Evidence-Based Psychiatric Medicine: Sexual Abuse and Self-Injurious Behavior

Article excerpt

The Problem

You have a patient who heats up the blade of a knife and then burns himself with the heated blade. He says he was sexually abused in childhood and asks whether there is a connection between the abuse and self-injurious behavior.

The Question

What is the association between childhood sexual abuse and nonsuicidal self-injurious behavior?

The Analysis

We performed a Medline search that combined "self-injury" and "sexual abuse."

The Evidence

Self-injurious behavior (SIB) can be defined as "deliberate destruction of body tissue without conscious suicidal intent" (J. Am. Coll. Health 2008;56:491-8). In the DSM-IV, SIB is included only as a symptom of borderline personality disorder. However, SIB also occurs in other psychiatric conditions, such as schizophrenia; depressive or anxiety disorders; substance abuse; eating disorders; other personality disorders; and developmental disorders.

Recent research suggests that SIB occurs with similar frequency in men and women. These behaviors occur in clinical and incarcerated populations with a prevalence of 30%-61%, and in nonclinical groups with a prevalence of approximately 4% in U.S. adults and 5%-40% in adolescents (J. Dev. Behav. Pediatr. 2008;29:216-8).

Our search revealed a recent metaanalysis by E. David Klonsky, Ph.D., and Anne Moyer, Ph.D., both of the State University of New York at Stony Brook (Br. J. Psychiatry 2008;192:166-70). The authors searched three databases and combined various permutations of the following terms: self-injurious behavior; deliberate self-harm; self-mutilation or mutilative; self-destructive; and sex or sexual abuse. Studies in which all participants had sexual abuse histories or SIB were excluded, because no associations could be made.

Studies looking at self-injury with suicidal intent, or studies that did not distinguish between intent and no intent, were also excluded. Studies that examined patients who had developmental or psychotic disorders and studies not distinguishing between types of abuse (such as physical or sexual) were excluded as well. In all, 45 studies were included in the analysis.

The factors constituting SIB were not specifically described. However, the authors cited cutting and burning as examples of SIB. Furthermore, the way in which the history of sexual abuse was determined also was not discussed in this article. …