Negative Body Image Key to Self-Mutilation

Author: Carl Sherman, Contributing Writer

CAMBRIDGE, MASS. -- Understanding the patient's preoccupation with an intensely negative body image helps make sense of self-mutilation behavior, such as cutting, burning, or excoriation, Barent Walsh, D.S.W., said at a meeting on adolescent self-destruction sponsored by Cambridge Hospital.

The majority of cases involve a history of sexual or physical abuse, in which the self-mutilation behavior represents a repetition compulsion based on self-punishment and self-loathing -- a way to "connect with the most powerful event of a lifetime," said Dr. Walsh, executive director of the Bridge of Central Massachusetts, a nonprofit human services agency in Northboro.

Although they may superficially resemble each other, self-mutilation differs from suicide attempts in key respects. Most importantly, the self-mutilator aims to modify and gain relief from unpleasant affect, while the intent of a suicide attempter is to terminate consciousness to escape pain.

Self-mutilation "gets rid of anger, tension, sadness, or a feeling of emptiness or deadness," Dr. Walsh said at the meeting, also sponsored by Harvard Medical School.

Self-mutilation typically causes physical damage of low lethality potential, is highly repetitive, and usually involves diverse methods over time.

Suicide attempts rarely follow this pattern, he said.

The psychic pain that triggers self-mutilation is generally described as intermittent and uncomfortable, while the psychic pain that triggers suicide attempts usually is described as unendurable and persistent.

Patients describe a sense of immediate relief following a self-mutilation episode, while most suicide attempters feel worse, Dr. Walsh said.

Periods of optimism and a sense of control over one's situation is more common with self-mutilators; hopelessness and helplessness is fundamental to the suicide attempter's state of mind.

And while an impaired body image may be part of the suicide attempter's generally negative view of the self, the world, and the future, it is not a focus as it is for the self-mutilator, Dr. Walsh said.

Self-mutilation does not usually require crisis intervention, but it could merit referral to a psychiatric emergency room and possible hospitalization under certain circumstances, he said. Such referral may be warranted when physical damage is severe enough to require medical treatment or when the involvement of certain body parts -- the face, the breasts, or the genitals -- suggests psychotic decompensation.

Generally, therapy should be multimodal. Contingency management and behavioral contracting often can effect a rapid reduction in self-mutilation frequency, particularly when the patient is motivated to quit by social embarrassment.

Family therapy may effectively explore how the family may be helping to maintain the patient's dysfunctional body image.

Cognitive-behavioral therapy should teach the patient to see self-mutilation as the final link in a chain.

If triggers can be identified -- such as "when I think of my mother" or "when I look at my body in the shower" -- the patient may be guided to interrupt the sequence early. This is done by substituting benign behaviors that will release tension, such as snapping a rubber band on the wrist.

Longer-term therapy may be necessary to uncover the roots of self-mutilation, which most often involve sexual abuse. An individual who has been abused may view her body as a "coconspirator" and feel guilt about the physiologic arousal that surrounded the experience. "The body becomes the enemy: ugly, contaminated, dirty," Dr. Walsh said.

Not all self-mutilators have been sexually abused, however, and the question of how such profound alienation from their bodies developed is often a mystery. Early childhood illness that necessitated "violative" medical procedures and major problems around sexual orientation are likely possibilities, he suggested.

Gay and lesbian adolescents who are "out" are less likely to cut themselves than those who are struggling with the issue, Dr. Walsh observed.