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Section 8
Self-Injury Concept Formation – Nursing Diagnosis Development

Question 8 | Test | Table of Contents

Nurses in psychiatric hospital settings frequently encounter clients who inflict injury upon themselves, especially clients diagnosed with borderline personality disorders. These clients may use glass from light bulbs or broken plastic tableware to cut themselves. Although the wounds are often superficial, at times the injuries do require suturing. Other clients may burn their bodies with cigarettes, leaving scars up and down their arms. Nurses have noted that these individuals often report feelings of relief and well-being after the injury.

The Phenomenon of Self-Inflicted injury
Clients who self-injure present unique manage­ment challenges to nursing staff. Since the clients’ behavior serves as a relief mechanism for them, they often require constant vigilance. To help the client recognize feelings associated with self-injury behaviors, to verbalize them, and find other coping mechanisms requires great skill and patience from the nurse. Often the client’s behaviors elicit strong feelings from staff, including anxiety, guilt, anger, and sometimes the urge to retaliate. Perceiving self-injury behavior as manipulative or attention-seeking, caretakers often disagree about methods to handle the situation (Feldman, 1988). They may also struggle with feelings of inadequacy, for clients who self-injure can de-skill the most competent nurses.

Society accepts some forms of self-mutilation as normal. Examples of culturally sanctioned forms include ear piercing, cosmetic eyebrow plucking, hair twisting, nail and hair clipping, and circumcision (Conn & Lion, 1983; Menninger, 1938). Nail biting and tattoos fall on the outer limits of socially accepted self-injury (Harry, 1987). Normal forms of self-injury are seldom painful and usually self-limiting (Menninger, 1935).

Religious beliefs involving self-mutilation, especially around healing practices and the sealing of pacts, are accepted in some cultures. Public self-torture has been practiced as a form of religious worship. Ceremonial mutilation admits boys into the adult community of some cultures (Favazza, 1987). Clitorectomies are also a form of mutilation carried out in some cultures (Conn & Lion, 1983).

Acts of self-injury in early childhood are common. However, by four or five years of age behaviors such as head banging, hair pulling, biting, and scratching have usually become extinct. After age five these behaviors are considered abnormal (Oliver, Murphy, & Corbett, 1987).

Differentiation of the Phenomenon
Various terms have been used interchangeably to describe the same phenomenon in the literature. Self-injurious behavior (SIB) is used most often with mentally retarded children, while self-mutilation behavior (SMB) is more commonly used for injuries inflicted by clients with borderline personality disorder.

Self-injury versus suicide.
Many nurses mistakenly categorize risk for self-injury as risk for suicide; they are actually two separate phenomena. Although clients who self-mutilate may accidentally kill them­selves, the lethality of self-injury behavior is low compared with suicide attempts (Pattison & Kahan, 1983). Simpson (1975) studied 24 individuals who cut their wrists. He found that on a scale of 1-4 (4 equal­ing the least lethal), all self-injury acts were rated as 4.

Usually, self-inflicted wounds are repeated, superficial, and numerous, rather than deep and singular as seen in suicide attempts. Thus, one of the major differences between self-injury and suicide is the intent underlying the behavior. Clients who attempt to commit suicide want to kill themselves, while clients who self-injure want relief from the tension they feel (Walsh & Rosen, 1988).

Self-injury versus self-destructive behavior. Self-injury is also different from other self-destructive behaviors, such as bingeing, drug abuse, alcoholism, smoking, and high risk-taking. Self-injury is a circumscribed event, occurs in a short time span, and is done with conscious awareness of the consequences of the behavior. In contrast, self-destructive behaviors occur over a long period of time and often involve denial of the destructive consequences (Pattison & Kahan, 1983). While many clients may demonstrate self-destructive behaviors, clients who self-injure tend to fall into one of several major categories.

Clients At Risk
Borderline personality disorders. Individuals who self-injure by cutting or scratching themselves, burn­ing themselves, or ingesting substances or objects most frequently carry the diagnosis of borderline personality disorder (Gardner & Cowdry, 1985). The individual with a borderline personality disorder demonstrates a pattern of unstable and intense interpersonal relationships, an affective instability, chronic feelings of emptiness and boredom, impulsiveness that often is self-destructive, and identity disturbances. Self-mutilating clients with this disorder are often attractive, intelligent young women between the ages of 16 and 25 (Siomopoulos, 1974).

Clients in a psychotic state. Within this group the most severe form of self-injury is genital self-mutilation, which is rare in both males and females. Between 1900 and 1979 there were only 53 published cases of male genital self-injuries (Greilsheimer & Groves, 1979) and four cases of female genital self-mutilation (Goldney & Simpson, 1975). These clients were psychotic at the time of the mutilation and were thought to have experienced command hallucinations (Goldfield & Click, 1973). Eye enucleation, another severe form of self-injury, also is rare. Seventeen cases have been reported in the literature (Eisenhauer, 1985). These clients were usually psychotic and often had religious delusions at the time of the injury (Ananth, Kaplan, & Lin, 1984; Soulios & Firth, 1986).

Prisoners. Prisoners may inflict self-injury to force a move to a different area of the prison that they perceive as safer (Toch, 1975). Cooper (1971) reported that in Peruvian prisons inmates may self-injure to escape or stop beatings by police. Prisoners also may self-injure to draw attention to serious grievances.

Children. Pathological self-injury in childhood usually occurs in children who have been diagnosed as having schizophrenia or a pervasive develop­mental disorder (Putnam & Stein, 1985). Some battered children also have been found to self-injure. Green (1978) noted that abused children had a significantly higher incidence of self-injury than that evidenced in two control groups. Children who are moderately to severely mentally retarded and autistic frequently self-injure. The most common self-injuries are repetitive head banging, biting, hitting, scratching, hair pulling, and slapping (Schroeder, Schroeder, Smith, & Dalldorf, 1978). Seldom do children use instruments to inflict injury (Bachman, 1972).

Concept Analysis
To clarify the concept of self-injury, the procedure of concept analysis was applied. Concept analysis is a means of identifying the essential characteristics or attributes of a concept (Avant & Walker, 1988).
Assumptions. In analyzing any concept the underlying assumptions need to be made explicit. The authors make the following assumptions in regard to self-injury:

Definition and defining attributes. Kirmayer and Carroll (1987) define self-mutilation as a syndrome "characterized by intense feelings of tension and dysphoria that are dramatically relieved by cutting or other forms of nonlethal self-injury" (p. 212).

Their definition highlights the first characteristic of self-injury: It represents a deliberate act by an individual upon him/herself. Favazza (1989) describes self-injury as "deliberate destruction" (p. 142), while Barron and Sandman (1984) note it is "a repetitive self-inflicted action" (p. 501).

A second element is that self-injury produces immediate tissue damage. In other words, self-injury involves "damaging a part of the body" (Feldman, 1988, p. 252); performing "injurious acts upon the body" (Pattison & Kahan, 1983, p. 867); producing "destruction or alteration of body tissue" (Favazza, 1989, p. 137); or taking "measures . . . to render imperfect some part of the body’ (Phillips & Alkan, 1961, p. 429). While the tissue damage is not usually life-threatening, it may require medical attention.

The third defining attribute of self-injury revolves around the issue of motivation—the intent is to injure rather than to kill. This attribute clearly distinguishes self-injury from suicide. Favazza (1989) and Feldman (1988) note self-injury is "without conscious suicidal intent" (p. 137) and "without a conscious intent to die" (p. 252). Kirmayer and Carroll (1987) describe the intent as "nonlethal," while Walsh and Rosen (1988) use the word "non-life threatening."

Operational definition. Incorporating these three attributes, the authors offer the following operational definition: Self-injury is a deliberate act upon the self, with the intent to injure rather than to kill, which produces immediate tissue damage of the body.

- Sebree, R; Popkess-Vawter, S. Self-Injury Concept Formation: Nursing Diagnosis Development. Journal Perspectives in Psychiatric Care; 1991; 27,2; (27-35)

Personal Reflection Exercise #8
The preceding section contained information about self-injury concept formation. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Suicide, self-harm, and suicide ideation in nurses and midwives:
A systematic review of prevalence, contributory factors, and interventions

- Groves, S., Lascelles, K., & Hawton, K. (2023). Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions. Journal of affective disorders, 331, 393–404. https://doi.org/10.1016/j.jad.2023.03.027

Peer-Reviewed Journal Article References:
Knutson, D., Jacobs, S. C., Hakman, M., & Milton, D. C. (2021). Profiles of distress and self-harm among LGBTQ+ transitional youth in a rural state. Journal of Rural Mental Health, 45(2), 107–120.

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.

Witt, K., & Robinson, J. (2019). Sentinel surveillance for self-harm: Existing challenges and opportunities for the future [Editorial]. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(1), 1–6.

QUESTION 8
What is the difference between self-injurious behavior (SIB)and self-mutilation behavior (SMB)? To select and enter your answer go to Test.

Excerpt of Bibliography referenced in this article

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