Self-injury in female versus male psychiatric patients: A comparison of characteristics, psychopathology and aggression regulation

Abstract

Self-injurious behavior (SIB) is 1.5–3 times more likely in women than in men. However, there is minimal research on SIB in male populations. Therefore, we carried out a comparative study in 399 psychiatric inpatients (265 females and 134 males) by means of self-reporting questionnaires assessing SIB, psychopathological symptoms, personality disorders and aggression regulation. Compared to female patients with SIB (46.2%), males admitting SIB (31.3%) showed more burning, reported more pain experience, took less care of their wounds and concealed them less often; in males the SIB mainly served social-oriented functions (e.g., getting attention). Female SIB patients displayed more cutting, scored higher on agoraphobic and interpersonal sensitive complaints, and reported more often sexual abusive experiences. In both male and female patients SIB was linked to more clinical symptoms and personality disorders than in patients without SIB. In general, self-injury can be considered a sign of more severe psychopathology.

Introduction

Self-injurious behavior (SIB) refers to the direct and deliberate damage of one’s own body tissue without suicidal intent (Favazza, 1998). It is estimated to occur in 4% of the general adult population and in 21% of the adult psychiatric population (e.g., Briere and Gil, 1998, Nock and Prinstein, 2004). One of the most consistent findings in the literature is that SIB occurs 1.5 to 3 times more often in women than in men (e.g., Robinson and Duffy, 1989, Yates, 2004). These findings should be interpreted with caution, because the available literature is based primarily on psychiatric samples, with an overrepresentation of women. Recent data, using various samples, reveal less pronounced gender differences (e.g., Briere and Gil, 1998, Callias and Carpenter, 1994). There is minimal research on SIB in male populations, and virtually no data on non-incarcerated subjects.

There are many reports of self-injury among prisoners (see Winchel & Stanley, 1991). Based on reports from three men’s prisons, Toch (1975) estimated a rate of 2.2–7.7%. Virkkunen (1976) compared male prisoners with and without SIB (2 groups of 40 subjects each), all fulfilling criteria for antisocial personality disorder: among the self-injurers there was a significantly higher rate of fighting, outbursts of rage, drug abuse, and anxiety. Shea (1993) obtained MMPI data from 30 self-injuring and 30 non-injuring male inmates: the former showed more somatic complaints, subjective distress, alienation, immature defenses, and acting-out tendencies. Matsumoto et al. (2005) investigated 796 male inmates of a juvenile prison. In comparison to other inmates, self-cutters began smoking and drinking earlier, and used more frequently illicit drugs; they also reported more often childhood physical abuse, suicide attempts, suicidal ideation, and outward violence toward persons or objects; finally, they scored significantly higher on bulimia and dissociation. In 1986 military recruits (62% men), Klonsky, Oltmanns, and Turkheimer (2003) found that 4% reported a history of deliberate self-harm, a rate roughly equivalent for men and women. Self-harmers scored higher on measures of borderline, schizotypal, dependent, and avoidant personality disorder, and reported more symptoms of anxiety and depression. Hillbrand, Krystal, Sharpe, and Foster (1994) reported that male patients in a forensic psychiatric institution who practiced self-injury were more likely to engage in outwardly directed aggressive behavior than those without SIB.

Chowanec, Josephson, Coleman, and Davis (1991) investigated 424 males (aged 13–17 yrs) divided into three groups: self-harmers, those referred for psychiatric examination, and an incarcerated general population. Compared with the general population, subjects in the two mental health groups were younger, had greater family needs, reported more educational problems, were more likely to have escaped from a previous placement, and committed more rule violations. The self-harming group, when compared with the psychiatrically referred group, had a greater number of prior offenses, was more disruptive in school, performed worse on a problem-solving task, and committed more rule violations. Finally, Zweig-Frank, Paris, and Guzder (1994) studied self-injury in 121 male patients with personality disorders and looked for possible relationships with other psychological risk factors (e.g., different types of abuse), dissociation or diagnosis. Thirty-two subjects with borderline personality disorder reported self-injury. There were no relationships between any of the psychological risk factors and self-injury. Self-injurers had higher scores on the Dissociative Experiences Scale in univariate analysis but in multivariate analyses dissociation did not discriminate between subjects with or without SIB.

In general, men tend to injure themselves more severely than women and have “less concern about bodily disfigurement” (Hawton, 2000, p. 484). They are also more likely to engage in public and violent self-harm (e.g., punching themselves or against a wall, breaking bones) or in dangerous behavior (e.g., joyriding) as a means of self-harm (Taylor, 2003). But there is remarkable lack of comparative research on this issue. In a study of adolescent psychiatric inpatients Kumar, Pepe, and Steer (2004) found that 19 male and 31 female adolescents endorsed comparable reasons for cutting themselves and that self-reported depression was positively associated with the number and intensity of different motivations for SIB. According to Rodham, Hawton, and Evans (2004), female self-cutters reported more often than their male counterparts that they wanted to punish themselves and tried to get relief from a terrible state of mind.

Because of the striking lack of comparative research on SIB in male versus female psychiatric patients, we carried out the present study. We have addressed two main research questions: (1) Do male and female patients differ from each other with respect to SIB characteristics, psychopathological symptoms, personality disorders and aggression regulation? (2) Are there clear differences between patients with or without SIB?