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Let’s Talk About Self Injurious Behaviors

  • By: Dr. Jerry Kartzinel
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Self injurious behaviors (SIBs) can be some of the most distressing behaviors a parent can witness!  I have seen many different displays of SIBS including:

•    Hitting of body parts: head and thighs most common
•    Biting of hands, wrists, and lips
•    Poking of eyes
•    Grabbing and pinching self
•    Pulling body parts really hard, for example the “pinkie” toe
•    Jumping and falling directly onto knees
•    Pulling hair
•    Body slams into walls, furniture

The good news is we can usually stop these behaviors as soon as we can identify the source or sources.  I am convinced that the majority of children who exhibit SIBS do so in order to somehow minimize discomfort with what they are feeling.  Sounds strange to most of us, but this can make sense.  Let me give you an example.

When I was working with teens in a “half-way” house, I had the opportunity to take care of “cutters.”  These teens would cut themselves, intentionally, usually at night.  The next day, they would come to my clinic for a “patch.”  After gaining their confidence, I would ask them why.  I was told that they have such severe emotional pain or anxiety and that somehow, the physical pain would block this emotional pain and they could go to sleep.  So, how does physical pain decrease the mental anguish?

The physiologic response to pain results in the body producing and releasing substances called endorphins and enkephalins which belong to the family of opioids.  These in turn, bind to opioid receptor sites in the brain and block pain.  This process is likely the source of “runner’s high”, or that euphoric feeling of wellness after a strenuous workout.

Pain, be it psychological or physical in its origin, may be provoking the outward manifestation of a SIB response in order to generate these opioid-like acting agents making this pain more tolerable.  Hence, it would be wise to figure out the source of pain, fix it, and see if this diminishes the SIBs.  That is what I work to do in my clinic: Stop the pain and watch the SIBS diminish or entirely resolve.

Sources of Pain:
•    Constipation
•    Diarrhea
•    Dysbiosis (abnormal gut bugs)
•    Inflammation:
-Abdominal pain
-Gastritis
-Esophagitis
-Colonitis
-Sinusitis
•    Headaches/migraines
•    Arnold Chiari Malformation
•    Allergies
•    Anxiety
•    Sleep disruption
•    TOO much therapy/demands on the child
•    Parental disharmony

Treatment:
This depends on the underlying medical problems.  Each one of these potential sources must be explored and considered.  For example, a 10 day course of Pepcid, an “over-the-counter” antacid can tell you really quickly if some of the SIBS might be due to reflux and inflammation of the swallowing pipe, called the esophagus.  Or, a 5-7 day trial of Ibuprofen (such as Motrin or Advil) that improves SIBS suggests the source IS pain, and could point to, for example, headaches.
After exclusion of the common sources of SIB, I sometimes have to resort pharmacologic management.  Though I generally try very hard not to use medications, I will due to the severity of the behaviors.

Medications to consider in order to control SIBS after all treatable sources of pain/discomfort have been addressed and the SIBS are still not resolved include:

•    Abilify
•    BuSpar
•    Depakote
•    Neurontin
•    Propranolol
•    Risperdal
•    SSRI: Prozac, Zoloft, Lexapro, etc

And in those states where legal, medical marijuana can be considered.

It is worth mentioning that compared to the other medications listed above; the side effect profile for medical marijuana is truly minimal.  It also seems to be very effective in those children with high levels of anxiety which apparently then manifest with SIBs.  Once the anxiety is removed, SIBs just seem to stop.  This medication can be ingested in a capsule, administered as a tincture, or even baked into the child’s food.  The use of medical marijuana continues to be highly controversial and though some states approve its use, the state laws do conflict with federal laws.

Of course, these medications must be prescribed (or “recommended” in the case of medical marijuana) by physicians who can monitor the effectiveness and potential side effects.  Generally, we can avoid many of these medications by addressing the medical concerns first.

And that’s my approach to SIBs.

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