Alternative Considerations and Article Conclusion (from Non-suicidal self-injury: A brief overview and diagnostic considerations)
Given the way the DSM-IV-TR is structured, where disorders are grouped based on similar symptoms, there is no other obvious place to locate self-injury as an Axis I disorder. Nevertheless, when thinking about how best to classify self-injury, I believe it is important to enter the larger discussion of whether the current classification of disorders needs to be adjusted to reflect higher order factors involved. In such a system, mental disorders that are more closely empirically related etiologically are also more closely related “geographically” in a classification system—that is, they are more likely to be grouped together. This method attempts to address issues related to both the large heterogeneity seen within mental disorders, as well as the often high comorbidity found between certain disorders (see Watson, 2005 for a discussion and example). Applying such an approach to self-injury, we would be considering empirically the question of in what way is the phenomenon of self-injury similar to and different from other mental disorders? What etiologies does self-injury share with other disorders (including with respect to underlying psychological processes)? Are some types or patterns of self-injury more closely empirically related to certain disorders compared with others?
In this approach, types of self-injury would be classified based on etiological factors it shares with other disorders. For example, it may be that people who repeatedly self-injure where an affect regulation process is prominent share much more etiologically with at least one “subgroup” of people who binge and purge as a way to also manage affect. This shared etiology would be reflected diagnostically in that these disorders would be more closely linked—with both possibly subsumed under a higher order factor
(such as disorders of affect regulation).
Rather than a dimensional approach, we might think of this more as a categorical, symptom-higher order factor approach. Likely, it is one that could both retain clinical utility (by maintaining ease of communicating information), as well as potentially enhancing it by having important treatment implications. It might highlight where and in what ways a transdiagnostic approach to psychological treatment is warranted. For example, if affect dysregulation is a key underlying process, it would be a target for treatment regardless of whether there is also self-injury or bingeing and purging as part of the disorder—a common factor that would be highlighted by the classification system itself. As well, of course, the unique elements of each disorder would also need to be addressed.
Self-injury is an important, clinically relevant behaviour that may warrant greater attention in diagnostic classification systems than it currently receives. There are, however, many issues that require further consideration before deciding how to best proceed.
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