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JAMA Network Insights
July 10, 2019

Working With Patients Who Self-injure

Author Affiliations
  • 1McLean Hospital, Harvard Medical School, Belmont, Massachusetts
JAMA Psychiatry. Published online July 10, 2019. doi:10.1001/jamapsychiatry.2019.1241

Clinicians can address self-harm through expressing supportive concern and contextualizing it within life difficulties, especially interpersonal stressors. It is especially disturbing to physicians that humans deliberately inflict damage to their own bodies. Yet physicians commonly encounter patients who self-harm. They constitute 9% of patients in emergency departments1 and up to 20% in psychiatric hospital settings.2 The most common type of self-harm is cutting, but burning, self-poisoning, deliberate and nonrecreational risk taking, self-battery, and other forms of self-harm also occur.3 These behaviors occur in states of high mental anguish or dissociation,4 with the aim of distracting or punishing oneself, expressing anger, or reestablishing normal feeling when numb. Deliberate acts of self-harm are not intended to end life. They are distinct from medically and psychologically serious suicide attempts. There is evidence that such behaviors are associated with altered activity in areas of the brain implicated in pain processing, including the anterior cingulate cortex and amygdalae.5 Moreover, self-harm may function as a vital but self-destructive form of stress regulation by increasing functional connectivity between the amygdalae and the superior frontal gyrus in individuals with borderline personality disorder (BPD) who are distressed, but not in healthy controls.6 Theoretically, these alterations in pain processing may diminish fear of more severe self-injury through habituation to physical pain7 and over time may lower inhibitions to committing fatal suicide attempts. Self-harm is among the strongest risk factors for suicide, transdiagnostically.7

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