The neurobiology of deliberate self injury
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The Neurobiology of Deliberate Self-Injury. Sarah Swannell BSocSc(Hons)Psych Senior Research Technician Discipline of Psychiatry The University of Queensland. What is deliberate self-injury?.

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The neurobiology of deliberate self injury l.jpg

The Neurobiology of Deliberate Self-Injury

Sarah SwannellBSocSc(Hons)Psych

Senior Research Technician

Discipline of Psychiatry

The University of Queensland


What is deliberate self injury l.jpg
What is deliberate self-injury?

  • Deliberate destruction or alteration of body tissue without suicidal intent (Favazza, 1989) & done to relieve an undesirable emotional or psychological state

  • Low lethality & low intent to die

  • Repetitive

  • Borderline Personality Disorder

  • PTSD, depression, bi-polar disorder, schizophrenia, antisocial personality disorder


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Prevalence

  • 60% of psychiatric patients

  • 40% of high school students and university students


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Why do people self-injure?

  • to feel better

    • release tension

    • stop dissociating

    • turning emotional pain into physical pain which is easier to handle

    • avoiding suicide


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but how does self-injury make some people feel better?

  • what happens in the brain when people self-injure?


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The 5phases of self-injury

  • Perception of threat  unwanted negative emotion (desire to terminate it)

  • Choice of coping technique

  • Self-injury

  • Unknown mechanism of action

  • Objective and subjective tension relief


Phase 1 perception of threat l.jpg
PHASE 1. Perception of Threat

Immediate reaction

Sensory cortex  amygdala hypothalamus pituitary gland  adrenal gland

Delayed reaction

Sensory cortex  amygdala prefrontal cortex

Unwanted negative emotion


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Vulnerabilities to experiencing unwanted negative emotion

  • more intense negative emotions

  • longer lasting negative emotions

  • BPD & PTSD studies

    • the Hypothalamic-Pituitary-Adrenal Axis (HPA) axis is more sensitive (Yehuda et al., 2001)

    • History of trauma


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PHASE 2. Choice of coping technique

Serotonin system

Prefrontal cortex-limbic system connection

Prior learning

Beliefs


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Serotonin System

  • Impulsivity & aggression

    • Low levels of 5-HIAA in CSF of depressed suicide attempters (Asberg et al., 1976)

    • Reduced levels of 5-HIAA in male borderlines (Brown et al., 1982)

    • Low serotonin correlated with suicide attempts, assaultiveness, instability, aggression & impulsiveness (Coccaro et al., 1989; Markowitz et al., 1995)

    • Self-mutilators had more personality pathology, greater lifetime aggression, more antisocial behaviour, and lower levels of serotonin activity (Simeon et al., 1992)


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  • Post-mortem studies of suicides found fewer presynaptic serotonin transporter sites in ventromedial prefrontal cortex, hypothalamus, occipital lobe, brainstem(Mann, 1998)

  • Peer-reared monkeys have lower serotonergic activity in comparison to maternally raised monkeys (Higley et al., 1993)

  • Adverse rearing sets serotonergic functioning at a lower level (Mann, 2003)


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Prefrontal cortex-limbic system connection serotonin transporter sites in ventromedial prefrontal cortex, hypothalamus, occipital lobe, brainstem

  • Emotion dysregulation via: dysfunctional transmission between prefrontal cortex and limbic system (amygdala/anterior cingulate are under inhibitory control of the prefrontal cortex)

    • dorsolateral prefrontal cortex (PFC) is implicated in effortful regulation of affect

    • the orbitofrontal cortex, middle temporal gyrus, cingulate cortex, and the caudate nucleus are implicated in the identification and production of affect (Ramel, 2005).

  • The ventromedial prefrontal cortex has been widely implicated in impulse regulation (Potenza, Leung, Blumberg, Peterson, Fulbright, Lacadie, Skudlarski & Gore, 2003; Fukui, Murai, Fukuyama, Hayashi,& Hanakawa, 2005).


Prior learning l.jpg
Prior Learning serotonin transporter sites in ventromedial prefrontal cortex, hypothalamus, occipital lobe, brainstem

  • Observation, accident

  • Lack of physical pain

    Beliefs

  • Action is needed to reduce unpleasant feelings

  • Self-injury is acceptable

  • My body and self is disgusting and deserving of punishment

  • Overt action is needed to communicate feelings to others

  • I must control my body and myself


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PHASE 3. Self-injury serotonin transporter sites in ventromedial prefrontal cortex, hypothalamus, occipital lobe, brainstem

  • Noxious stimuli depolarize nociceptors & signals  dorsal root ganglia  dorsal horns in spinal cord

    • a) projection neurons  sensory info to brain

    • b) local excitatory & inhibitory interneurons  to brain & regulate flow of info to brain

  • Noxious stimuli travel up the spinal cord via anterolateral pathways and transmitted contralaterally to the brain.

  • Chemical signals arrive at thalamus, periaqueductal grey matter, primary sensory cortex and associated cortices, reticular formation, medulla, pons, midbrain, hypothalamus, and caudal anterior cingulate cortex (Ploghaus et al., 1999).

  • normally this results in subjective pain


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Endogenous opioid system serotonin transporter sites in ventromedial prefrontal cortex, hypothalamus, occipital lobe, brainstem

  • Approx 60% feel no pain(Bohus et al., 2000; Russ et al., 1993)

  • Abuse/neglect/trauma can alter EOS & reduce sensitivity to pain (Kirmayer et al., 1987; van der Kolk, 1989; Dubo et al., 1997; van der Kolk et al., 1991)

  • Decrease in pain sensitivity following early traumatic experiences has been reported in both animal and human studies (Russ et al., 1993)


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PHASE 4. Unknown action with recency and severity of cutting


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PHASE 5. Tension relief with recency and severity of cutting

  • Objective (psychophysiological measures) & subjective tension relief (Haines et al., 1995; Brain et al., 1998)

    • personalised imagery script

    • Finger pulse amplitude (FPA), electrocardiograph (ECG), heart rate (HR), respiration (RESP)

    • skin conductance level (SCL)


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Implications for clinicians with recency and severity of cutting

  • Something is going on in the brain when people self-injure

  • Understand your clients

  • Work within your client’s limitations

  • Improve resilience, coping skills

  • Reduce stress


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