1. Deliberate self-injury involves deliberately damaging body tissue without suicidal intent in order to relieve negative emotions. It is commonly seen in people with borderline personality disorder, PTSD, depression and other mental health conditions. 2. The neurobiology of self-injury involves 5 phases - perception of threat leading to a negative emotion, choosing self-injury as a coping mechanism, the act of self-injury, an unknown mechanism of action that provides relief, and the experience of tension relief. 3. During self-injury, the brain's serotonin system and prefrontal cortex-limbic connections are involved, along with activation of the endogenous opioid system which can reduce pain sensitivity and increase opioid

1. The NeurobiologyThe Neurobiology
of Deliberate Self-of Deliberate Self-
InjuryInjury
Sarah Swannell BSocSc(Hons)Psych
Senior Research Technician
Discipline of Psychiatry
The University of Queensland

2. What is deliberate self-injury?
• Deliberate destruction or alteration of body
tissue without suicidal intent (Favazza,
1989) & done to relieve an undesirable
emotional or psychological state
• Low lethality & low intent to die
• Repetitive
• Borderline Personality Disorder
• PTSD, depression, bi-polar disorder,
schizophrenia, antisocial personality disorder

3. Prevalence
• 60% of psychiatric patients
• 40% of high school students and university
students

4. Why do people self-injure?
• to feel better
–release tension
–stop dissociating
–turning emotional pain into physical
pain which is easier to handle
–avoiding suicide

5. but how does self-injury make
some people feel better?
• what happens in the brain when
people self-injure?

6. The 5 phases of self-injury
1. Perception of threat  unwanted
negative emotion (desire to terminate it)
2. Choice of coping technique
3. Self-injury
4. Unknown mechanism of action
5. Objective and subjective tension relief

7. PHASE 1. Perception of Threat
Immediate reaction
Sensory cortex  amygdala hypothalamus
pituitary gland  adrenal gland
Delayed reaction
Sensory cortex  amygdala  prefrontal cortex

Unwanted negative emotion

8. Vulnerabilities to experiencing
unwanted negative emotion
• more intense negative emotions
• longer lasting negative emotions
• BPD & PTSD studies
– the Hypothalamic-Pituitary-Adrenal Axis (HPA)
axis is more sensitive (Yehuda et al., 2001)
– History of trauma

9. PHASE 2. Choice of coping technique
Serotonin system
Prefrontal cortex-limbic system connection
Prior learning
Beliefs

10. Serotonin System
• Impulsivity & aggression
– Low levels of 5-HIAA in CSF of depressed
suicide attempters (Asberg et al., 1976)
– Reduced levels of 5-HIAA in male borderlines
(Brown et al., 1982)
– Low serotonin correlated with suicide attempts,
assaultiveness, instability, aggression &
impulsiveness (Coccaro et al., 1989; Markowitz et al., 1995)
– Self-mutilators had more personality pathology,
greater lifetime aggression, more antisocial
behaviour, and lower levels of serotonin
activity (Simeon et al., 1992)

11. • Post-mortem studies of suicides found fewer
presynaptic serotonin transporter sites in
ventromedial prefrontal cortex, hypothalamus,
occipital lobe, brainstem (Mann, 1998)
• Peer-reared monkeys have lower serotonergic
activity in comparison to maternally raised
monkeys (Higley et al., 1993)
• Adverse rearing sets serotonergic functioning at a
lower level (Mann, 2003)

12. Prefrontal cortex-limbic system connection
• Emotion dysregulation via: dysfunctional
transmission between prefrontal cortex and limbic
system (amygdala/anterior cingulate are under
inhibitory control of the prefrontal cortex)
– dorsolateral prefrontal cortex (PFC) is implicated in
effortful regulation of affect
– the orbitofrontal cortex, middle temporal gyrus,
cingulate cortex, and the caudate nucleus are
implicated in the identification and production of affect
(Ramel, 2005).
• The ventromedial prefrontal cortex has been
widely implicated in impulse regulation (Potenza, Leung,
Blumberg, Peterson, Fulbright, Lacadie, Skudlarski & Gore, 2003; Fukui, Murai, Fukuyama, Hayashi,& Hanakawa,
2005).

13. Prior Learning
• Observation, accident
• Lack of physical pain
Beliefs
• Action is needed to reduce unpleasant feelings
• Self-injury is acceptable
• My body and self is disgusting and deserving of
punishment
• Overt action is needed to communicate feelings to
others
• I must control my body and myself

14. PHASE 3. Self-injury
• Noxious stimuli depolarize nociceptors & signals  dorsal
root ganglia  dorsal horns in spinal cord
– a) projection neurons  sensory info to brain
– b) local excitatory & inhibitory interneurons  to brain & regulate
flow of info to brain
• Noxious stimuli travel up the spinal cord via anterolateral
pathways and transmitted contralaterally to the brain.
• Chemical signals arrive at thalamus, periaqueductal grey
matter, primary sensory cortex and associated cortices,
reticular formation, medulla, pons, midbrain,
hypothalamus, and caudal anterior cingulate cortex
(Ploghaus et al., 1999).
• normally this results in subjective pain

15. Endogenous opioid system
• Approx 60% feel no pain (Bohus et al., 2000; Russ et
al., 1993)
• Abuse/neglect/trauma can alter EOS &
reduce sensitivity to pain (Kirmayer et al., 1987; van
der Kolk, 1989; Dubo et al., 1997; van der Kolk et al., 1991)
• Decrease in pain sensitivity following early
traumatic experiences has been reported in
both animal and human studies (Russ et al.,
1993)

16. • In sample of BPD cutters, highest opioid
levels correlated with recency and severity
of cutting (Coid et al., 1983)
• Plasma opioid levels were higher in BPD
patients who had SIB without pain
compared to normals (Simeon et al., 2001).

17. PHASE 4. Unknown action

18. Noxious stimuli from
tissue damage
Spinal cord
Sensory cortex
Limbic system (amygdala)

19. PHASE 5. Tension relief
• Objective (psychophysiological measures)
& subjective tension relief (Haines et al., 1995; Brain et
al., 1998)
– personalised imagery script
– Finger pulse amplitude (FPA),
electrocardiograph (ECG), heart rate (HR),
respiration (RESP)
– skin conductance level (SCL)

20. Implications for clinicians
• Something is going on in the brain when
people self-injure
• Understand your clients
• Work within your client’s limitations
• Improve resilience, coping skills
• Reduce stress