Journal of Psychiatric and Mental Health Nursing, 2014, 21, 857–858

Editorial From expression to symptom to disorder: the psychiatric evolution of self-harm in the DSM

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (American Psychiatric Association, 2013 pp. 801–804) has introduced two new conditions for further study: suicidal behavior disorder and nonsuicidal self injury (NSSI). While I believe there is a long overdue need to distinguish self harm from a suicidal act, it does raise concerns about the evolution of an expression of distress to firstly a symptom of mental disorder and now potentially a disorder in its own right. In the past self-harm and suicidality have been conflated as similar behaviours. However it could be argued that a person-centred response requires an ability to distinguish between these behaviours. There also needs to be awareness that the same person may engage in both behaviours and that for some people selfharm behaviours can progress to suicidal behavior. While acknowledging the distinction between self harm and suicide attempt and that the two can overlap, the construction of self-harm as a potential psychiatric disorder raises a number of concerns. The DSM-5 (American Psychiatric Association, 2013 p.803) describes NSSI as intentional self-inflicted damage to the surface of his or her body of a sort likely to include bleeding, bruising, or pain with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). It is defined as being accompanied with one or more of the following expectations: relief from negative feeling or cognitive state; resolution of an interpersonal difficulty; and the inducement of a positive feeling state. For the diagnosis it needs to have occurred on five or more days in the previous year, and it needs to be associated with at least one of the following: interpersonal difficulties or negative feelings and thoughts; prior to engagement in the act, a period of preoccupation with the intended behavior which is difficult to control; thinking about self-injury that occurs frequently. The text suggests that individuals often learn of this behavior on the recommendation or observation of another. Unusually for the DSM enterprise that claims to be atheoretical, the proposed diagnosis posits two theories for the behaviours: 1) positive or negative reinforcement of the behavior; and 2) a form of self-punishment. It is noted that the great majority © 2014 John Wiley & Sons Ltd

of individuals who engage in NSSI do not seek clinical attention. A number of questions are raised by this definition: why is damage to the surface of the body the object of concern?; why are dichotomous measurements used (i.e., ‘five days’, ‘at least one of the following’); why is severity not considered? – but two questions are of central concern –Why is this behavior being constructed as a psychiatric disorder? And why is clinical attention being directed at this behavior at this point in time? Placing people in diagnostic categories treats them as objects and effectively constructs them as epiphenomena of their actions (Mirowsky & Ross, 2002). The person and their experiences are effectively decentralized and the focus on behavior becomes a simplification of the uniquely complex human condition. As described by Butler & Malone (2013) self harm can be understood as a coping mechanism to regulate overwhelming feelings and to endure life. For many people it provides a form of selfexpression in response to unbearable distress (Crowe, 1996). Because it is not always a socially sanctioned form of self-expression (although it could be argued that it is sanctioned within some social or cultural groups) does this mean it is evidence of mental disorder? Most self harming behavior occurs in adolescence and young adulthood (American Psychiatric Association, 2013 p.804) and most self-harming behaviour resolves spontaneously (Moran et al., 2012). If this behavior is constructed as evidence of mental disorder it has disturbing implications for those that engage in the behavior as a form of self-expression. While the diagnosis is made in relation to very specific behaviours that occur in very specific contexts once it is made it constructs the whole person as abnormal and mentally disordered (Crowe, 2000a). Do we want young people to be labeled as abnormal during a turbulent period of their development? So why is clinical attention being directed at NSSI at this time? One explanation may be that in the previous DSM self-harm was defined as a symptom of Borderline Personality Disorder and that this diagnosis was inappropriately applied to anyone who self-harmed. While other criteria 857

Editorial

are required for the diagnosis of Borderline Personality Disorder these can be ignored or misattributed in clinical practice if it is the self-harm that comes to clinical attention (Crowe, 2004). This may account for the sharp rise in use of this diagnosis over the past 20 years. Another explanation may be that it has become increasingly evident that people who experience a range of serious mental disorders also self harm but it is not a symptom of these diagnoses e.g., bipolar disorder, anxiety disorders, depressive disorders (Skegg, 2005). A third explanation may be related to the increasing research interest in transdiagnostic symptoms i.e., symptoms that occur across a number of disorders/ health problems such as sleep disturbance (Insel et al., 2010). The DSM is constrained by its categorical diagnostic process which does not allow for an easy shift to a transdiagnostic symptom focus. Yet another possibility is that the authors of the DSM-5 genuinely believe that psychiatry is best placed to help people who self-harm. A final explanation may be the continued expansion of the psychiatric domain over increasingly more aspects of everyday life. By naming an aspect of everyday life as a mental disorder psychiatry can treat and receive payment for treating more and more people. It could be argued that psychiatry has increasingly turned its attention to public health

References

issues e.g., drug and alcohol abuse, caffeine use disorder, internet gaming disorder and self-harm is just the latest issue to be co-opted as a disorder (I expect sugar ingestion disorder to be the next!). Mental health nurses need to examine their role in relation to self-harming behaviours. Levels of underpinning distress and the severity of the self-harm will determine the need for involvement. It could be argued that mental health nurses have co-opted psychiatric discourse into their everyday practice and thus constructed a limited and dependent role for themselves and have failed to explore other possibilities for those that they nurse (Crowe, 2000b). Nurses need to be careful not to accept any new diagnoses without question and to look beyond the psychiatric diagnosis to a wider consideration of the person’s needs that could be better articulated in a clinical formulation (Crowe, Carlyle, & Farmar, 2008). MARIE CROWE Department of Psychological Medicine and Professor, Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, PO Box 4345, New Zealand e-mail: [email protected]

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From expression to symptom to disorder: the psychiatric evolution of self-harm in the DSM.

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