May 10, 2012

Severe Self Injurious Behavior

A small percentage of people with developmental disabilities engage in frequent self injurious behavior. Self injury takes variety of forms including biting, digging, hitting, slapping, kicking, head banging, and ingesting inedible items. These behavior occurs for several reasons:

1. Self abusive behavior is more common with individuals who are nonverbal and have no consistent way of expressing themselves. Consequently, self abusive behavior often is communicating pain, discomfort, frustration, task demands, need for attention, etc. Self abuse can be used to communicate any intense emotional reactions.

2. Most self abusive behavior involves strong proprioception (tension to joints, tendons, and muscles), which reduces stress chemicals (cortisol) in the nervous system. Hitting, kicking, biting, and head banging provides strong proprioception that reduces stress chemicals during times of emotional outbursts. When the stress chemicals accumulate to boiling point, the “fight or flight” stress response is activated, seeking strong proprioception to reduce the stress chemicals.

3. Abusing yourself produces strong reactions from others and these reactions can increase the frequency of self abuse. The person learns that self injury gains a lot of attention, and also allows them to escape situations that they want to avoid. People around them will do anything to stop the self abuse. The individuals learn that the behavior can create a lot of control over their social environment (people let them escape unwanted situations, give them what they want, let them have their way in order to pacify them).

4. Self abusive behavior can be used to mask, or dull pain. Individuals may bang their head to mask pain from headaches and ear infections. They may hit themselves in the jaw to distract from toothaches. When self abuse begins, or increases significantly, medical evaluation is important.

5. Self abusive behavior can be for self stimulation, to help regulate the nervous system. It can alert the nervous system when under-aroused, and release stress chemicals when over-aroused. This behavior often occurs frequently during times of no activity or when overwhelmed by too much activity.

Severe and persistent self injury can start for any of the above reasons, but can become addicting over time. The pain from self injury stimulates the body to release endorphins which is the body’s natural pain killer. Endorphins act like opiates, which feel good, and the person can get addicted to the “feel good” endorphins. Not only do endorphins help dull the sense of pain, but it also feels good. The individual self injures to stimulate the release of endorphins to maintain the “feeling.” Since the endorphins act to dull the pain, the behavior Is not felt as painful. Now, self abuse that occurs for this reason can get worse over time. Like all addiction, the body begins to “habituate” (gain a tolerance for) the stimulation, requiring the individual to do it more intensively, to stimulate the pain to release the endorphins. The brain has a defense mechanism to dull the sense of pain over time, making it necessary to increase the intensity to stimulate the endorphins. In addition, scaring that can occur from the injury dulls the pain, requiring the individual to dig or bite deeper to stimulate pain. These individuals will gradually go from minor injuries to creating severe injury as the skin becomes more and more scared. The individual then has to gouge or tear out tissue to get deeper for pain. In such case the medication naltrexone can be used to block the body’s release of endorphins. By doing so, the self abuse hurts more, plus it no longer releases the “feel good” endorphins. If this works, the self abuse begins to hurt more, and doesn’t release the “feel good” chemicals that is addicting.

In many cases chronic, persistent self injurious behavior ends up being maintained by several of the above functions. It can start because of only one of the functions, but once started, can gain many secondary values by the addition of several of the other functions. In most cases, professional help is needed to isolate the functions, and develop effective strategies to treat each function.
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