Dissociative Symptoms in a Deliberate Self-Harm and Comparison Female Adolescent Sample

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Post author: Gill I’Anson

Abstract

Research suggests that deliberate self-harm (DSH) is most prominent amongst teenage females. Some researchers propose that DSH is associated with dissociative symptoms and may be a facilitator to DSH.  However, many of these studies are based on adult, psychiatric, populations, which may not be representative of non-psychiatric populations.  This study compared DSH and non-DSH teenage female patients attending an A&E department on the HADS, SDQ-5 and Dissociation Questionnaire.  Results show that the groups were significantly different on all measures.  Regression analysis indicated that dissociation differentiated the two groups better than depression or anxiety did.

Background

The term ‘Deliberate Self-Harm’ (DSH) is generally used to cover all aspects of self-injurious behaviour and suicide attempts (Bird & Faulkener, 2000).  Therefore the term is used to describe a range of different acts and motivations to act, not all of which involve the intention to die. Research and reviews of the DSH literature indicate that suicide (e.g. Hawton, 1992; Walsh & Rosen, 1988) and DSH (e.g. Bird and Faulkener, 2000; Hawton et al. 2000) rates are increasing and are particularly high amongst female adolescents (e.g. Blumenthal, 1990; Welch, 2001; Bird & Faulkener, 2000).  It is also clear that DSH occurs in both psychiatric and non-psychiatric populations (e.g. Groholt et al.2000; Harkavy-Friedman et al.1987; Smith & Crawford, 1986), and is a high risk factor for completed suicide (Kreitman & Foster, 1991). Data fromEnglandandWalessuggest that around 1% of people who attempt suicide go on to kill themselves within a year of an attempt, a rate which is 100 times greater than that among the general population (Bird & Faulkener, 2000).

Young people may be more vulnerable to self-harm for various reasons.  They may have relatively less power over the circumstances of their lives than older people. They may be concerned with issues of independence and separation/individuation and yet living with or dependent on families that provide insufficient nurture or are abusive, or they may be struggling with issues of sexuality or being bullied by peers (Babiker & Arnold, 1996).  Two North American studies of adolescent suicide attempts seen in the hospital emergency room found that the precipitants to the event were most commonly parental/family problems, girlfriend/boyfriend problems and school problems (Kienhorst et al.1987; Tishler et al.1981).  This may reflect the fact that teenagers have had less time to develop mature coping mechanisms or time to resolve adolescent emotional difficulties.  Alternatively they may have difficulty resolving the more complex emotional difficulties caused by the kinds of childhood abuse that frequently underlie self-harm (Van der Kolk et al.1991; de Young, 1982).  For example Green (1987) found that 41% of abused and neglected children engaged in head banging, biting, burning and cutting themselves.

The last decade has seen increasing empirical investigation of the psychological processes underpinning suicidal behaviour.  Traditionally, psychological risk factors for DSH have been identified as depression, alcoholism, substance abuse, schizophrenia, personality disorder, and child abuse (O’Connor & Sheehy, 2000). However, bearing in mind that DSH occurs in the general population, traditional DSH theories have suffered from a lack of consideration of the bias inherent in the data collection methods and populations studied.  For example research with psychiatric populations may be restricted in its relevance to a wider DSH population.

Factors Associated With DSH

High rates of childhood sexual abuse have been found in DSH participants in psychiatric populations (e.g. Anderson et al. 1993; Brown & Anderson, 1991) and non-psychiatric populations (e.g. Gilliland, 1995; Law et al.1998), although the rate tends to be higher amongst psychiatric samples.  Problem-solving deficits have been noted in DSH samples (e.g. McLeavey et al.1987; Rotherham-Borus et al.1990) and it is hypothesised that these deficits may be influenced by deficits in autobiographical memory recall noted in DSH populations (Williams & Broadbent, 1986; Williams, 1996). It is argued that an over-general memory database is not conducive to creative problem solving as it provides fewer prompts for the generation of potential strategies to overcome life difficulties.

The role of depression in suicidal behaviour is unclear.  Inconsistent evidence is found in the research literature, with significant relationships more prominent in psychiatric populations (e.g. Harris & Lannings, 1993; Robbins & Alessi, 1985) than non-psychiatric populations (e.g. Taylor & Stansfeld, 1984).  It may be that ‘hopelessness’, an element of depression, is the most important factor in DSH (e.g. MacLeod et al.1993; O’Connor & Sheehy, 2000).  However, Williams et al. (1992) point out that autobiographical memory deficits may also play a role in hopelessness, as an individual who finds it difficult to access specific memories of happier times will find it equally difficult to predict discrete positive events.

A review of the DSH literature reveals two issues: 1). Much of the existing research has been with psychiatric populations.  Such populations may not be representative of the whole DSH population, many of who do not have contact with mental health services, but use health services such as Accident and Emergency departments. 2). Little attention has been paid to dissociation, which some research shows to be associated with DSH (e.g. Van der Kolk et al.1991; Orbach et al.1995).  This role may be over and above mental health problems such as depression.

Dissociation - A Possible Factor In DSH?

Dissociation is predominantly characterised by disturbance or alteration of the integrative functions of memory, identity or consciousness (American Psychiatric Association, 1987) (APA). It is assumed that dissociation is a kind of mental avoiding or escaping activity, when physical avoidance of, or actual escape from highly threatening (i.e. traumatic) stimuli is impossible.  The dissociation of a traumatic experience is reinforced by the resulting reduction in anxiety, tension and pain.  The Diagnostic Statistical Manual of Mental Disorders – (4th edition), (APA, 1994) recognises five dissociative disorders: dissociative amnesia, dissociative fugue, depersonalisation disorder, dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS).

The importance of investigating the relationship between DSH and dissociation can be concluded from three research and theoretical sources:

1. High rates of DSH found in dissociative patients.

Suicidal ideation and suicide attempts are some of the most common presenting features of DID.  Putnam et al. (1986) noted suicidality as a presenting symptom in nearly 70% of 100 cases of DID reported to them by 92 clinicians throughoutNorth America.  Ross & Norton (1989) found that 72% of their 236 DID case sample had attempted suicide.  Loewenstein (1991a) noted that secondary symptoms such as self-destructive behaviours are often associated with dissociative symptoms.  Hornstein & Putnam, cited in Hornstein (1993), studied 44 children diagnosed as having DID.  They found that 95.3% of the cases had documented histories of a combination of physical and sexual abuse, neglect, abandonment and/or domestic violence, and that 40% of the sample engaged in self-mutilating behaviour.  However, DID is an extreme form of dissociation and may not be representative of all dissociative disorders.

2. Common risk factors for DSH and dissociation.

Deficits in autobiographical memory have been found in studies of suicide attempters (e.g. Williams, 1996) and are a characteristic of dissociative disorders (e.g. Bryant, 1995; Weingarten et al.1995).  These memory deficits may play a role in problem-solving deficits and hopelessness (O’Connor et al. 2000; Williams et al.1992). Dissociative symptoms may also be implicated in producing a sense of ‘hopelessness’ so often noted in suicidal populations (e.g. MacLeod et al.1993). Repeated traumatic experience and the following intrusive experiences seen in Post Traumatic Stress Disorder and dissociative disorders may contribute to the individual feeling powerless and hopeless.  Dissociation (Chu and Dill, 1990; Terr, 1991; Van der Kolk, 1991) and self-harm (e.g. Law et al.1998; Coll et al.1998) are both associated with childhood abuse and neglect.

3. Possible theoretical reasons why dissociation may be a precipitating factor in DSH.

DSH and dissociation may be more closely related than simply being a result of similar childhood experiences.  Some theorists have suggested that dissociation plays an active role in self-harm.  Orbach (1995) argues that dissociative processes may facilitate deliberate self-harm in the following ways: withdrawal from reality, apathy towards the body, analgesia for pain and distortion of body perception.  Through these dissociative processes the individual is able to inflict injury on him/herself by shielding him/herself from the pain and horror associated with such experiences.  However, Baumeister (1990) suggests that dissociative processes are an integral part of the development of the suicidal tendency and not just the act itself.  Dissociative processes enable the individual to escape from unbearably painful experiences.  Baumeister suggests that the dissociative state may increase the likelihood of suicide through the diminished inhibition against acting out self-destructive tendencies.  Shneidman (1980) hypothesises that constriction, a symptom of dissociation, narrows the ideas and options for the potential suicide producing a tunnel vision where ordinary thoughts, emotions and responsibilities are unavailable to the conscious mind, leading to a sense of hopelessness.

Previous research has found a relationship between dissociation and DSH.  Orbach et al. (1995) found a relationship between suicidal behaviour and dissociation, primarily ‘bodily dissociation’ symptoms.  Van der Kolk et al.’s (1991) study of personality disorder patients also found that self-destructive behaviours were correlated with dissociative symptoms.

This study aims to build upon the existing literature on the association between dissociation and DSH, by investigating whether an association is found in a teenage, non-psychiatric population of individuals who have self-harmed.  The study also aims to determine whether depression and anxiety differentiate between DSH participants and non-DSH participants as well/better than dissociative symptoms.  Such investigation will help us understand what psychological dysfunctions are involved in DSH, thereby providing empirical data on which therapeutic intervention can be based.

Discussion

This study examined associations between DSH, dissociation, depression and anxiety in teenage girls attending an A&E service.  There were three main findings. 1) The DSH group was found to show significantly higher levels of dissociation, anxiety and depression than the control group. The groups were best separated by their dissociation scores as measured by the DIS-Q total and SDQ score.  2) The anxiety  and dissociation measures differentiated the groups more significantly than the depression scores.  3) No significant differences were found on any measure between the ‘first time’ and the ‘repeaters’ in the DSH group.

The finding that dissociative symptoms best differentiated the groups adds to an increasing body of empirical evidence pointing to the importance of dissociation as a mental mechanism associated with DSH (e.g. Low et al. 2000; Orbach et al.1995; Van der Kolk et al.1991).  This study also demonstrates that the relationship between dissociation and DSH is relevant to adolescent non-psychiatric populations, as most of the previously reported data come from adult, psychiatric samples.

The DSH group demonstrated high clinical levels of anxiety rather than depression, suggesting that it may be anxiety rather than depression that plays a major role in DSH.  This finding is contrary to the theory that depression plays a central role in DSH (e.g. Christoffel et al.1988; Friedman et al.1984; Withers & Kaplan, 1987) and also contradicts some of the existing research that has found that anxiety disorders fail to differentiate between self-harmers and control groups (e.g. Straus et al. 2000).

As Orbach et al. (1995) suggest the measure of bodily dissociation (SDQ-5) best differentiated between the two groups.  This finding suggests that bodily dissociation specifically may be associated with DSH.  It also has clinical implications as the SDQ-5 is a short measure that may be useful in assessing patients’ dissociative symptoms.

Clinical Implications

The relationship between dissociation and DSH may be explained in two ways:

1.That individuals who have dissociative experiences are then more likely to self-harm, perhaps due to the facility dissociation mechanisms provide or/and instigated by intolerable affect created by traumatic experience (Power & Dalgleish, 1997).  Putnam (1997) believes that pathological dissociators exhibit self-destructive behaviours as a maladaptive coping response towards the primary and secondary symptoms of dissociation.  These behaviours reflect the underlying disturbances in core developmental processes such as affect regulation, sense of self and metacognitive self-monitoring judgements.

2. Individuals who self-harm develop dissociative capacities to help cope with the physical and psychological pain of their DSH behaviour.  However, the dissociation may then trigger further DSH.  For example, Favazza & Conterio (1989) hypothesise that the experience of dissociation itself may be aversive so that self-harming behaviour then becomes a way of coping with dissociation.  Somatic dissociation may have best differentiated the groups because it was specifically somatic dissociation that disinhibits individuals to self-harm or physical self-harm may have meant that somatic dissociation specifically was elicited.

Either way, the dissociative symptoms require acknowledgement and intervention as they are integral to the self-harming behaviour.  Low et al. (2000) suggest “the stabilisation of the patient through control and mastery of the traumatic memories and associated affect is a necessary prelude to exploration of the nature of the trauma”   (p276). Other researchers have also highlighted dissociation as the crucial area for intervention with self-harm patients (Brodsky et al.1995).  The degree to which dissociation can be reduced may determine the effectiveness of psychological interventions for DSH (Low et al. 2000).

The finding that dissociative symptoms differentiated between the groups better than depression has implications for the theoretical understanding of what leads to DSH and also the risk assessment of DSH.  Although feelings of hopelessness, the amount of planning involved in the act and depression may be predictors of further DSH, dissociative symptoms may be another useful or perhaps more reliable predictor of DSH behaviour if dissociation leads to DSH.  The Pierce scores did not correlate with dissociation scores.  This may be because dissociation may not provide a suitable measure of prediction of future DSH.  Alternatively, the Pierce, currently used to predict vulnerability to repeated DSH, may not be able to predict future DSH as well as if it took account of dissociative symptoms.  It is impossible to determine how useful dissociation measures might be in clinical settings without further research.

Contact: gianson@ctcps.co.uk

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