{{short description|Insertion of foreign objects into soft tissues under the skin or into muscle}} '''Self-embedding''' is the insertion of foreign objects either into soft tissues under the skin or into muscle.<ref name= "Bennet et. al 2011">{{Cite journal | doi = 10.1542/peds.2010-2877| pmid = 21555492| title = Self-Embedding Behavior: A New Primary Care Challenge| journal = Pediatrics| volume = 127| issue = 6| pages = e1386–91| year = 2011| last1 = Bennett | first1 = G. H.| last2 = Shiels | first2 = W. E.| last3 = Young | first3 = A. S.| last4 = Lofthouse | first4 = N.| last5 = Mihalov | first5 = L.| doi-access = free}}</ref> Self-embedding is typically considered deliberate self-harm, also known as nonsuicidal self-injury, which is defined as "deliberate, direct destruction of tissues without suicidal intent."<ref name= "Cerruti et. al 2011">{{Cite journal | pmid = 20471075 | year = 2011 | last1 = Cerutti | first1 = R | title = Prevalence and clinical correlates of deliberate self-harm among a community sample of Italian adolescents | journal = Journal of Adolescence | volume = 34 | issue = 2 | pages = 337–47 | last2 = Manca | first2 = M | last3 = Presaghi | first3 = F | last4 = Gratz | first4 = K. L. | doi = 10.1016/j.adolescence.2010.04.004 }}</ref>
==Controversy== Based on the review of the literature it is unclear whether self-embedding falls under the definition of deliberate self-harm. Some studies include self-embedding as a deliberate self-harm behavior<ref name= "Cerruti et. al 2011"/> while others exclude it.<ref>{{Cite journal | doi = 10.1007/s10964-005-7262-z| title = Nonsuicidal Self-Harm Among Community Adolescents: Understanding the "Whats" and "Whys" of Self-Harm| journal = Journal of Youth and Adolescence| volume = 34| issue = 5| pages = 447–457| year = 2005| last1 = Laye-Gindhu | first1 = A. | last2 = Schonert-Reichl | first2 = K. A. | s2cid = 145689088}}</ref> Most definitions of deliberate self-harm include the stipulation that the behavior is performed without conscious suicidal intent.<ref name= "Cerruti et. al 2011"/><ref name="Chapman et. al 2006">{{Cite journal | pmid = 16446150 | year = 2006 | last1 = Chapman | first1 = A. L. | title = Solving the puzzle of deliberate self-harm: The experiential avoidance model | journal = Behaviour Research and Therapy | volume = 44 | issue = 3 | pages = 371–94 | last2 = Gratz | first2 = K. L. | last3 = Brown | first3 = M. Z. | doi = 10.1016/j.brat.2005.03.005 | s2cid = 1918485 }}</ref> The connection between self-embedding and suicidal ideation is unclear. Although most self-injurious behaviors are not associated with suicidal intentions, self-embedding has been found to be associated with suicidal ideation.<ref name= "Bennet et. al 2011"/> A study found that suicidal ideation is the most commonly reported reason for self-embedding, however not all acts of self-embedding are accompanied with suicidal ideations.<ref name= "Bennet et. al 2011"/> Additionally, most people that partake in self-embedding behavior report having previous suicidal attempts and suicidal ideations.<ref name="Young et. al 2010">{{Cite journal | pmid = 20823372|url=https://www.researchgate.net/publication/46170105 | year = 2010 | last1 = Young | first1 = A. S. | title = Self-embedding behavior: Radiologic management of self-inserted soft-tissue foreign bodies | journal = Radiology | volume = 257 | issue = 1 | pages = 233–9 | last2 = Shiels We | first2 = 2nd | last3 = Murakami | first3 = J. W. | last4 = Coley | first4 = B. D. | last5 = Hogan | first5 = M. J. | doi = 10.1148/radiol.10091566 }} {{Open access}}</ref> Other distinctions between self-embedding and other self-injurious behaviors are that self-embedding is highly comorbid with behavioral health diagnoses and has a high prevalence of repetitive behavior.<ref name="Young et. al 2010"/> Self-embedding is similar to other forms of self-injury in that one of the purposes of engaging in the behavior is to relieve emotional distress by inflicting physical pain.<ref name="Young et. al 2010"/> [[Image:Pelvis_of_Albert_Fish_(X-ray).jpg|thumb|Albert Fish with 27 inserted needles]] [[Image:Human_arm_full_of_needles_(x-ray).jpg|thumb|An X-ray image of Graphophone needles driven into the flesh by a psychiatric patient.]]
==History== One of the first reported cases of self-embedding was in 1936 when Albert Fish, a serial killer and cannibal, was caught and executed.<ref>''Murder Cases of the Twentieth Century – Biographies and Bibliographies of 280 Convicted or Accused Killers'', David K. Frasier, McFarland & Company (Publisher), Copyright September, 1996</ref> An X-ray of his pelvis revealed about 27–29 needles inserted into his groin; the image was used as evidence at his trial.<ref name="Crime library">"Albert Fish". Crime Library. Archived from the original on 16 December 2008. Retrieved 2008-12-16</ref> He also embedded needles into his abdomen.<ref name="Crime library"/> In 1986 Gould and Pyle described self-embedding behavior in their book ''Anomalies and Curiosities of Medicine''.<ref name= "Bennet et. al 2011"/> They included reports of adult European women with hysteria who self-embedded by inserting needles into their body.<ref name= "Bennet et. al 2011"/> In 2010 a study by Young et al. was one of the first to describe self-embedding in an adolescent population.<ref name="Young et. al 2010"/>
==Epidemiology== The majority of people who engage in self-embedding are white teenage females with psychiatric diagnoses.<ref name= "Bennet et. al 2011"/> Self-embedding has a high comorbidity<ref name= "Bennet et. al 2011"/> with other psychological disorders such as post-traumatic stress disorder, dissociative disorder, and borderline personality disorder.<ref name="Young et. al 2010"/> Additionally, deliberate self-harm is associated with externalizing pathology such as oppositional defiant disorder and conduct disorder.<ref name= "Cerruti et. al 2011"/> Adolescents who self-injure have higher mean depression scores and report more depressive symptoms than adolescents who do not self-injure.<ref name="Muehlenkamp & Guitierrez 2004">{{Cite journal | pmid = 15106884|doi=10.1521/suli.34.1.12.27769 | year = 2004 | last1 = Muehlenkamp | first1 = J. J. | title = An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents | journal = Suicide and Life-Threatening Behavior | volume = 34 | issue = 1 | pages = 12–23 | last2 = Gutierrez | first2 = P. M. }}</ref> They also report more symptoms of anxiety.<ref>{{Cite journal | pmid = 16268774 | year = 2005 | last1 = Andover | first1 = M. S. | title = Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder | journal = Suicide and Life-Threatening Behavior | volume = 35 | issue = 5 | pages = 581–91 | last2 = Pepper | first2 = C. M. | last3 = Ryabchenko | first3 = K. A. | last4 = Orrico | first4 = E. G. | last5 = Gibb | first5 = B. E. | doi = 10.1521/suli.2005.35.5.581 }}</ref> Life stressors such as sexual abuse, witnessing family violence or experiencing a traumatic event have also been found to be associated with deliberate self-harm.<ref name= "Cerruti et. al 2011"/> The frequency and the presence of deliberate self-harm are correlated with the number of stressful life events adolescents report. Adolescents with a history of deliberate self-harm report more stressful life events and those with higher rates for these experiences were more likely to repetitively engage in the behavior.<ref name= "Cerruti et. al 2011"/> Empirical studies have identified risk factors and correlates for self-injurious behavior.<ref name="Nock 2010">{{Cite journal | doi = 10.1146/annurev.clinpsy.121208.131258| pmid = 20192787| title = Self-Injury| journal = Annual Review of Clinical Psychology| volume = 6| pages = 339–63| year = 2010| last1 = Nock | first1 = M. K. | s2cid = 146591211}}</ref> Some of these factors include a history of childhood abuse, the presence of a mental disorder, poor verbal skills, and identifying with Goth subculture.<ref name="Nock 2010"/>
The mean age for nonsuicidal self-injury is 13–15 years and for suicidal self-injury is 15–17 years of age.<ref name= "Bennet et. al 2011"/> About 2% of inmates each year engage in self-injurious behavior, which includes the insertion of foreign objects into the body.<ref name="Klein 2010">{{Cite journal | pmid = 22396349|url=http://www.jaapl.org/content/40/1/119 | year = 2012 | last1 = Klein | first1 = C. A. | title = Intentional ingestion and insertion of foreign objects: A forensic perspective | journal = The Journal of the American Academy of Psychiatry and the Law | volume = 40 | issue = 1 | pages = 119–26 }} {{Open access}}</ref> The lifetime prevalence rates of deliberate self-harm in adolescence ranges from 13%–56% in non-clinical community samples.<ref name= "Cerruti et. al 2011"/> Approximately 4% of the United States population and 13–23% of adolescents report a history of nonsuicidal self-injury.<ref name="Young et. al 2010"/> The most commonly used objects for insertion are long and thin such as sewing needles and paperclips.<ref name="Klein 2010"/> Also urethral insertion of foreign objects is more common in males than females with a 1.7:1 ratio.<ref name="Klein 2010"/>
==Symptoms== In order to assess self-embedding different aspects of the behavior must be examined such as the type of object used, the site of insertion, the number of objects inserted, the motivation behind the behavior and if the patient has other psychiatric diagnoses.<ref name="Klein 2010"/> The most common symptoms for epithelial insertion of foreign objects are infection, abscess formation, or sepsis at the site of insertion.<ref name="Klein 2010"/> Symptoms of urethral insertion include frequent urination, painful urination, and blood in urination.<ref name="Klein 2010"/> Urethral stricture can occur with multiple attempts to insert an object into the urethra.<ref name="Rahman et. al 2004">{{Cite journal | last1 = Rahman | first1 = N. U. | last2 = Elliott | first2 = S. P. | last3 = McAninch | first3 = J. W. | title = Self-inflicted male urethral foreign body insertion: endoscopic management and complications | journal = BJU International | volume = 94 | issue = 7 | pages = 1051–1053 | year = 2004 | pmid = 15541127 | doi = 10.1111/j.1464-410X.2004.05103.x | s2cid = 38657876 }}</ref> Mucosal tears are associated with multiple objects being inserted or with multiple attempts as well.<ref name="Rahman et. al 2004"/> In order to assess the size, location and number of foreign objects a radiological evaluation is needed.<ref name="Rahman et. al 2004"/> Symptoms for vaginal insertion are vaginal pain, discharge, bleeding, and foul odor, which can indicate infection.<ref name="Klein 2010"/>
==Treatment==
=== Image guided foreign body removal (IGFBR) === To treat urethral insertion of foreign objects endoscopic retrieval is utilized and an antibiotic is given.<ref name="Rahman et. al 2004"/> If there is an infection or abscess formation at the site of insertion, surgical removal of the object is necessary.<ref name="Wraight et. al 2008">{{Cite journal | doi = 10.1016/j.bjps.2007.04.004|pmid=17584535| title = Deliberate self-harm by insertion of foreign bodies into the forearm| journal = Journal of Plastic, Reconstructive & Aesthetic Surgery| volume = 61| issue = 6| pages = 700–3| year = 2008| last1 = Wraight | first1 = W. M. | last2 = Belcher | first2 = H. J. C. R. | last3 = Critchley | first3 = H. D. }}</ref> If a patient has multiple objects inserted in a certain area surgical removal is recommended unless the risks of surgery outweigh the benefits.<ref name="Wraight et. al 2008"/> Percutaneous image guided foreign body removal (IGFBR) is another less invasive option for removing foreign bodies that leaves minimal scarring.<ref name="Young et. al 2010"/> Multiple studies have found IGFBR as a safe and effective technique for the removal of foreign bodies.<ref>{{Cite journal | pmid = 22310140 | year = 2012 | last1 = Zhu | first1 = Q | title = Percutaneous extraction of deeply-embedded radiopaque foreign bodies using a less-invasive technique under image guidance | journal = The Journal of Trauma and Acute Care Surgery | volume = 72 | issue = 1 | pages = 302–5 | last2 = Chen | first2 = Y | last3 = Zeng | first3 = Q | last4 = Zhao | first4 = J | last5 = Yu | first5 = X | last6 = Zhou | first6 = C | last7 = Li | first7 = Y | doi = 10.1097/TA.0b013e31822c1c50 | s2cid = 13214322 }}</ref><ref>{{Cite journal | pmid = 22208762 | year = 2012 | last1 = Bradley | first1 = M | title = Image-guided soft-tissue foreign body extraction - success and pitfalls | journal = Clinical Radiology | volume = 67 | issue = 6 | pages = 531–4 | doi = 10.1016/j.crad.2011.10.029 }}</ref> In this procedure hydrodissection can be used to define the foreign body more precisely and facilitate its removal.<ref>{{Cite journal | doi = 10.1016/j.cult.2007.12.001| title = Soft Tissue Foreign Bodies: Sonographic Diagnosis and Therapeutic Management| journal = Ultrasound Clinics| volume = 2| issue = 4| pages = 669–681| year = 2007| last1 = Shiels | first1 = W. E. }}</ref>
=== Psychological treatments === Problem-Solving Therapy and Dialectical Behavior Therapy are two empirically supported Cognitive Behavioral Therapies for non-suicidal self-injurious behavior.<ref name="Muehlenkamp & Guitierrez 2004"/> Problem-Solving Therapy (PST) teaches clients problem-solving skills and general coping strategies so that they can more effectively deal with future problems.<ref name="Muehlenkamp & Guitierrez 2004"/> Additionally, clients learn to identify and resolve the problems they encounter.<ref name="Muehlenkamp & Guitierrez 2004"/> The findings for the effectiveness of PST in reducing non-suicidal self-injury have been mixed. Some studies have found that PST has reduced suicidal behaviors compared to usual treatments however maintenance beyond one year was not found.<ref name="Muehlenkamp & Guitierrez 2004"/> Dialectical Behavior Therapy (DBT) aims to teach clients general coping skills and address any motivational obstacles to treatment.<ref name="Muehlenkamp & Guitierrez 2004"/> Therapy includes validating the client's experience and working with the client on problem-solving skills and behavioral skills such as emotional regulation.<ref name="Muehlenkamp & Guitierrez 2004"/> DBT has been used to treat both suicidal behaviors and non-suicidal self-injurious behaviors. DBT has been shown to reduce self-injurious behaviors in multiple studies.<ref name="Muehlenkamp & Guitierrez 2004"/>
==Theory==
=== The Experiential Avoidance Model (EAM) === According to this model, the maintenance of deliberate self-harm behavior is due to negative reinforcement.<ref name="Chapman et. al 2006"/> Deliberate self-harm is reinforced because it prevents or takes away negative emotional experiences.<ref name="Chapman et. al 2006"/> The experiential avoidance model was developed to account for deliberate self-harm for various populations not just ones with psychopathology.<ref name="Chapman et. al 2006"/> Experiential avoidance behaviors are those that “function to avoid or escape from unwanted internal experiences."<ref name="Chapman et. al 2006"/> The mechanism for this model involves an individual experiencing an event that evokes an aversive emotional response, which causes the individual to want to escape from that unpleasant emotional state.<ref name="Chapman et. al 2006"/> The individual engages in deliberate self-harm, which reduces or gets rid of the aversive emotional response. This behavior is then negatively enforced.<ref name="Chapman et. al 2006"/> Many studies have found that 80–94% of people report feeling better after engaging in deliberate self-harm, with relief being the most reported.<ref>{{Cite journal | pmid = 6659009|doi=10.1111/j.1943-278X.1983.tb00006.x | year = 1983 | last1 = Bennum | first1 = I | title = Depression and hostility in self-mutilation | journal = Suicide and Life-Threatening Behavior | volume = 13 | issue = 2 | pages = 71–84 }}</ref> Furthermore, studies done on the self-reported reasons for deliberate self-harm have found that the primary reasons given for engaging in the behavior are related to avoiding, eliminating or escaping internal experiences.<ref name="Briere et. al 1998">{{Cite journal | pmid = 9809120 | year = 1998 | last1 = Briere | first1 = J | title = Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions | journal = The American Journal of Orthopsychiatry | volume = 68 | issue = 4 | pages = 609–20 | last2 = Gil | first2 = E | doi=10.1037/h0080369 }}</ref><ref>{{Cite journal | pmid = 2711856|doi=10.1111/j.1600-0447.1989.tb10259.x | year = 1989 | last1 = Favazza | first1 = A. R. | title = Female habitual self-mutilators | journal = Acta Psychiatrica Scandinavica | volume = 79 | issue = 3 | pages = 283–9 | last2 = Conterio | first2 = K |s2cid=45853995 }}</ref> A study conducted on female college students investigated emotional responses of women with and without deliberate self-harm and found that women who engage in self-harm reported higher levels of experiential avoidance.<ref name="Chapman et. al 2006"/> Factors that may underlie an increase in experiential avoidance are higher levels of impulsivity or novelty seeking and heightened levels of aversive physiological arousal to emotional events.<ref name="Chapman et. al 2006"/> Other factors include a low tolerance for emotional distress and a failure to use different, less maladaptive behaviors in response to emotional arousal.<ref name="Chapman et. al 2006"/>
The EAM provides multiple hypotheses for how deliberate self-harm provides an emotional escape. The opioid hypothesis explains that deliberate self-harm elicits endogenous opioids, which leads to analgesia and relief of emotional distress.<ref name="Chapman et. al 2006"/> Studies have found elevated levels of opioid peptides in people who engage in deliberate self-harm<ref>{{Cite journal | pmid = 6136696|doi=10.1016/S0140-6736(83)90572-X | year = 1983 | last1 = Coid | first1 = J | title = Raised plasma metenkephalin in patients who habitually mutilate themselves | journal = Lancet | volume = 2 | issue = 8349 | pages = 545–6 | last2 = Allolio | first2 = B | last3 = Rees | first3 = L. H. |s2cid=22616918 }}</ref> however, there is not much research supporting an increase in opioid levels after deliberate self-harm.<ref name="Chapman et. al 2006"/> Another explanation could be that individuals who engage in deliberate self-harm have increased activity of the opiate system which can lead to a feeling of dissociation and numbness<ref>{{Cite journal | pmid = 12374476|doi=10.1521/suli.32.3.313.22174 | year = 2002 | last1 = Saxe | first1 = G. N. | title = Self-destructive behavior in patients with dissociative disorders | journal = Suicide and Life-Threatening Behavior | volume = 32 | issue = 3 | pages = 313–20 | last2 = Chawla | first2 = N | last3 = Van Der Kolk | first3 = B }}</ref> and deliberate self-harm provides physical pain that ends this dissociative state.<ref>{{Cite journal | pmid = 1192328 | year = 1975 | last1 = Simpson | first1 = M. A. | title = The phenomenology of self-mutilation in a general hospital setting | journal = Canadian Psychiatric Association Journal | volume = 20 | issue = 6 | pages = 429–34 | doi = 10.1177/070674377502000601 | s2cid = 45975192 | doi-access = free }}</ref> An alternative explanation for why deliberate self-harm provides relief is that it shifts attention away from the unpleasant emotions being experienced.<ref name="Chapman et. al 2006"/> Empirical evidence for this hypothesis is mixed; some studies have found distraction to be one of the most common self-reported reasons for engaging in deliberate self-harm<ref name="Briere et. al 1998"/> while others have found the contrary.<ref name="Brown et. al 2002">{{Cite journal | doi = 10.1037/0021-843X.111.1.198| pmid = 11866174| title = Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder| journal = Journal of Abnormal Psychology| volume = 111| issue = 1| pages = 198–202| year = 2002| last1 = Brown | first1 = M. Z. | last2 = Comtois | first2 = K. A. | last3 = Linehan | first3 = M. M. }}</ref> The self-punishment hypothesis claims that deliberate self-harm can decrease emotional arousal by confirming an individual's negative self-concepts such as that they are bad or have done something wrong.<ref name="Chapman et. al 2006"/> Multiple studies have found that self-punishment is commonly reported as a reason for engaging in deliberate self-harm.<ref name="Brown et. al 2002"/><ref>{{Cite journal | pmid = 12819435 | year = 2003 | last1 = Penn | first1 = J. V. | title = Suicide attempts and self-mutilative behavior in a juvenile correctional facility | journal = Journal of the American Academy of Child & Adolescent Psychiatry | volume = 42 | issue = 7 | pages = 762–9 | last2 = Esposito | first2 = C. L. | last3 = Schaeffer | first3 = L. E. | last4 = Fritz | first4 = G. K. | last5 = Spirito | first5 = A | doi = 10.1097/01.CHI.0000046869.56865.46 }}</ref> Self-punishment is reinforced because it “alleviates distress associated with negative thoughts about oneself" and has the potential to lessen external punishment.<ref name="Chapman et. al 2006"/>
=== Nock's Theoretical Model ===
Based on his review on the literature on self-injury, Matthew Nock, developed a theoretical model on the development and maintenance of self-injury. According to Nock's model self-injury is performed repeatedly because it is an immediate effective way of influencing one's social environment and regulating one's emotional and cognitive experience.<ref name="Nock 2010"/> Additionally, factors that contribute to problems in regulating one's affective and cognitive state and influencing one's social environment such as poor social skills lead to an increased risk of self-injury.<ref name="Nock 2010"/> These general risk factors also increase the likelihood of engaging in other maladaptive behaviors such as alcohol or substance abuse.<ref name="Nock 2010"/>
This model follows a functional perspective in which behaviors are caused by the events that immediately precede and follow them.<ref name="Nock 2010"/> Four types of reinforcement processes can maintain self-injury: intrapersonal negative reinforcement, intrapersonal positive reinforcement, interpersonal positive reinforcement, and interpersonal negative reinforcement. Intrapersonal negative reinforcement refers to self-injury being followed by a decrease or stop of aversive thoughts or feelings.<ref name="Nock 2010"/> Intrapersonal positive reinforcement involves self-injury being followed by an increase in desired thoughts or feelings such as a feeling of satisfaction.<ref name="Nock 2010"/> Interpersonal positive reinforcement occurs when self-injury is followed by a desired social event such as attention or support.<ref name="Nock 2010"/> Finally, interpersonal negative reinforcement occurs when self-injury is followed by a decrease or stop of a social event.<ref name="Nock 2010"/> Many studies investigating the motives reported for engaging in self-injury provide evidence for this four-function model.<ref name="Brown et. al 2002"/><ref>{{Cite journal | doi = 10.1017/S003329170700027X| pmid = 17349105| title = Characteristics and functions of non-suicidal self-injury in a community sample of adolescents| journal = Psychological Medicine| volume = 37| issue = 8| pages = 1183–92| year = 2007| last1 = Lloyd-Richardson | first1 = E. E. | last2 = Perrine | first2 = N. | last3 = Dierker | first3 = L. | last4 = Kelley | first4 = M. L. | pmc=2538378}}</ref>
==References== {{reflist|30em}}
Category:Self-harm