Although much less research has examined self-injury among substance-dependent patients, some research suggests that one-quarter to one-third may have histories of self-injury.
The relationship between self-injury and suicide is complex. There is evidence that a strong correlation between suicidality and self-injury exists. Self-injury and suicidal behavior are most easily differentiated by intent, method, and psychological impact. Empirical evidence suggests that there are a limited number of methods used in suicide attempts and completed suicides. Nonetheless, the methods chosen for self-injury are likely to vary. Alternatively, the number of methods used may reflect a subtype of self-injury, as suggested by latent class analyses forwarded by Klonsky and Olino 45 and Whitlock et al.
The psychological impact of self-injury also differentiates it from nonfatal suicide attempts. Self-injury is typically associated with decreases in negative emotion and reports of increases in positive affect.
It is possible that this is because self-injury may be easier to conceal than a suicide attempt, which may be more lethal. Finally, it is important to consider when self-injury becomes a risk for suicide. Although there is a paucity of data in this area, some recent research by Muehlenkamp and Gutierrez 15 , 63 indicates that people who self-injure are more likely to attempt suicide if they report being repulsed by life, are attracted to death, report not being afraid of suicide or death, are highly or chronically self-critical, exhibit apathy, or have tenuous family connections.
Regarding this last factor, some research has also found that parental criticism is a predictor of both self-injury and suicide attempts as well as suicidal ideation.
There is a dearth of information about the course of self-injury. Research has established that the typical age of onset for this behavior is between 14 and 24 years of age, with a bimodal peak in onset among people 12 to 14 and 18 to 19 years of age.
This same trend was seen among people with other personality disorders, for whom the rate of self-injury decreased from Conversely, in a cross-sectional study of 43 inpatients with BPD and 40 non-BPD inpatients, Sansone and colleagues 70 found that the mean number of types of self-injury steadily increased from childhood until the mids, and then remained relatively stable through the sixth decade of life for both groups.
Patients with BPD reported a significantly higher number of types of self-injury than patients without BPD from late childhood until the late 20s. Both of the aforementioned studies examined select groups of participants ie, patients with BPD, inpatients who are not necessarily representative of people who self-injure as a whole.
In aggregate, the existing data suggest that self-injury is most likely to occur only a few times, but the behavior may increase in frequency and severity when combined with other psychosocial factors, such as a psychiatric disorder or comorbid suicidality. Nonetheless, the available data pertaining to the long-term course of self-injury is quite limited at this time and reflects an area that requires substantially more research. Physicians in primary care and family medicine settings commonly have a trusting relationship with a patient that has developed over several years.
In the best of circumstances this relationship involves a great deal of trust on the part of the patient. This kind of trust can take a long time to build with a behavioral health clinician who is new and unfamiliar to the patient.
People who self-injure, especially adolescents, are most likely to disclose their self-injury to family and friends first, particularly Internet-based acquaintances.
Recent research by Fortune and colleagues 72 suggests that a subset of those who experience urges to self-injure will actually seek help from a primary care physician as their first resource before self-injuring; a larger subset will seek help after self-injuring. In this situation, the physician has a unique role in helping the patient. A primary care physician's recommendation for either finding alternatives to self-injury if the patient wants to eg, exercise 73 or seeking more intensive behavioral health treatment may be vital parts of assisting the self-injuring patient.
Although no empirical data on this topic exists, clinical experience and basic behavioral principles make it logical to conclude that patients may be more responsive to a trusted physician's concerns about self-injury.
In this way, these clinicians serve a vital role in monitoring the status of the patient's behavior, ensuring continuity of care and, if needed, reconnecting the patient with behavioral health services.
Although some recommendations for therapists working with self-injurers have been published, 6 , 7 , 74 no specific guidelines have been forwarded for working with self-injurers in nonpsychiatric settings. Nonetheless, the patient-physician relationship represents a valuable type of therapeutic relationship, and some of the same strategies recommended for use by psychotherapists are likely to be useful for primary care physicians. These strategies discussed below include understanding a patient's self-injury and using validation strategies.
Providing effective psychological interventions requires several years of training. However, one technique that can be used by primary care physicians is developing an understanding of the behavior.
The questions needed to assess the behavior discussed later in this article can be extended to questions that may stimulate a process of change. Motivational interviewing MI techniques 75 provide a useful set of tools and structure for stimulating the change process while simultaneously assessing risk.
As described by Kress and Hoffman 76 in their work on the use of MI with self-injurers, appropriately framed questions can be used as effective tools for eliciting the necessary information for risk assessment, thus allowing the practitioner to make referrals for appropriate services. More importantly, these types of inquiries can elicit a patient's commitment to getting treatment for their self-injury, making follow-through on referrals to behavioral health services more likely.
It seems like self-injury serves a function for you. Are there any disadvantages to continuing to do this to yourself? It sounds like it's difficult to handle the stress in your life without self-injuring. How would your life be different right now if you were not self-injuring? There are a lot of options for getting help for this problem. What do you think you would need to help you stop self-injuring? Inherent to understanding self-injury is the concept of validation. As noted by Nafisi and Stanley 74 and Muehlenkamp, 77 validation of a patient's feelings can foster a stronger patient-clinician relationship.
For psychotherapists, this can mean greater progress in therapy. In a primary care context this can translate to greater adherence to medical advice and a higher probability of follow-through on referrals to behavioral health specialists. Validation also communicates to the patient that the clinician has heard them and has taken their experiences seriously enough to try to understand them. Accurate reflective listening is an essential validation strategy, particularly for patients reporting self-injury.
Complementing reflective listening is the validation skill of confirming a patient's thoughts, feelings, and behaviors within the context of current circumstances. Note that validation is not endorsement of a particular behavior or decision, but rather communicating that others in the exact same circumstances as the patient ie, same stress level, same dilemma, same skills deficits, same family history would probably make similar decisions.
Finally, articulating suspected unspoken thoughts or feelings is also validating for patients. I imagine it's hard to admit that you hurt yourself to cope with stress. Although research focusing on self-injuring patients in primary care settings has been extremely limited, there is anecdotal evidence that family physicians are increasingly faced with the dilemma of providing some form of treatment to patients who engage in self-injury.
There are 2 main considerations in evaluating risk. The first is evaluating the severity level of the patient's self-injury, which is based on the frequency of the behavior and the number of different methods used. In evaluating these domains, considering the approximate frequency and the number of times the patient has engaged in self-injury is important.
A handful of instruments have been created to assess self-injury, including paper questionnaires and interview-style methods. Regardless of the instrument or method used for assessment, a thorough evaluation of the immediate harm that self-injury poses to the patient as well as the motivations for self-injury 87 are essential for managing risk and determining the level of care to which the patient needs to be referred eg, outpatient behavioral medicine consultation or acute inpatient care.
Both Walsh 6 , 7 and Claes and Vandereycken 88 have outlined important guidelines for psychologists and psychiatrists to follow when conducting a thorough assessment of patients who self-injure.
However, most of these recommendations have been offered from the behavioral health care professional's perspective. No guidelines for the assessment of self-injury presenting in primary care settings have been published to date.
This is likely because of the nascent research literature regarding both the treatment and assessment of self-injury in primary care settings. Nonetheless, if a physician in a primary care setting encounters a patient who injures himself or herself, there is an onus of responsibility to facilitate that patient's care in the same way that the physician would facilitate the care of any other condition that requires more intensive clinical attention.
As with other conditions, an adequate assessment is required to determine the most appropriate treatment or referral. With the multitude of clinical data points that a primary care physician must synthesize, a routine structure for the assessment of self-injury can be useful.
As noted earlier, identification of risk for escalation of the self-injury and for suicide is of most importance. This requires a practitioner to synthesize clinical data in a systematic way that indicates a patient's risk level.
There are no specific standards of care yet published in the psychiatric literature regarding the data points essential to assess for when working with patients who engage in self-injury.
We recommend the use of a conservative decision-making process for referring patients to behavioral health clinicians. Given the typical complexity of self-injury, referring patients with moderate risk indicators for outpatient services is appropriate. High-risk patients may warrant immediate inpatient services if they are an imminent danger to themselves or cannot commit to safety. At the very least these patients should be evaluated immediately by a behavioral health practitioner.
Self-injury may naturally elicit strong emotional responses from anyone, including health care professionals. Recommended practice guidelines for approaching a brief assessment of self-injury suggest that an effective evaluation should be approached using a nonjudgmental, dispassionate manner that blends interest in the patient with concern about helping them get treatment if they would like it.
It is important that the patient feels that his or her distress has been heard and, ideally, understood by the clinician. In both of these situations, the natural emotional responses eg, disgust, fear must be contained in an effort to thoroughly evaluate the patient and provide him or her with appropriate care. Ignoring such a finding or reacting in a condescending manor would impede a physician's ability to provide the necessary evaluation and treatment.
In short, demonstration of interest aimed at understanding the functions and severity of the self-injury, in the same way one would show interest in a wound or infection that a patient presents with, is likely to be the most productive approach in a primary care setting.
Identifying an effective treatment approach for self-injury can be a challenging aspect of working with people who engage in this behavior. Even after a treatment response is achieved, the positively and negatively reinforcing nature of this behavior often makes successful management of self-injury complicated and challenging. Nonetheless, effective treatments do exist.
This section describes the current existing therapies for self-injury and supporting data for those approaches. Data regarding treatments for self-injury are also summarized in Table 3.
At present there are no medications that are currently approved by the Food and Drug Administration for the specific treatment of self-injury. However, there is some limited data supporting specific pharmacological agents as potential treatments for self-injury in adults who are not developmentally delayed. In this open-label trial, 50 mg of naltrexone was administered daily. Complete abstinence from self-injury was observed in 6 of the 7 participants over a mean follow-up period of Two participants resumed self-injuring when the medication was briefly stopped and then returned to abstinence when naltrexone therapy was resumed.
A similar finding was reported by Griengl et al. After the start of naltrexone, the patient remained abstinent from self-injury during a week follow-up period. In addition to providing tentative support for naltrexone as a potential pharmacotherapy for self-injury, the authors of both case reports described above suggest that these cases also support the endogenous opioid system model of chronic self-injury.
The endogenous opioid system model posits that self-injurers may have inherently low levels of opiate activity. Based on this model, opiate antagonists such as naltrexone would ostensibly block the positive reinforcement mechanism involved in self-injury. Case-based support has also been found for clozapine as a treatment for self-injury. Despite a very small sample, Chengappa et al 96 reported statistically significant decreases in episodes of self-injury after the start of clozapine therapy.
In addition, self-injury ceased completely in 3 of the 7 patients. For all patients, daily clozapine dosages ranged from to mg, and treatment length ranged from 4 to 12 months. In addition, 2 reports have provided preliminary evidence for the use of topiramate for the treatment of self-injury.
In their study of topiramate as an adjunctive treatment for manic symptoms in bipolar disorder, Chengappa et al 98 reported an ancillary finding that 2 participants with comorbid bipolar disorder I and BPD who exhibited manic symptoms and self-injury stopped injuring themselves after commencement of topiramate the dosage was unspecified.
The data presented regarding pharmacological treatment of self-injury is preliminary evidence at best. In most cases, the pharmacological agents were added or started after the failure to obtain a treatment response with several other medications. Although these data represent potentially promising starting points for systematic clinical studies, the strength of the current evidence is not conducive to recommending these agents for the treatment of self-injury.
Randomized, placebo-controlled trials would be required to establish the efficacy, safety, and action mechanisms of these agents for the treatment of self-injury. Thus the current strength of recommendation taxonomy SORT level of evidence rating for all pharmacological interventions for self-injury is 3 and SORT recommendation rating is C. To date there are no known empirical trials of treatments specifically addressing nonsuicidal self-injury.
Treatments that do address this behavior have historically done so in the context of concomitant suicidal behaviors or other related forms of psychopathology eg, BPD. Therefore, the treatments discussed in this section are specific to BPD. Data from trials of these therapies pertaining to their effects on self-injury are highlighted. Although a detailed description of the theoretical basis for all treatments is beyond the scope of this manuscript, a basic description of each treatment is provided below, followed by outcome data.
In general terms, TFP aims to help patients change their affective and behavioral responses to stress, especially in interpersonal contexts, by providing extensive opportunities for discussion of the patient-therapist relationship during regular therapy sessions twice per week for 1 year.
Through intensive focus on the therapy relationship as a primary content of sessions, the patient can learn new understandings of and responses to interpersonal relationships, as well as the necessary affective and behavioral control techniques required for fostering healthier interpersonal relationships.
An initial effectiveness study of 23 outpatients with BPD found that the severity of self-injury and the level of medical care required after self-injury were reduced after 1 year of TFP. Subsequent randomized clinical trials of the efficacy of TFP , compared this treatment to dialectical behavior therapy DBT 29 and an active placebo.
Similarly, Clarkin et al reported improvements in impulsivity, social functioning, depression, anxiety, and suicidality in their controlled trial finding treatment equivalence between DBT and TFP on this latter variable , but no data on self-injury was reported.
It is logical to conclude and proponents of TFP contend that a treatment that treats the crux of a psychopathology will result in changes to the myriad manifestations of that psychopathology, such as self-injury. However, as it pertains to self-injury specifically, the data about TFP published to date are relatively weak. Moreover, Clarkin et al's original findings of the potential effects of TFP in reducing the severity of self-injury have not been replicated in or at least have not been reported in subsequent trials.
Currently, the data supporting TFP as a treatment for self-injury is level 2 evidence and SORT recommendation rating of C for the use of or referral for this treatment, owing primarily to a lack of replication or, at least, a lack of publication of findings about the effectiveness of TFP for reducing self-injury.
Further research on this treatment is needed to determine its effectiveness in modifying self-injury. The general theoretical premise of MBT is that BPD results from a patient's lack of awareness of the relationships between thoughts and emotions, which adversely impacts interpersonal attachments. The initial effectiveness study was a nonrandomized trial comparing MBT administered by psychiatric nurses and supervised by clinical psychologists to general milieu psychiatric treatment treatment-as-usual [TAU] for 19 patients with BPD.
Bateman and Fonagy 98 reported significantly fewer episodes of self-injury and suicide attempts in the MBT group than the TAU group at the month assessment, and a significantly lower proportion of self-injuring patients in the MBT group than the TAU group was observed at the month assessment despite no significant differences in proportions at baseline. However, no data about self-injury was presented by the authors for this follow-up. However, the data for MBT as a treatment for self-injury remains as level 2 evidence at best.
This is largely because of a lack of an active treatment comparison group, a lack of randomization, and a lack of replication thus far. Furthermore, although potential mechanisms of change in MBT have been articulated, the setting in which MBT was conducted a partial hospitalization program also provided for a multitude of other therapeutic interactions.
It may be reasonably argued that 18 months of structured, intensive therapeutic contact 5 hours per week in the case of MBT in a partial hospitalization program of any kind may yield similar effects. Therefore, the active component of MBT that produces change remains unclear. When considering the outcome data for MBT, the evidence for this therapy as an intervention for self-injury is level 3, with a SORT recommendation rating of C. Manual Assisted Cognitive-Behavioral Therapy.
Manual assisted cognitive behavioral therapy MACT was developed as a brief, cost-effective intervention for the reduction of self-injury in patients with a history of repeated self-injurious behaviors.
This treatment combines 2 to 6 sessions of individual cognitive-behavioral and solution-focused psychotherapy with self-directed bibliotherapy. The bibliotherapy component employs 6 short book chapters that focus on teaching patients emotion management skills, ways to cope with negative thought patterns, and skills to prevent relapse into self-injury. Both therapy sessions and bibliotherapy components focus on problem solving.
This is accomplished in part by helping the patient understand the origins and triggers for their self-injury through use of a behavioral chain analysis form, as well as via thought and behavior monitoring forms. Results indicated that the MACT group had lower monthly rates of self-injury and longer times until the next episode of self-injury than the TAU group, but neither of these differences reached statistical significance.
Patients receiving MACT had up to 7 sessions of individual, solution-focused therapy along with a 6-chapter, page book described above. Results of this larger trial revealed that MACT was not associated with a significantly greater reduction in self-injury at either 6- or month assessment than was TAU, and that MACT was not associated with a significant change in self-injury from pre- to posttreatment assessment. In addition, survival analyses revealed that MACT participants went for a longer period of time days than TAU participants days before their repeat episode of self-injury, although this difference was also not statistically significant.
Similar to the study by Evans et al, this second trial was also characterized by substantial heterogeneity in the way treatment actually occurred within each group, which may account for a lack of group differences. Likewise, TAU included individual problem-solving therapy, seeing a general practitioner for treatment, group therapy, psychodynamic psychotherapy, or brief counseling.
Thus, the failure to find any differences between groups is perhaps not surprising because the design and execution of the study was not conducive to comparing the effects of discrete treatment conditions on a unitary outcome measure.
Additional research is needed to more rigorously evaluate this treatment and further refine the treatment components. DBT 30 was developed as a cognitive-behavioral treatment for chronically suicidal and self-injuring patients diagnosed with BPD. This model postulates that BPD is a pervasive disorder of the emotion regulation system, which develops as a result of a transactional relationship between caustic and abusive conditions in one's developmental environment and a genetic predisposition toward rapid and frequent fluctuations between emotional extremities and intensities.
There are 4 modes of treatment involved in standard, adult DBT: The 4 modes of treatment are structured around the 4 stages of treatment: Patients who enter a DBT program commit to 1 year of treatment and to working toward the goal of reducing all self-injurious behaviors including suicidal behaviors as the primary goal of treatment.
Secondarily, patients agree to address any behaviors that are obstacles to the first goal. In this way, behaviors that sabotage treatment are reduced and the potential for therapy to be effective is increased. Group psychosocial skills training also takes place weekly and serves as a required didactic supplement to the weekly individual therapy session.
This initial effectiveness study randomly assigned female patients with BPD and a history of at least 2 suicide attempts or 2 episodes of self-injury during the past year to either 1 year of DBT or 1 year of treatment by a mental health service provider in the community. DBT patients received the treatment package described above, whereas the TAU patients received a diverse array of other treatments that may or may not have included individual therapy sessions. Initial results revealed that patients who received DBT had significantly fewer episodes of self-injury at each 4-month assessment interval point, including posttreatment.
However, this difference was not significant at the month follow-up assessment. Analyses combined suicide attempts and nonsuicidal self-injury, making specificity of treatment effects hard to identify.
Thus, DBT was equally as effective at reducing self-injury as nonbehavioral treatment by experts. However, during the course of this 2-year trial, patients receiving DBT had significantly lower mean medical severity across all self-harming self-injurious and suicidal behaviors and significantly fewer suicide attempts than did the TAU participants.
DBT has also been adapted, modified, and evaluated for inpatient and adolescent populations. Thus far, no randomized controlled trials have been conducted; however, evidence with lower strength is available.
Barley and colleagues reported the effects of integrating skills training onto an inpatient personality disorders unit. This study evaluated, among other variables, self-injury outcomes in patients admitted to an inpatient facility. Compared with self-injury data from the general psychiatry inpatient unit in the same hospital, patients on the personality disorders unit evidenced significantly fewer episodes of self-injury after DBT was implemented.
More recently, Bohus et al adapted DBT for an inpatient setting. The treatment used a standard DBT protocol of individual therapy, skills training, and skills coaching fitted into a 4-week program. That 19 of the 24 inpatients were medication-free throughout the latter study is a noteworthy consideration. Finally, Rathus, Miller, and colleagues, — and Katz and colleagues have adapted DBT for adolescent populations.
Rathus et al originally adapted DBT by reducing treatment length to 12 weeks, reducing the skills taught, and including the family in skills training. However, there was a significant decrease in suicidal ideations in the DBT group at posttreatment. No data about self-injury specifically was reported. Katz et al adapted inpatient DBT for adolescents, implementing a 2-week program that consisted of daily skills training and individual DBT.
Results of a quasi-experimental study found that this adaptation of DBT significantly reduced self-harm behavior in aggregate, including self-injury, during a 1-year follow-up period. In addition, significant reductions in suicidal ideations were found at discharge and 1-year follow-up.
DBT has been subjected to more scrutiny than any other treatment for self-injury. However, the data about the actual effectiveness of DBT are mixed and suggest a modest effect of this treatment on self-injury. The studies discussed above were generally well-designed randomized, controlled trials. However, there are some notable shortcomings of DBT research.
First, compared with other treatments, DBT has only been systematically evaluated in women. This is a substantial limitation of the generalizability of DBT to the populations it purports to treat. Second, from a design perspective, research about DBT is limited by a lack of comparison with specific alternative treatments. The original studies , compared DBT to a condition in which patients received an indeterminate level of therapeutic contact.
Perhaps any patient with BPD who receives 3 hours of structured, goal-directed contact weekly would improve to a greater degree than would patients who may only receive 30 or 60 minutes of group or individual treatment. Although the degree of change evidenced in this first trial was significant, the most recent trial of DBT did not find significant between-group differences for self-injury.
The comparison condition was slightly better defined and ostensibly consisted of greater expertise in this latest study, but it was still lacking a clear description of the alternative treatment. Another problem with DBT, as with other treatments, is an inadequate or inconsistent definition of outcome measures for self-harm behaviors.
In Linehan et al's recent clinical trial, medical severity of self-harm behaviors was examined across types of self-harm. The data from the DBT literature are promising and clearly suggest treatment effects. Thus far these data give more hope for suicide prevention and self-injury reduction than any other treatment. However, the current data leave us with unanswered questions: For whom is DBT best suited eg, only white women? What is DBT best suited for treating? Research on DBT could be greatly enhanced by including well-defined comparison treatments.
Finally, one oft-cited concern about DBT is the considerable startup cost involved in implementing a program because of the extensive training required. Hundreds of patients have now been treated in clinical trials of interventions that address self-injury see Table 3 for a summary of findings. Although some research and analyses have been more sound than others, the research evaluating all the known interventions has shortcomings.
Across all clinical trials and all treatment modalities for self-injury interventions, it seems that one common theme among effective therapies is consistent therapeutic contact during a relatively long-term course of treatment. Another common theme is the acquisition of new skills during treatment. Regardless of the terminology or theory used, the effectiveness of TFP, MBT, and DBT ie, the effective treatments is contingent on a patient's ability to learn how to do things differently.
Whether learning how to relate to or interact with others more assertively, how to take care of themselves more consistently, or how to tolerate distress more effectively, patients receiving all of these treatments are required to learn, develop, and apply new skills to get better.
It is possible that an intervention based on a transtheoretical model would prove to be a more efficacious treatment than the current extant therapies.
Future research may be best directed toward identifying the active components in each of these treatment approaches to determine the most effective and comprehensive package. Self-injury is a serious behavioral problem that may be increasing in prevalence. These patients present a higher safety risk than does the typical clinic patient. Nonetheless, effective evaluation of self-injury can be completed rapidly using the protocol provided and is essential to effective risk management and referral to appropriate psychosocial and behavioral therapies.
Nonetheless, treatment of self-injury among primary care patients begins with an effective patient-physician relationship. This may allow for better follow-up on the patient's part and stronger reinforcement of any new skills learned in therapy.
Effective psychotherapeutic treatments are available for patients who self-injure. Regardless of the type of psychotherapy used, all treatments seem to share the common thread of addressing underlying psychological dysfunction and skill deficits. The key to management of self-injury is getting the patient connected with the appropriate behavioral health services. Risk assessment of patients who self-injure is also critical.
A first step in this direction is identifying patients who self-injure. Once self-injury is detected, assessment of the patient's risk level is the next important step. Validation and understanding of the patient's self-injurious behavior serve as valuable tools both for tempering an emotional response and for eliciting important information from a patient who self-injures. Kerr , PhD , Jennifer J.
Muehlenkamp , PhD and James M. Previous Section Next Section. Psychiatric Disorders and Self-Injury The presence of psychopathology elevates the probability of self-injurious behaviors and thoughts, and self-injury is associated with more symptoms and greater severity of psychopathology among both men and women.
Dissociation and Dissociative Disorders Dissociation is a clinical phenomenon in which an individual has the subjective perception of being psychologically, and in some cases physically, disengaged from reality.
Major Depressive Disorder Only two studies to date has provided explicit data about self-injury and major depressive disorder MDD.
Alcohol Dependence Although much less research has examined self-injury among substance-dependent patients, some research suggests that one-quarter to one-third may have histories of self-injury. What effect is this having on your life? Is there anything that's motivating you to stop self-injuring right now? Validation Inherent to understanding self-injury is the concept of validation.
Assessment of Self-Injury Although research focusing on self-injuring patients in primary care settings has been extremely limited, there is anecdotal evidence that family physicians are increasingly faced with the dilemma of providing some form of treatment to patients who engage in self-injury.
In this window In a new window. Instruments for Assessing Self-Injury A handful of instruments have been created to assess self-injury, including paper questionnaires and interview-style methods. Special Considerations for Primary Care Settings No guidelines for the assessment of self-injury presenting in primary care settings have been published to date. Suicidal ideations during or before self-injury Types of self-injury in which the patient engages Onset of self-injury Place location on the body that is injured Severity and extent of damage caused by self-injury Functions of the self-injury for the patient Intensity or frequency of self-injury urges Repetition of self-injury Episodic frequency of self-injury View this table: This may take a variety of forms, including closely mimicking the scholarly peer review processes used in science and medicine.
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