Social contributions. The act of self-mutilation typically grabs the attention of a therapist, friends, or spouses. Operant conditioning—where the positive rewards of help, empathy, and attention follow self-mutilation—may reinforce and perpetuate the behavior.1 Other social contributions may include:
- dysfunctional family systems
- lack of social support
- poor communication skills
- role expectations, such as school/work performance, sexuality, or career obligations.13
When social pressures demand immediate decisions, impulsive self-mutilators may feel an urgency to act instead of using other coping mechanisms. Leibenluft et al published what may be the only empiric study that addresses this “inner experience” of the self-mutilator with borderline personality disorder.14 In our case example, the pressures of an imminent divorce trial triggered Mrs. K’s most recent cutting behavior. She did not have a strong support system and—in her desperation to control something—she resorted to cutting.
Pharmacologic treatment
Just as the cause of self-mutilation is multidimensional, so is its treatment. Research has focused on medications, individual therapy, and social therapy. Not surprisingly, these approaches resemble the treatment of other impulse control disorders.
Most of the evidence for drug treatment of self-mutilation comes from case reports and small openlabel studies. A variety of medication classes have been tried.
Antidepressants. In theory, if reduced serotonin neurotransmission helps drive pathologic self-mutilation, then using selective serotonin reuptake inhibitors (SSRIs) to increase serotonin availability may reduce impulsivity. For example, Velazquez described the case of an 11-year-old boy whose finger-chewing behavior diminished with fluoxetine therapy.15
Most of the SSRI studies have examined self-mutilation in the context of treating personality disorders, especially borderline personality disorder. SSRIs have been shown to modestly reduce anger and negative affective states, but the studies do not refer specifically to their effect on the frequency of self-mutilation. Given the present evidence, SSRIs appear to be an appropriate first-line treatment for self-mutilation because of their:
- overall safety profile
- effectiveness in treating mood lability and reactivity
- documented deficits in serotonergic neurotransmission.
Still, little empiric data exists regarding their use in treating self-mutilation, and prescribers should watch for possible side effects. No SSRI appears to be best suited to treat this disorder. Base initial selection on prior medication trials and on whether a drug’s side effects could work in the patient’s favor. For example, paroxetine’s more sedating properties may benefit a patient with difficulty sleeping, whereas sertraline’s more activating properties may help the lethargic patient with psychomotor retardation.
Atypical antipsychotics are often used in patients with borderline personality disorders or mental retardation to reduce impulsive physical aggression and mood lability. Their wide range of pharmacologic effects—including serotonin and dopamine blockade—suggests why they may have thymoleptic properties related to mood, anxiety, impulsiveness, and overall behavioral control. Small trials have demonstrated that olanzapine and clozapine may help control self-mutilation,16,17 but controlled trials are lacking.
Mood stabilizers. Case reports have described use of lithium, divalproex, and topiramate to reduce the frequency of self-mutilation, but—as with antipsychotics—controlled studies are lacking.18 Mood stabilizers are appropriate in self-mutilators with co-existing bipolar disorder and possibly in those whose self-mutilation has cycling or circadian properties.
Anxiolytics. The sedative effects of benzodiazepines such as lorazepam or clonazepam may help control agitation and attempts to self-mutilate in emergent inpatient settings. This drug class carries a high abuse potential and may cause behavioral disinhibition, especially with mentally retarded patients. These properties limit benzodiazepines’ usefulness in outpatient treatment of self-mutilation.
FIVE PRINCIPLES OF DRUG MANAGEMENT OF SELF-MUTILATION
- Use medications to lay the groundwork for psychosocial interventions. When mood and thought are stabilized, patients can think more clearly and be more receptive to therapy.
- Consider SSRIs as a first-line approach, followed by atypical antipsychotics, mood stabilizers, and typical antipsychotics. Target doses may vary; some patients respond to lower antipsychotic doses than are used for psychotic disorders.
- Choose medications to target co-existing symptoms, such as insomnia, heightened arousal states, and behavioral agitation.
- Discuss the limitations of medications with patients and families, so that their expectations are realistic and do not impede recovery.
- Monitor prescriptions closely; self-injuring patients are impulsive and at risk for unintentional (or intentional) overdose.
Opiate antagonists. Naltrexone and nalmefene have been shown to be effective in other impulse control disorders, such as pathologic gambling and kleptomania.19,20 In self-mutilation, the use of opiate antagonists has been limited to case reports in patients with autism or mental retardation.
Although unproven, it may be that self-injurious behaviors are reinforced by a release of endogenous opioids. In theory, then, blocking opiate release would reduce the behaviors, as patients would then respond more normally to pain. The behavior would extinguish without the reward.19,20
Opiate antagonists, which purportedly reduce urges and cravings to drink or to gamble, may also block urges and cravings to self-mutilate. Problems with using these agents include the need for periodic liver function tests and side effects such as nausea and gastrointestinal disturbances.