When the body is the target—Representations of one’s own body and bodily sensations in self-harm: A systematic review
Introduction
Typically, we try to protect our own bodies and this is supported by internal representations that specify one’s body identity and spatial parameters (Ehrsson, 2007; Ehrsson et al., 2004; Graziano and Cooke, 2006; de Vignemont, 2018), as well as by protective functions of the skin and sensations from other body parts e.g. nociception or hunger (Craig, 2002; Woolf, 2010). But in self-harm the body becomes the target. Self-harm, which encompasses all types of deliberate self-injurious behaviour (e.g. non-suicidal self-injury, deliberate self-harm, suicide attempts), is a significant risk factor for later completed suicide (Carroll et al., 2014; Saunders and Smith, 2016), and yet the reasons why individuals engage in these behaviours remain poorly understood.
The most prominent model for why people engage in self-harm in both inpatient and non-clinical community samples is the affect or emotional regulation model (Klonsky, 2007; Moller et al., 2012; Muehlenkamp and Brausch, 2012), where the role of self-harm is to alleviate acute negative emotions such as depression, anger, and anxiety (Klonsky, 2007; Moller et al., 2012). Existing evidence supports this model with both experimental and observational data indicating that (1) self-injurious adolescents typically report higher levels of negative affect than those who did not self-injure; (2) acute negative affect typically precedes self-harm; (3) decreased negative affect and relief are typically present after self-harm; and (4) the majority of self-injurious adolescents report an ongoing desire to alleviate negative affect, as well as ongoing difficulties with regulating other emotions (Di Pierro et al., 2014; Klonsky, 2007, 2009).
Poor affect/emotional regulation appears to be a key factor in facilitating and maintaining self-harm, and yet, there remains a significant portion of adolescents who experience high levels of negative affect and never engage in self-harm (Muehlenkamp and Brausch, 2012). This suggests that other psychological and cognitive processes need to be taken into consideration in order to fully understand why people engage in such behaviours.
An additional factor underlying self-harm could involve differences in the way one’s own body is represented. It is possible that disturbances in internal body representations (i.e. all types of perceptual, conceptual and emotional aspects that can be measured or evaluated with respect to one’s own body and could in principle have a body protective function; Medina and Coslett, 2016) contribute to self-harm. Such body representations are crucial for efficient and safe interactions with the external world and also for one’s sense of self as a distinct entity (Medina and Coslett, 2016). Disturbances in representations of one’s own body and its sensations are common and have been linked to a range of different disorders including eating disorders, body dysmorphia, and neuropathic pain (de Vignemont, 2010; Longo, 2015; Moseley et al., 2012). The body is relevant to self-harm as it is the target of such behaviour and self-harm rates are, for example, substantially elevated among those with eating disorders, where body image disturbance is a central pathology (Svirko and Hawton, 2014; Muehlenkamp and Brausch, 2012). Despite growing evidence (Cerutti et al., 2012; Duggan et al., 2015; Muehlenkamp and Brausch, 2012; Nelson and Muehlenkamp, 2012; Orbach et al., 2001), body representations are not commonly recognised in self-harm risk factor models or in current intervention approaches. A link between disturbance in body representations/sensory perceptions and self-harm has been found in several clinical and non-clinical groups, but to fully understand the role of these disturbances in facilitating and maintaining self-harm, it is important to systematically review the findings across groups.
Aspects of the body that are commonly studied in the literature range from second-order, multisensory or higher-level representations of the body (e.g. body image, body ownership, body schema; Longo, 2015) to first-order or basic somatosensory perception and interoception (e.g. bodily sensations involving both internal and external stimuli; Craig, 2002; Critchley et al., 2004). Alteration or disturbance of such representations and sensory perceptions can result in a wide variety of deficits ranging from changes in the experience of bodily control or bodily ownership to low-level deficits in tactile detection and mislocalisation (Medina and Coslett, 2016). Body representations and sensory perceptions, or disturbances of these, can be assessed using a myriad of explicit and implicit measures ranging from questionnaires and rating scales to perceptual and action-based tasks (Longo and Haggard, 2012).
The association between body representations/sensations and self-harm has been studied using such measures, mainly within the context of dissociation and depersonalisation, both of which are present in a broad range of mental disorders (Dorothy et al., 2014; Hunter et al., 2004). Dissociation is the process whereby disconnections or lack of connections are present between experiences usually associated with each other and may involve awareness, consciousness, memory, identity, or perception. Dissociation is frequently experienced as feeling unreal, outside your body, numbness or nothing (Hunter et al., 2004; Dorothy et al., 2014). It is a common reaction to stressful, emotionally-charged traumatic situations and is often seen in those exposed to maltreatment in childhood (Kaess et al., 2013; Wachter et al., 2009). One aspect of dissociation is ‘depersonalisation’, a psychological state whereby a person feels that his or her body is not real or detached from them (Cerutti et al., 2012). Most self-harm studies have focused on the broader dissociative construct (e.g. amnesia, imaginative involvement, absorption), as measured by the Dissociative Experiences Scale (DES; Gratz et al., 2002). Few have focused specifically on the experience of physical or bodily dissociation (or otherwise known as body disownership) (Cerutti et al., 2012; Levinger et al., 2016; Orbach et al., 2001). For example, Cerutti et al. (2012) incorporated the Cambridge Depersonalisation Scale (CDS), which partly assesses the experience of extraneousness of one’s body, and found that university students (Mean age = 23.3 years) with a history of deliberate self-harm reported significantly higher CDS levels compared to those without a history of self-harm.
Studies which have measured changes in body representations and sensory perceptions outside the context of dissociation have also provided support for a link between bodily disturbances and self-harm (Forrest et al., 2015; Kubiak and Sakson-Obada, 2016; Muehlenkamp and Brausch, 2012; Orbach, 2003; Orbach et al., 2001). For example, body image, as measured using the Body Investment Scale, has been suggested to be a potential mediator of the association between emotional dysregulation and self-harm (Muehlenkamp and Brausch, 2012). Furthermore, Forrest et al. (2015) found that impaired interoception, i.e. sensing one’s internal physiological sensations, may be an important underlying mechanism in serious self-injury, and Orbach et al. (2001) reported self-injurious individuals tend to experience their body differently from other populations across a range of bodily processes, including dissociation, insensitivity, and lack of control. Overall, it remains unclear as to which specific types or aspects of body representations and sensations are associated with self-harm, or whether certain constructs are more pertinent to self-harm than others. To our knowledge, no study to date has systematically reviewed the association across different measures of bodily representations and sensations.
Changes and disturbances in body representations and sensory perceptions may be a particularly relevant risk factor for adolescent self-harm, considering it is a time when the body becomes more salient to one’s self-concept (Cash and Pruzinsky, 2002) and when self-harm is typically first reported (Heath et al., 2008; Plener et al., 2016; Muehlenkamp et al., 2012a, 2012b). The potential role of bodily disturbances as a risk factor for self-harm may help to partially explain why the developmental period of adolescence represents such a crucial time, associated with high prevalence rates and emergence of the behaviour (Duggan et al., 2015; Swannell et al., 2014; Plener et al., 2016).
Our primary aim was to systematically review the association between self-harm and various measures of body representations and sensations, as well as to identify potential confounders and mediators of the association. A secondary aim was to systematically review studies for adolescents and young adults (12–25 years), as well as older age groups (+25 years) in order to critically examine if the association between disturbances in body representations/sensations and self-harm is different between those of younger and older age.
Section snippets
Data sources
We conducted a systematic review that adheres to the guidelines detailed in the PRISMA Statement (Moher et al., 2009). The protocol of this systematic review was registered at PROSPERO, as CRD42016050291. An electronic literature search was conducted in October 2016 which covered relevant international databases, including PubMed, PsycINFO, EMBASE, and Social Science Database (final search conducted in January 2018). Additional records were identified through citation databases, such as the Web
Results
The systematic search strategy identified 64 individual studies (from 67 publications; some publications reported on the same dataset) reporting on 275 183 participants (M = 4300, Range = 55–74698) from 20 countries (see Fig. 1). The majority of studies were cross-sectional (87.5%), with eight reporting longitudinal data (follow-up range = 2 months–7 years). There was a mixture of data sources, with 14.1% (n = 9) of studies reporting national household or school-based surveys, 1.5% reporting
Discussion
This was the first systematic review to investigate and critically analyse the association between measures that tap into aspects of body representations/sensations and self-harm. To summarize the results: overall, persons engaging in self-harm reported greater levels of body dissatisfaction, body disownership, somatic complaints, and interoceptive deficits compared to non-injuring control groups; however, there was subscale variability and gender differences (stronger evidence for adolescent
Declarations of interest
All authors declare that they have no conflicts of interest.
Financial disclosures
Emily Hielscher is supported by the Dr F and Mrs ME Zaccari Scholarship, Australia.
James G Scott is supported by a National Health and Medical Research Council Practitioner Fellowship Grant #1105807.
Regine Zopf is supported by an Australian Research Council (ARC) Discovery Early Career Researcher Award (DE140100499).
Acknowledgements
We thank Nicky Foxlee, a medical librarian, who assisted with devising the search strategy for this systematic review.
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