help develop a relationship of trust and caring. Let the patient do most of the talking.
Many nurses are afraid to ask the patient, "Were you feeling like you wanted to hurt yourself, or were you feeling suicidal?" It's okay to ask this. You need to understand the behaviors' meaning to the patient to address the situation properly. It may help to start by simply asking, "What did this injury mean to you?"
Every day, some people live with thoughts of self-harm and some live with suicidal thoughts. People may experience either or both thoughts concurrently without acting on them. Assess each patient individually for these thoughts.
Some ways of asking about SIB are more effective than others. When patients have difficulty talking about their feelings, you can ask them to express themselves in the third person. For instance, ask them, "If your injuries could speak for you, what would they tell us?" Using open-ended questions or statements encourages the patient to provide more explanation. Consider these examples:
* "Tell me about your scars."
* "Tell me what happened."
* "What was happening before you injured yourself?" (This can help you identify the patient's triggers.)
Other questions you might ask include the following:
* "Did you feel like you wanted to hurt yourself or kill yourself?" (If necessary, explain the difference.)
* "Are you safe now?"
* "Are you thinking about hurting yourself now?"
Initiate safety precautions according to your facility's policies and procedures and the healthcare provider's orders. Discuss the need for psychiatric consultation with the healthcare team. The person engaging in SIB will probably need ongoing in-depth individual or group therapy later on. Sometimes medications such as selective serotonin reuptake inhibitors and neuroleptics are prescribed.
Throughout the physical assessment, be alert for injuries on patients' arms, legs, abdomen, breasts, or any other body part.
* While auscultating heart and lung sounds, look for injuries and scars.
* Ask questions such as, "Do you have any wounds, cuts, bruises, or burns?"
* If you see an injury, ask, "Do you have any other wounds?" Remember that patients may be hiding other wounds. You can say, in a matter-of-fact way, "I need to assess your wounds so we can be sure to provide the proper care and avoid infection."
Consider these issues during your assessment to help plan effective nursing care.
* Are there patterns or frequencies of harm? This may provide clues to when a patient is likely to self-harm again.
* Does the patient respond to triggers and know what they are? This knowledge allows staff to remove or decrease triggers when possible, or be available for support.
* How severe is the self-harm, and is the harm in dangerous areas? (For example, did the patient insert objects into body cavities or self-injure close to arteries?) Suicidal patients require one-to-one observation; even if the patient denies being suicidal, if the self-harm was severe or dangerous, this patient may also need one-to-one observation. Organizations often have specific assessment forms or protocols for this purpose.
After you've taken steps to keep the patient safe, turn your attention to addressing SIB issues that underlie the self-destructive behavior. How you respond to SIB can increase or decrease a person's feelings of guilt.5,10
Here are some approaches that you can take in acute care and ED situations:
* Remain matter-of-fact and calm instead of overreacting. Validate patients' feelings with comments such as, "I'm sorry that you're having a difficult day."
* Because most patients who engage in SIB have a general lack of trust, tell them that healthcare efforts are individualized and focused on helping them. Emphasize that they're in control of their treatment.4
* Encourage patients to express their feelings. Be empathetic rather than sympathetic: Listen and attempt to understand the emotions without feeling sorry for the patient or getting personally involved, which violates professional boundaries.
* Don't punish or restrain patients because doing so reinforces patients' beliefs that they deserve punishment.
* Avoid asking why the behavior occurred, and don't add to shameful feelings by criticizing patients.
* Be respectful of the patient's personal space. Because many people who engage in SIB have been abused, they may be uncomfortable with touch and physical closeness. Tell the patient before touching him or her and explain what you're doing throughout your assessment and during any procedures or nursing care. Keep private parts draped or covered.
* Although you can't stop or limit every trigger, be alert to each patient's particular triggers, and be available to lend support when triggers can't be avoided.
* Provide patients with as much autonomy as possible.4 For example, let patients choose the time of medications, explain tests and procedures, and offer options when possible.
* Because many patients who engage in SIB have a history of being abused, it may be beneficial to arrange for same-sex or opposite-sex caregivers (depending on the patient's history) to avoid potentially triggering tests or procedures.
* Provide as much consistency in caregivers and routine as possible. For example, if at all possible, arrange schedules to avoid giving the patient a different caregiver every 4 hours, or a new one every day.
* Don't make promises you can't keep. Broken promises reinforce negative self-concepts and discourage trusting relationships.
* Encourage patients to determine coping alternatives to self-harm, such as calling or texting a friend or counting to ten.8 Encourage patients to attempt these alternatives before engaging in SIB. Because this approach doesn't take away the option of SIB, it helps the person feel more in control.4
* Don't force patients into contracts in which they promise they won't harm themselves. It's better to ask them to try not to self-harm and to use their list of alternatives before resorting to self-harm. This gives patients a sense of control, helps develop trust with the caregiver, and minimizes a sense of failure if they do engage in SIB.4
* Praise every alternative to SIB and every attempt to avoid self-harm.
* When a person does engage in SIB, use a matter-of-fact tone and non-guilt-inducing approaches. For example, while dressing a wound, calmly state, "Let's get this cleaned up." Then pause briefly and ask what happened. Don't place blame and guilt by using a negative tone of voice or by saying, "Why did you do this?" Your appropriate response will help the patient to minimize specific acts of SIB and focus on ways to cope with stress more effectively.5
* Offer relaxation techniques as alternatives, but don't push patients into them. Deep relaxation can make some people feel more vulnerable as they let down their guard.5
* Encourage patients to focus on their strengths and healthy coping options. They must learn to see themselves as survivors, rather than as victims, and learn more healthy coping behaviors. They can't do this without our encouragement.
The more you understand about SIB, the better able you'll be to provide therapeutic nursing care for patients with SIB. Use the information discussed here to keep patients safe and to improve their coping skills and quality of life in the future.
Often by accident, people learn that SIB helps them relieve stress for a brief period. Then the next time they're under stress, they again find temporary relief from stress through self-injury. This sets up an addictive pattern. After the SIB, they may feel guilty and suffer more blows to their self-esteem.5,13
Researchers Huband and Tantum found that two pathways-termed the spring and the switch-can lead to self-injuring. In their study, the more common pathway involved the spring, which can also be described as a winding-up sensation. Female participants recalled self-injuring "as a result of an unpleasant and ill-defined emotional state that intensified over time before it became intolerable."5
Ms. S had an experience that demonstrates the spring pathway (wind-up response) situation. She was in a group of people when a young male patient made an inappropriate sexual remark. This spurred Ms. S to remember past abuse. She spent the next half hour becoming tense, obsessing about her feelings, and feeling guilty for any role she thought she played in her past abuse. As these feelings overwhelmed her, she searched for something with which to cut herself.
In contrast, the switch pathway spurs the person to quickly engage in SIB as though turning on a light switch. The person may be unaware of what led to the SIB.
An example of the switch (quick response) pathway came from Ms. B as she explained some of her scars. She pointed to a recent scar on her arm and explained that she was shopping when a man brushed past her backside. She explained that she initially only vaguely recalled the situation, but after pondering it, she realized that when the man brushed past her, she immediately felt out of control. As a result, she went to the nearest bathroom and cut herself before she knew what had happened. Later Ms. B said her feelings may have related to being sodomized as a child.
In both cases, the self-injuring led to a feeling of relief, but the relief was rapidly replaced by guilt about the self-injury.
1. Centers for Disease Control and Prevention. Suicide and self-inflicted injury. http://www.cdc.gov/nchs/fastats/suicide.htm. [Context Link]
2. Lesniak RL. Self-injury behavior: how can nurses help? J Christ Nurs. 2008;25(4):186-193. [Context Link]
3. Gunderson JG. A BPD brief: An introduction to borderline personality disorder: diagnosis, origins, course, and treatment. National Education Alliance for Borderline Personality Disorder. 2006. http://www.borderlinepersonalitydisorder.com/BPD-brief.shtml. [Context Link]
4. Muehlenkamp JJ. Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. J Ment Health Couns. 2006;28(2):166-185. [Context Link]
5. Huband N, Tantam D. Repeated self-wounding: women's recollection of pathways to cutting and of the value of different interventions. 2004. Psychol Psychother. 2004;77(Pt 4):413-428. [Context Link]
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8. National Alliance on Mental Illness. Self-harm in young adults. Fact sheet. http://www.nami.org/Content/ContentGroups/Helpline1/SelfInjury_Fact_Sheet_FINAL.. [Context Link]
9. Roux SL, Overcash J. Scratching the surface: addressing self-harm in adolescents. Nurse Pract. 2008;33(6):30-36. [Context Link]
10. Duperouzel H, Fish R. Why couldn't I stop her? Self-injury: the views of staff and clients in a medium secure unit. Br J Learn Disabil. 2008;36(1):59-65. [Context Link]
11. Parker G, Malhi G, Mitchell P, Kotze B, Wilhelm K, Parker K. Self-harming in depressed patients: pattern analysis. Aust N Z J Psychiatry. 2005;39(10):899-906. [Context Link]
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13. Ferentz L. Self-injurious behavior. NYUChild Study CenterLetter. 2002;6(2):1-4. http://www.aboutourkids.org/files/articles/nov_dec_3.pdf. [Context Link]
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