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Evidence-Based Psychiatric Medicine: sexual abuse and self-injurious behavior.

The Problem

You have a patient who heats up the blade of a knife and then burns himself with the heated blade. He says he was sexually abused in childhood and asks whether there is a connection between the abuse and self-injurious behavior.

The Question

What is the association between childhood sexual abuse and nonsuicidal self-injurious behavior?

The Analysis

We performed a Medline search that combined "self-injury" and "sexual abuse."

The Evidence

Self-injurious behavior (SIB) can be defined as "deliberate destruction of body tissue without conscious suicidal intent" (J. Am. Coll. Health 2008;56:491-8). In the DSM-IV, SIB is included only as a symptom of borderline personality disorder. However, SIB also occurs in other psychiatric conditions, such as schizophrenia; depressive or anxiety disorders; substance abuse; eating disorders; other personality disorders; and developmental disorders.

Recent research suggests that SIB occurs with similar frequency in men and women. These behaviors occur in clinical and incarcerated populations with a prevalence of 30%-61%, and in nonclinical groups with a prevalence of approximately 4% in U.S. adults and 5%-40% in adolescents (J. Dev. Behav. Pediatr. 2008;29:216-8).

Our search revealed a recent metaanalysis by E. David Klonsky, Ph.D., and Anne Moyer, Ph.D., both of the State University of New York at Stony Brook (Br. J. Psychiatry 2008;192:166-70). The authors searched three databases and combined various permutations of the following terms: self-injurious behavior; deliberate self-harm; self-mutilation or mutilative; self-destructive; and sex or sexual abuse. Studies in which all participants had sexual abuse histories or SIB were excluded, because no associations could be made.

Studies looking at self-injury with suicidal intent, or studies that did not distinguish between intent and no intent, were also excluded. Studies that examined patients who had developmental or psychotic disorders and studies not distinguishing between types of abuse (such as physical or sexual) were excluded as well. In all, 45 studies were included in the analysis.

The factors constituting SIB were not specifically described. However, the authors cited cutting and burning as examples of SIB. Furthermore, the way in which the history of sexual abuse was determined also was not discussed in this article. Presumably, this history was determined by self-report. Sample sizes ranged from 28 to 2,849 participants, with a total of 13, 687 study participants. Ages ranged from 14 to 48 years. The percentage of females ranged from 0% to 100%.

The studies included patients with depression and outpatient personality disorders; psychiatric emergency department patients; borderline personality disordered in-and outpatients mixed psychiatric patients; forensic cases; eating-disordered patients; substance abusers; conversion-disordered patients; trauma or abused patients; nonclinical high school and college students; and general population or community samples, including one of the homeless.

The mean weighted aggregate phi coefficient was 0.23 (range, 0.01-0.45). A phi coefficient is a measure of the degree of association between two variables. This measure is similar to the correlation coefficient in its interpretation. The type of sample was a significant factor of the strength of the relationship between sexual abuse and SIB. That is, the relationship was stronger for clinical (phi coefficient = 0.24) than nonclinical samples (phi coefficient = 0.18).

Studies with smaller study samples tended to show a stronger association. Studies with samples of more than 125 participants had phi coefficients of 0.21, whereas studies with fewer than 125 participants had phi coefficients of 0.33.

The authors concluded that a phi coefficient of 0.23 means that there is a small relationship between childhood sexual abuse and SIB, and that "childhood sexual abuse accounts for no more than 5% of the variance in the development of self-injurious behavior. ... The two might be associated because they are correlated with the same psychiatric risk factors, as opposed to there being a unique or etiological link between them."

The Conclusion

Current best available evidence suggests that a very small relationship exists between childhood sexual abuse and self-injurious behavior.

DR. LEARD-HANSSON is a forensic psychiatrist who practices in San Diego. DR. GUTTMACHER is chief of psychiatry at the Rochester (N.Y.) Psychiatric Center. They have no financial interest in any product or service discussed in this column.
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Author:Leard-Hansson, Jan; Guttmacher, Laurence
Publication:Clinical Psychiatry News
Date:Feb 1, 2009
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