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Section 9
Mental and Personality Disorder's Role in Self-Harm

Question 9 | Test | Table of Contents

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In the last section, we discussed how self-control is essential in treating a self-mutilating client.

As you know the Diagnostic and Statistical Manual of Mental Disorders categorizes mental disease into two distinct sections: Axis I and Axis II disorders.

In this section, we will examine the various mental disorders with which adolescent self-mutilators are diagnosed. These include Axis I disorders such as depression, thought disorders, anxiety disorders, and post traumatic stress disorder, and the Axis II disorder of borderline personality disorder.

Axis I, those disorders dealing with mood, anxiety, and thought, are common among self-mutilators.

6 Axis I Disorders

♦ # 1 - Major Depression
One of the most frequent mood disorders associated with self-injury is, unsurprisingly, major depression. To deal with the severe pain of this depression, Olivia developed a strategy for blotting out feelings from the conscious awareness. Fifteen year old Olivia told me, "Sometimes, I would be so sad and lonely; I'd just block everything out. To prove to myself that I wasn't hurting anymore, I'd cut myself. Seeing the blood but not feeling the pain proved that I was beating my depression."

♦ # 2 - Bipolar
Another mood disorder common among self-injurers is bipolar disorder. As you know, bipolar disorder is characterized by periods of depression alternated with an uncontrollable elation or mania. In his manic periods, Adam, age 14, couldn't sleep and engaged in wild schemes or impulsive and reckless behavior. When he crashed into his depressive phase, Adam used self-injury to regulate his state of mind. Adam told me, "I felt like I was doing something to slow down my low times. Also, it helped me express my frustration at having to be depressed again."

Adam responded to mood-stabilizing medications, but Olivia required several months of therapy and anti-depressants. There is usually never a clear cut cure-all to self-injury, as you are well aware, even when a medically treatable disease is the underlying cause.

♦ # 3 - Anxiety Disorders
Other types of Axis I disorders commonly associated with self-injury are anxiety disorders. As you know, an anxiety disorder produces extreme tension, agitation, and episodes of disorganizing panic. To maintain control in their lives, self-injurers use pain in order to have some sort influence on their surroundings. Adam, the 14 year old who suffered from bipolar disorder, also had chronic panic attacks. He stated, "The panic got real bad. Everything piled up. I didn't deal with anything and it all piled up."

♦ # 4 - Thought Disorders
Thought disorders are also generally associated with teen self-injurers. Some self-injurers describe periods of being out of touch with reality. Their thinking grows jumbled and their thoughts seem to loosen. Sometimes, clients hallucinate or hear disembodied voices that "command" them to harm themselves. Often times, this results from overwhelming social pressures. Mindy, age 15, suffered from periods of delusions and paranoia in which she believed others were watching her or were out to harm her. She had just started high school, and was not socially accepted.

As a result, Mindy soon believed she was unworthy of anyone's respect and began to convince herself that no one at her school could ever be a friend. Mindy related one of her hallucinogenic episodes as follows, "It sounded like there was a guy right behind me, like whispering in my ear, 'They're all looking at you. They think you're ugly and they don't care what you do to yourself.' I wanted them to care. So I started burning myself and wearing short sleeves to show off my scars. I showed them I wasn't afraid of them, that I could hurt myself just as much as the other kids could hurt me." Mindy's bouts of paranoia resulted in her self-injury.

Do you have a self-injuring client that's suffering from paranoid episodes?

♦ # 5 - Obsessive-Compulsive Disorder
One diagnosis that I have found to be less common, but very influential in the client's life is obsessive-compulsive disorder. As you know, an OCD sufferer experiences anxiety and distress because of recurring, unwanted thoughts, impulses, or mental images. For fourteen year old Teresa, the urge to self-injure took on the quality of an obsessive-compulsive problem. Teresa stated, "It was like, I couldn't get it out of my head, you know? The urge to cut myself was just there and if I didn't do it, I felt really anxious and I couldn't do anything else."

♦ # 6 - PTSD
In addition to depression, bipolar, anxiety, and OCD another disorder to be applied to self-injurers is post traumatic stress disorder. Those diagnosed with PTSD are the victims of a distressing experience earlier in life. Deborah, age 13, had been violently beaten by her uncle when she was under his guardianship after her parents died. Deborah said that her cutting and bruising helped to dissolve the memories of the beatings. When she injured herself, she wasn't thinking about the abuse. Ironically, many of her methods mirrored her uncle's violent behavior.

♦ Axis II Disorders - Borderline Personality Disorder
Axis II disorders, those that deal with behavior and personality styles, also play a role in some self-injurers lives. The Axis II disorder most frequently linked to clients who self-injure is borderline personality disorder.

To diagnose a self-injurer with BPD, I look for at least 4 of the following symptoms:
1. A pattern of unstable and intense interpersonal relationships;
2. Impulsiveness;
3. Abrupt mood swings;
4. Inappropriate, intense anger;
5. Identity disturbance;
6. Chronic feelings of emptiness or boredom;
7. Frantic efforts to avoid abandonment; and finally
8. Self-mutilating and suicidal tendencies.

Seventeen year old Maggie, a self-injurer, was exhibiting several of these symptoms which led to diagnose her with BPD. During discussions about her family, any question I put to her that tried to transfer blame away from her mother caused Maggie to rise from her chair and go into violent rants. She frequently displayed boredom during sessions except for her sporadic tirades, and often related to me her desire to, as she put it, "end all this crap" by committing suicide.

In this section, we discussed four mental disorders with which adolescent self-mutilators can be diagnosed. These include Axis I disorders such as depression, thought disorders, anxiety disorders, and post traumatic stress disorder, and the Axis II disorder of borderline personality disorder.

In the next section, we will examine various arguments that clients use to persuade themselves that they do not have a problem with self-mutilation. These include arguments: of a personal event, of necessary emotional cleansing, and of communication. We will also include ways to address these arguments.
Reviewed 2023

Peer-Reviewed Journal Article References:
Andrewes, H. E., Hulbert, C., Cotton, S. M., Betts, J., & Chanen, A. M. (2017). Ecological momentary assessment of nonsuicidal self-injury in youth with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 8(4), 357–365.

Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.

Frei, J. M., Sazhin, V., Fick, M., & Yap, K. (2021). Emotion-oriented coping style predicts self-harm in response to acute psychiatric hospitalization. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 42(3), 232–238.

Kruzan, K. P., Whitlock, J., & Hasking, P. (2020). Development and initial validation of scales to assess Decisional Balance (NSSI-DB), Processes of Change (NSSI-POC), and Self-Efficacy (NSSI-SE) in a population of young adults engaging in nonsuicidal self-injury. Psychological Assessment, 32(7), 635–648.

Reas, D. L., Pedersen, G., Karterud, S., & Rø, Ø. (2015). Self-harm and suicidal behavior in borderline personality disorder with and without bulimia nervosa. Journal of Consulting and Clinical Psychology, 83(3), 643–648.

Sansone, R. A., Sellbom, M., & Songer, D. A. (2018). Borderline personality disorder and mental health care utilization: The role of self-harm. Personality Disorders: Theory, Research, and Treatment, 9(2), 188–191.

QUESTION 9
What are the Axis I disorders commonly associated with self-injury? To select and enter your answer go to Test.

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