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Should self-injury be classified as a mental disorder? (from Non-suicidal self-injury: A brief overview and diagnostic considerations)

Diagnostic Considerations

To date, there is no specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders IV-TR [DSM-IV-TR] that addresses a pattern of repetitive self-injury as a separate syndrome although some have suggested it be included (e.g., Favazza & Rosenthal, 1993; Muehlenkamp, 2005; Pattison & Kahan, 1983). Self-injury is listed as a symptom of a mental disorder in some instances (e.g., borderline personality disorder). In this section, three issues will be briefly considered: (1) whether or not self-injury should be included as a mental disorder, (2) whether or not self-injury should be classified as an impulse control disorder, and (3) how else self-injury might be classified.

Should self-injury be classified as a mental disorder?

Based on how a mental disorder is defined in the DSM-IV-TR (American Psychiatric Association, 2000, see p. xxxi), it would appear that self-injury of a repetitive nature could qualify as a mental disorder (at least conceptually). That is, there is empirical support that self-injury is most typically associated with present distress. It may or may not be associated with impairment in functioning, though likely often is. It is associated with increased risk for suicide, and in some cases, accidental death or significant physical injury. It is not socially sanctioned and current empirical literature reveals impairments in psychological functioning that are believed to contribute to the behaviour.

Arguments in favour of the inclusion of repetitive self-injury as a separate disorder include: to encourage consistency in the term(s) used to describe self-injury; to promote further research in this area, as well as funding for both research and treatment services; to increase knowledge among researchers and clinicians about self-injury; to be able to provide an apt diagnosis for individuals seeking assistance for repetitive self-injury who do not meet criteria for any other mental disorder and who may require a diagnosis in order to receive services (e.g., Muehlenkamp, 2005).

There may also be reasons for a cautionary approach. A reviewer of the present article raised the question, “does self-injury occur chronically and in a large enough subset of the population to justify having self-injury as a separate mental disorder?” Further research is needed to answer this question, as we currently do not know. If self-injury does not occur independently of other disorders, critics might argue self-injury should not be treated as a separate mental disorder but instead be viewed as a symptom or associated feature.

It is also currently unclear what constitutes the typical course, or variations of course, that self-injury may take as, to date, empirical research examining this issue is lacking. The lack of prospective, longitudinal data makes it difficult to interpret meanings and implications of cross-sectional studies of prevalence rates since we do not know what happens to people who self-injure over time, including the question of how many people go on to self-injure in a clinically significant, chronic way. Nor do we know how the presence, form, and frequency of self-injury relate to the development (or not) of other mental disorders. Longitudinal, prospective studies designed to address these issues will be particularly helpful in refining our knowledge and understanding.

You are reading the series, Non-suicidal self-injury: A brief overview and diagnostic considerations by Tracy Riley.

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