Nonsuicidal Self Injury – Cutting to stop pain

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Cutting – nonsuicidal self injury.
Photo courtesy of Pixabay.com

What is cutting – Non-suicidal Self-Injury?

Non-suicidal self-injury often called cutting, is another of those troubling conditions that send people to hospitals, physical and mental hospitals. Intentional self-burning, head banging, hair pulling, hitting yourself and repetitive skin picking are other examples of this thing we call Non-suicidal self-injury. Non-suicidal self-injury causes a lot of suffering for those who do it and for those around them, and yet this problem, like anger, does not get the recognition of a separate diagnosis. FYI Hair pulling has gotten its own diagnosis called Trichotillomania.

Deliberate self-injury is a behavior. Like many behaviors, it can be misunderstood. If someone waves at you, they may be calling you over, they may be telling you to get away from where you are or it may be a way to say hello. It might even have another meaning. Self-injury is like that, a behavior, which may have different meanings.

Non-suicidal self-injury is a condition that has been researched and has been proposed for inclusion in the DSM as a recognizable mental illness. Currently, it is not a “stand-alone diagnosis.” Non-suicidal self-injury is listed in the back of the DSM-5 as a “condition for further study.”

If someone engages in non-suicidal self-injury, the kind we think is a mental illness, the most likely way it gets categorized is as a symptom of Borderline Personality Disorder. Sometimes it is a symptom of Borderline Personality Disorder or Borderline traits, sometimes not. Borderline Personality disorder is the only mental health condition that lists both suicide and Nonsuicidal self-injury as symptoms despite the high or increased rates of self-harm in other disorders like depression, bipolar and alcohol use disorders. First, the things Nonsuicidal self-injury is not and then what we or I think it is.

What Non-suicidal self-injury is not.

Non-suicidal self-injury is not simply a teen thing.

The kind of thing we mean when we talk about Non-suicidal self-injury, the one that gets diagnosed and treated is not a fad or a rite of passage. I know there are those who cut, tattoo or brand themselves because they want to scar their body to look cool or to impress their friends. This is not what we are talking about when we say Non-suicidal self-injury – the disease.

Nonsuicidal self-injury is not a request for attention.

Yes, some people do this behavior to get noticed or to get something they want. One way to differentiate this is to ask where they self-injury. Most people who seek attention cut in places that are clearly visible. Those who do it as a result of an emotional or mental issue cut or otherwise self-injure in places that are not visible, the stomach or the thighs and they often wear long sleeves, even in the heat of the summer, to cover the cuts. The distinction is that those who develop the illness Non-suicidal self-injury often try to hide their cutting.

What Nonsuicidal self-injury is.

A way to cope with emotional pain.

Transforming emotional pain into physical pain can seem like a way to escape that emotional pain. While it does work, at least some of the time it is not a desirable way to cope. Good coping mechanisms need to be not only effective but safe also. Treatments for Non-suicidal self-injury include lots of learning and practice of alternative coping skills sometimes referred to as recovery tools.

A way to cope with dissociation

Some people report they self-harm to feel or to feel real. This numbing out is a symptom of dissociation and related disorders. Dissociation is not always recognized for what it is. Dissociation needs treatment for what it is not just for the behaviors like anger or cutting.

If you live in chronic emotional numbness then the only time you may be able to feel anything is when you substitute physical pain for the constant numbing emotional hurts.

Non-suicidal self-injury is a way to regulate emotions.

Some people have difficulty regulating their emotions. They may have suffered traumas, grown up in a dysfunctional home or have personality characteristics that make them more prone to be overloaded with emotions. Take a look at the post Emotional Avalanches and Feelings Landslides which discusses how people can be suddenly swept away by feelings floods.

Cutting or other types of non-suicidal self-injury is one way some people cope with these feelings avalanches. Violent outburst is another way. The topic of violent outbursts and emotional regulation is covered in the series on “Anger Management.”

Rumination plays a major role in depression, anxiety, and anger as well as in causing emotional landslides.

Some of the links above may not be active yet. The bold-underlined terms mean that a post is up or will be coming shortly. I will try to get the links in here as the new articles post. If any links (the ones in blue) do not work let me know and I will work on fixing them.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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PTSD or Acute Stress?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Words about PTSD

PTSD.
Photo courtesy of Pixabay.com

What’s the difference between PTSD and Acute Stress?

Stressed

Feeling stressed out?
Photo courtesy of Pixabay.com

PTSD, Post-Traumatic Stress Disorder has made the news a lot recently. This is a good thing. More recognition of PTSD should result in more treatment and less suffering from those who have PTSD. Stress caused problems may or may not be from a Trauma.

What hasn’t gotten as much notice and should have, is the role of Acute Stress Disorder in the events that knock people down and cause a lot of suffering. Acute Stress Disorder creates a lot of problems for a lot of people. Reactions to severe stress can cause long-term changes in people’s feelings and behaviors. Many of these changes go unrecognized and untreated. Acute Stress Disorder may be missed more often than it is diagnosed. More on that later in this blog post.

Stress can harm you.

We know stress is a problem a lot of the time, for a lot of people. Outside the field of mental health, there are lots of blog posts and books on stress, what it is and how to deal with it.  I have written posts about stress and managing it for those of you who have too much stress in your life even if it does not get you a diagnoses or disability.

Stress, plain simple stress, can break people down even if they never meet the criteria for a mental illness. Think of stress like this:

Remember those spectacular car crashes at those televised car races? Some of those crashes were the result of car parts (or drivers) under stress. All day, for hundreds of miles that car and that poor car part, ran hard and fast. The stress just kept coming, then suddenly that part breaks, that car goes all which way and the crash occurs.

Stress on people can be like that. Too much stress too long and the person develops mental health problems. Some of those problems need a day off, others become diagnosable illnesses. In the past, we tended to think of stress related disorders like Post-Traumatic Stress Disorder (PTSD) as close cousins to Anxiety. That has started to change.

Beginning soon mental health professionals will begin to use new coding systems. The DSM-5 or the newer ICD codes. In those systems, Stress and Trauma-Related Disorders get their own chapter. While Stressor-Related Disorders can cause anxiety and have some symptoms in common with anxiety disorders they also have some differences.

Trauma- and Stressor-Related Disorders.

From the day you are born till the day you die too much stress can cause you a problem. One key factor in Trauma- and Stressor-Related Disorders is that there has to be a specific thing that happened to you, the stressor. Trauma is the king of all stressors.

So these things do not just suddenly happen for no reason and they are presumably not something you are born with. This fuzzes up the expression that mental illness is a brain disorder, in that the cause of these disorders are things that happen to you.

If life events result in acquiring a mental illness, then events, as in therapy and learning, can be helpful in treating that disorder.  Much of the treatments for stressor-related disorders are cognitive type therapies.

Trauma and Stressor-Related Disorders also can have features that are similar, we might even say overlap, depression, anxiety, obsessive-compulsive and the often overlooked dissociation. Not every other mental illness is caused by stress or trauma. We just need to be aware that sometimes there can be connections. This similarity to other issues results in a lot of stress-related disorders not being diagnosed until years later when the person is severely mentally ill or disabled.

What is Acute Stress Disorder and why is it important?

Acute Stress Disorder has two sets of “symptoms,” the things people experience that are a problem for them and the technical things professionals use to give out the diagnosis.

Some of the things you might experience as a result of having Acute Stress Disorder are also symptoms of other mental health issues or other mental illnesses. There are a variety of diagnoses that someone might get as a result of injuries they sustained due to stress.

These symptoms can impact your life in long-term ways. People may find their personality has changed.

Poor or no sleep is a cause for worry. Poor sleep now, predicts mental health issues down the road. In the aftermath of stressors, many people report that they do not sleep well. Some report bad dreams, nightmares or night terrors. A few days of bad sleep after you are stressed and you should get back to normal. If the sleep disturbance goes on for very long it starts to change your functioning and your life.

Panic attacks are common in the first month after a severe life stressor. The time period of thirty days becomes important when we try to separate Acute Stress Disorder from other problems. This panic attack may first be experienced immediately after a stressful incident and then go on to become Panic Disorder.

If you have been through a severely stressful incident it is not unusual for you to blame yourself for not expecting it, not doing something differently and not being able to prevent it. Rationally you should know that it may not have been possible to prevent what happened, but people commonly experience guilt or even shame over not being able to stop that trauma.

After a trauma, some people report that the happiness or joy has been sucked out of life. They stop caring about themselves or others. They may begin to take risks that they never took before. They drive too fast, gamble, take more sexual risks. Some trauma or stress survivors become angry, bitter and more argumentative. They get in more fights, verbally and physically. It is as if they have changed who they are and they no longer care.

If you knew about the traumatic experience you might understand why the changes in behavior occurred. If that trauma survivor kept the trauma a secret, and many do, you might think this was all bad behavior.

Trauma survivors, even those who do not go on to develop more serious mental health problems, may become confused or think they are losing their minds. They may get tested for or treated for concussions. They could have both a concussion and a longer term mental illness.

After a trauma or a crisis from the buildup of long-term stress, you may find it difficult to go back to places that remind you of the trauma. People become unable to go back to work, visit certain places or they avoid social situations.

How do professionals diagnose Acute Stress Disorder and why is that diagnosis so rare?

The official criteria for Acute Stress disorder are found in the DSM-5 or DSM-4-TR if your agency is still using that one. The DSM’s are published by the APA and you can order the full text from them. Here is my oversimplified plan language version of that criteria. I hope I do not make errors in this explanation.

A warning

Self-diagnosis or diagnosing your family and friends is a risky behavior. If after reading all this you believe you or someone close to you has Acute Stress Disorder, another Trauma- and Stressor-Related Disorder or any other mental health problem, go see a professional and get it checked out. There are treatments available for all of these conditions and there is no need to suffer alone.

There are 5 things the professional needs to look at for Acute Stress Disorder

  1. Did you experience a really bad Traumatic Stressor Recently?

There is a “waiting period” of 3 days. Most people have difficulty for a few days after a serious trauma. Then there is the requirement that the problems you are having must last UP TO 30 days. This is a huge thing for Acute Stress Disorder. If your problems go on more than 30 days the name we call this (diagnostic code) changes to something more long-term like Post-Traumatic Stress Disorder (PTSD.)

The result of this time factor is that a whole lot of people who have this problem do not ever get diagnosed. In outpatient settings, it can take 30 days to get your insurance settled and to get in for an appointment. In hospital settings this diagnoses may be found more often using “strict criteria” but in most other places the results of trauma do not show up till years later and the issues then get called something other than Acute Stress Disorder.

  1. You must have at least 9 of 14 possible symptoms.

This leads to lots of ifs. Depending on who is doing the evaluating some things get counted and not others. Another problem is that trauma victims do not like to talk about their trauma. One symptom is avoiding reminders of the trauma and talking about it again is a reminder. So not having said they have a symptom can rule people out who did, in fact, meet criteria and do have Acute Stress Disorder.

I will not go through all the 14 criteria here, just a few of the big ones.

You can’t get the trauma or stressor out of your head.

This is sometimes called intrusive thoughts. You may also have dreams and things will trigger the memories so much you begin avoiding those emotional triggers. After the 30 days waiting period this may become PTSD.

From now on you are in a bad mood and can’t get out of it.

The happiness and joy get sucked out of your life. You are in a bad mood all the time for no apparent reason. Some people, kids, and men mostly, become irritable, angry and possibly violent. In my view, Acute Stress Disorder and its aftermath are involved in a lot of these unexpected violent incidents.

People may “space out.”

Researchers have noted that zoning out, technically called dissociation, is common, almost universal in the first three days after a trauma. If that dissociation continues after the third day we think it indicates Acute Stress Disorder. After thirty days that dissociation gets diagnosed as something else. I believe that there are more cases of dissociation than get recognized. Some are ignored and some get another name like Psychosis NOS (not otherwise specified.)

Acute Stress Disorder is time limited.

Acute Stress Disorder must last more than three days and less than thirty. Beyond the thirty the name gets changed. Many people try their hardest to cope and do not report symptoms. They can’t work and go on disability for a while until that runs out. Some end up alone and homeless. They get angry, depressed or anxious and their relationships suffer. They develop panic attacks or obsessive-compulsive disorders. Some get other mental illness diagnoses.

Having Acute Stress Disorder really matters.

This disorder, like most things we call mental illness, really makes a difference in people’s lives. It interferes with their ability to work or go to school. Having Acute Stress disorder can interfere with or destroy relationships with family and friends. It causes the people who have it a lot of suffering even when they can’t express how or why they are suffering. It can also damage other important areas of your life, such as religious observances, hobbies and so forth.

Acute Stress Disorder is not something else.

Professionals are continually reminded to avoid putting the wrong label (diagnoses) on things. If you only have these symptoms because of a medical issue or because you are drunk or high when you have the symptoms then we do not say you have Acute Stress Disorder.

This does not mean that people with medical problems or who use drugs can’t get Acute Stress Disorder, we just want to be careful we do not get the diagnosis wrong and count as symptoms things that were not caused by the stressor.

One last thing to consider.

There are two other groups of mental health problems in the Trauma and Stressor-Related Disorder chapter. Attachments Disorders, those problems that begin in very early life and Adjustment Disorders, which are reactions to stress that may not be life-threatening but have a huge impact on your mental health. These groups of life problems, sometimes, they rise to the level of a mental illness or a mental health problem.

I have written elsewhere about how Attachment Disorders and Adjustment Disorders can wreck someone’s life if not attended to. I am out of time and space here to talk about these other groups of Trauma and Stressor-Related Disorders.

Hope this post did not run too long. I do not think I have written a post of this length in the past but this seemed like a topic that needed more space and discussion.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Dissociation?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Confusion.

Confusion.
Photo courtesy of Pixabay.com

Does Dissociation really happen? What causes it?

Personally, I think there is more misunderstanding around this condition than most other mental health issues. First off Dissociation is way more common than most people realize. It comes in varying intensities; much of it is mild and goes unrecognized, denied and undiagnosed.

Dissociation, particularly Dissociative Identity Disorder has so much stigma around it that when we see it in clinical practice, I believe most clinicians call it something else more acceptable, like stress or Posttraumatic Stress Disorder, and let it go at that. This leaves people with more severe cases of dissociation with less than adequate treatment.

My view is that milder forms of dissociation are a normal protective behavior for most vertebrates, humans included. Under stress, the brain stem engages the “F’s” and takes over the functions of the brain to ensure survival.

Dissociation in its milder forms is, as I understand it, a functional survival mechanism. It is a close cousin to daydreaming and alcoholic blackouts.

Some simple examples of Dissociation.

I am driving along, I am thinking about something I need to do tonight. In my mind, I am picturing a set of slides that I want to create for the power point. I realize all of a sudden that I am miles past my freeway exit and I have no memory of driving this way. My mind has blanked out.

At this point, I turn around, drive as fast as I can and reach my destination. Do I tell everyone about my “zoning out?” Not a chance. I make some lame excuse about traffic and getting off work late.

Next example, more severe

A woman who was gang-raped in the past is walking around downtown. She sees some men who are wearing gang colors and look kind of like the men that assaulted her. She becomes frightened and crosses the street, she begins walking fast to get away. A few minutes later she slows down. Her panic is subsiding. She looks around and finds she is walking through a neighborhood and she has no idea where she is or how she got here.

So now we can see a mechanism by which someone who is upset might do actions like run away and be functioning essentially on autopilot. High levels of stress, like high levels of alcohol in blackouts, might shut off the connection between current functioning and memory.

Does that mean this woman has some form of Dissociative Disorder?

Maybe, maybe not. The new DSM-5 lists five major kinds of Dissociative Disorders plus some specifiers and or sub-types.

This woman, now upset because this past problem, memories of the rape, is messing up her life and also a lot worried because she ended up in a strange neighborhood with no memory of how she got there comes to see a therapist.

She begins to talk about her experience. She had an experience that brought back memories of her rape (Intrusive thoughts.) She tried to avoid things, ran away (avoidance, yes.) She has been anxious for several nights since and has lost sleep over this. Maybe even had a nightmare and this has been affecting her home life and her relationship.

At this point she gets assessed, a treatment plan created and treatment begins.

She was embarrassed so she left out the part about walking for a while and having no memory how she got there.

Her diagnosis – it’s likely to be Posttraumatic Stress Disorder.

In clinical settings, the stress-related disorders get diagnosed a lot more than the dissociative disorders. Sometimes it is a judgment call. Which disorder are this woman’s symptoms more like? But I think we professionals may be overlooking a lot of dissociative symptoms. The result may be that in outpatient settings we are under-diagnosing Dissociative Disorder and over-diagnosing PTSD.

In carefully controlled research the prevalence of Dissociative Disorders of all 5 types exceeded 5% of the population. That makes dissociation up to 17 times more common than Schizophrenia.

Dissociative Disorders are the next chapter over in the DSM-5 from stress-related disorders. We see a huge overlap between those two groups. There is also an overlap with Borderline Personality Disorder another misunderstood condition.

If we think of all these conditions as reasonable responses to stress given the person’s biology and experiences we can see how some of the things that occur to a person with dissociation make sense.

Dissociative Disorders are most commonly found in the aftermath of traumatic events. Some of the symptoms of dissociation are embarrassment, confusion and a desire to hide the existence of your symptoms. If you are the victim of trauma and let on how much the trauma affected you, this might put you at risk to be revictimized.

People under stress will have gaps in their memory. People with dissociation may also not know they have those gaps until someone asks about something they can’t remember. This is referred to in the literature as “amnesia about the amnesia.”

Dissociative Disorders, all 5 of them according to the DSM-5, include both positive and negative symptoms. In the past the only other disorder that I remember being described that way was Schizophrenia, but as I think about them other disorders have both also.

Positive and negative symptoms do not mean they are good and bad. What this means is that people with a disorder lose the ability to do some things others can do. This loss is called negative symptoms.

They also develop symptoms that others do not have. These added symptoms are called positive symptoms.

Since I believe people can and do recover I think that these areas of altered functioning can vary in intensity and can get better or worse depending on time, traumas, conditions, and treatment. More on negative and positive symptoms in future posts.

Another area of concern in talking about dissociation is something called state or trait theory. Trait would imply that once you got it you always got it. So if you dissociate then you are a goner and who wants to believe that. But if dissociation is a state then you can move into and out of it.

One other cause of Dissociative symptoms are efforts to reprogram or expose someone to “thought reform.” This mental reprogramming, like brainwashing, results in a brain that at some level believes two contradictory things. Can you see how that brain could pop in and out of contact with others?

Last, despite all the press about extreme cases of dissociation and the recurrent belief that this is something that only happens to women, the research tells me it is, in fact, more common among men than women. I have some theories about why that might be but that like the rest of this needs to wait till another post.

Dissociative disorders vary from person to person and time to time. Nothing I can say will fit everyone and there is a lot to be said for listening to the “lived experience” of those who have these disorders. More to come on this topic, but in the meantime what do all of you think about this?

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.