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Ask the Mental Health Expert Archives 2001-2004

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Avoiding Self-Injurious Behavior

Q. I have a patient with long-standing depression in our inpatient unit. Her psychiatrist has prescribed Effexor XR during this hospitalization. She is withdrawn from the milieu therapy, and doesn't participate in group discussion.

For the past few months, she has gouged sores in the skin in 8 or 10 places. She keeps picking at these sores though we put Band-Aids on them daily, sometimes at every shift. It seems that she pick these absentmindedly; her hands are always in motion, scraping one site after another.

The psychiatrist advises ignoring the action, so it is not reinforced. As a nurse, I am disturbed by her self-mutilation. Do you have ideas for a nursing intervention?

A. Self-injurious behavior (SIB) is a very complex, often over-determined phenomenon. While it is true that mental health professionals should avoid reinforcing such behavior by rewarding it with undue attention, ignoring it is not likely to succeed either.

The key is, first, to determine how medically/surgically significant the SIB is (e.g., is the patient doing serious damage to an artery? Are the sores becoming infected? etc.); and second, to devise a strategy that addresses the SIB without becoming involved in a titanic struggle with the patient. This requires a sophisticated formulation of the underlying motivation and psychodynamics of the SIB. Of course, no patient can be allowed to do serious harm to him/herself, whether on or off the unit.

Picking at sores might or might not fall into that category, and a medical-surgical or dermatology consultation could settle that question. The harder part is formulating a therapeutic response. In their seminal book, "Self-injurious Behaviors", Gardner & Sovner (VIDA Publishing, 1994) note that, "?it is not unusual, especially following severe self-abuse, for staff or family to comfort the person or to attempt to prompt distraction by providing special attention, food, or a favored object or activity. As a result, SIBs may become functional in insuring that desired attention?or other forms of social interaction will occur..." This is clearly not helpful to the patient in the long run.

Gardner & Sovner offer detailed guidance on helpful interventions; e.g., minimizing reinforcers after the behavior; providing positive reinforcers (e.g., social contact) on a scheduled basis, independent of the SIB; and teaching the patient to use competing motor or communicative behaviors instead of the SIB--for example, teaching the patient to pull on a rubber band instead of scratching; write down her feelings on an index card instead of scratching; come to the nursing station when she feels like scratching, etc. These appropriate alternative behaviors can then be positively reinforced with praise, increased privileges, etc.

For more details, I suggest you get hold of the Gardner & Sovner book. Dr. Mary Zanarini and Kenneth Silk also discuss SIB in their chapter on Borderline Personality Disorder in our book, "The Difficult-to-Treat Psychiatric Patient," (edited by M. Dewan and R. Pies, American Psychiatric Press, 2001). You may also want to read the article, "Self-mutilating behavior", by C. Kehrberg, in J Child Adolesc Psychiatr Nurs 1997 Jul-Sep;10(3):35-40, which describes specific nursing interventions.

I would also strongly recommend obtaining consultation from a behavioral psychologist, if available, to help you design and implement such behavioral strategies--assuming that the patient's psychiatrist agrees! Otherwise, you are guaranteeing a "split" in the staff. I can tell you without hesitation that if the behavioral regimen is not followed consistently from nursing shift to shift, it is doomed to failure! Good luck with this challenging situation.

February 2003

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