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There is an undeniable stigma associated with self-injurious behaviours. In frequently under-resourced and over-loaded medical systems, it is understandable that health professionals might experience frustration when a patient presents with self-inflicted injuries (e.g. from NSSI) or physical sequelae of ‘deliberate’ behaviours (e.g. severely disordered eating, substance misuse).
Dr Gouldthorp is a clinical psychologist and the clinical coordinator of the Dialectical Behaviour Therapy program at Hollywood Private Hospital. She is the Principal Investigator of current grant-funded research into emotion regulation and eating disorders. In clinical practice she works primarily with trauma, personality disorders and eating disorders.
However, understanding the function of these behaviours is critical for health professionals, carers and, indeed, the patients themselves. This understanding can help increase compassion and reduce unwarranted stigma. It challenges the myths that these behaviours are ‘attention seeking’ or being used for some kind of manipulative purpose and highlights the unhelpfulness of common responses to these behaviours that the patient ‘just needs to try harder’.
Maladaptation
It can be helpful for health professionals to think of these behaviours fundamentally as maladaptive coping mechanisms that function to regulate emotions. Emotion dysregulation occurs from a complex interaction between neurocognitive, genetic/epigenetic, and environmental factors that combine to result in a skills deficit.
Difficulties in regulating emotions can result from learning and modelling of responses to emotional experience from key attachment figures in development (e.g. intolerance of emotional expression by caregivers, and modelling of maladaptive coping), and situational exposure (e.g. adverse life events, such as bullying, bereavement, or abuse).
The outcome of these experiences is that the individual does not have opportunities to learn effective skills for self-regulating emotions.
Effective skills are even more important when there is an underlying neurophysiological reactivity of emotions. A comprehensive body of research demonstrates that patients with behavioural symptoms of emotion dysregulation (e.g., with a primary diagnosis of Borderline Personality Disorder) have abnormalities in frontolimbic brain areas, with other research identifying potential links to genetic and epigenetic bases.
Specifically, there is baseline hyperactivity of limbic regions, which demonstrates a neuropsychiatric correlate of increased emotional reactivity in these patients compared to non-affected controls. In addition, these patients also tend to have hypoactivity of areas in the prefrontal cortex.
These regions would ordinarily downregulate limbic regions to reduce situationally inappropriate emotional reactivity. Consequently, these individuals experience, on a neurological level, an increased intensity and frequency of emotions and will find it comparatively more difficult to self-regulate these emotions.
Faced with this skills deficit in being able to self-regulate an overactive emotion system, it is understandable that these individuals will develop strategies to externally regulate their emotions – even if these are harmful or maladaptive. By helping patients and carers to conceptualise self-injurious and other harmful mental health-related behaviours in this way, doctors and other health professionals can take an active role in counteracting the shame and stigma associated with their presentation.
Treatment and prevention
Doctors also have the critical task of assisting patients to obtain effective treatment. Dialectical Behaviour Therapy (DBT) is an evidence-based psychotherapeutic treatment for emotion dysregulation which directly addresses the skills deficits associated with the presence of self-injurious coping behaviours and suicidality. Evidence also shows that DBT skills training attenuates baseline amygdala hyperactivity (i.e. reduces emotional over-reactivity), indicating that the observed behavioural changes are associated with neurocognitive changes.
Specifically, DBT teaches a set of specific skills designed to:
- Improve mindful awareness and attentional control
- Reduce reliance on maladaptive and self-destructive urges through the development of distress tolerance and crisis survival skills
- Modulate the intensity of emotions, as well as reduce vulnerability to emotional dysregulation by building up positive experiences and attending to health issues
- Improve interpersonal relationships through effective expression of emotions and negotiation.
By compassionately communicating to patients and carers the role of emotion dysregulation in underpinning self-injurious and destructive behaviours, doctors can play a critical part in reducing the stigma and shame that may otherwise prevent patients seeking or accessing appropriate treatment. It is through access to effective, evidence-based treatment such as DBT that we can begin to break the cycle of repeat presentations to emergency departments, and to reduce risk of suicide.
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