Anorexia Nervosa & Borderline Personality Disorder

Gold-Standard Treatments at Odds: 

Complications in Treating Combined Anorexia Nervosa & Borderline Personality Disorder

Any clinician can tell you that treating a life-threatening psychological condition such anorexia nervosa or borderline personality disorder is seriously challenging.  Treating a person with both anorexia nervosa and borderline personality disorder, however, is exponentially more difficult than the treatment of either condition alone.  This is largely because the gold-standard treatments for these disorders are at odds with one another: treating one life-threatening disorder exacerbates the other.  This post discusses how this happens and what to do.

To being to understand this problem, let's start with a discussion of why these disorders are life-threatening.  Eating disorders are life-threatening because the bodily impact of eating disordered behaviors such as severe caloric restriction and purging can respectively result in conditions like severe malnutrition and esophageal tears.  Borderline personality disorder is also life-threatening because people are at risk of engaging in impulsive behaviors, self-injury, and suicidal behavior when because they lack skills to regulate intense emotions.  Clearly, both disorders are life-threatening and must be addressed.  But what do you do if someone has both an eating disorder and borderline personality disorder?  Just treating both conditions at the same time seems like the obvious answer. Quickly after the implementation of this approach, however, one quickly discovers that the gold-standard treatments of the two life-threatening conditions are at odds.  

To further understanding as to why these treatments are at odds, let's first discuss the singular treatment of anorexia nervosa, one type of deadly eating disorder.  In anorexia nervosa, a person becomes underweight following a prolonged period of severe caloric restriction.  This severe caloric restriction is a behavioral strategy used to temporarily decrease the experience of fearing  fatness in a given moment.  In the treatment of this condition, the goal must be weight gain to ensure both physical and psychological recovery.  Further, from a psychological perspective, a person recovering from anorexia nervosa must endure the following exposures: 1) eating a large quantity of food many times per day (upwards of 4,000 calories), 2) eating a variety of high-fear foods every day such as pizza and burgers, 3) enduring a physical feeling of fullness that the eating disordered mind equates with immediate "fatness," 4) actual weight gain slowly occurring all day, every day for what is more often months, rather than weeks, and 5) not engaging in any "safety" behaviors that result in a respite from fear of fatness such as exercising, purging, and taking laxatives.  As such, the treatment of anorexia nervosa involves what can be viewed as a series of multiple, intense, all-day in vivo exposures, that carry on for months.  And because the person is in medical crisis, the intensity of this extended exposure cannot be lessened. There is no luxury of spacing out exposures based on psychological readiness in the treatment of anorexia nervosa.  A person with anorexia nervosa must be thrown into the metaphorical deep end.  As such, I imagine that the series of exposures involved in the treatment of anorexia nervosa are more intense than the treatment of any other disorder.

Now, let's discuss the singular treatment of borderline personality disorder.  In the treatment of borderline personality disorder, we are taught early on in graduate school that it is a bad idea to star therapy by addressing underlying trauma, which of course is normally treated with "prolonged exposure."  The idea is that if someone does not have skills to cope with intense negative emotions that arise when addressing trauma in exposure, they may be at increased risk for impulsive, self-injurious, and suicidal behaviors.  So, rather than implementing exposure in the treatment of borderline personality disorder, we are taught the focus in the treatment must be on skill building.*  Returning to a deep-end metaphor, learning coping skills is the equivalent of learning how to swim.  The skills, of course, are very helpful to know before being thrown into the deep end.  

As such, in the treatment of BPD, teaching skills decreases impulsive behaviors, the life-threatening component of the disorder.  A person with anorexia nervosa, however, is not immediately saved in the same way with skills.  Because the treatment of anorexia nervosa first requires medical & nutritional interventions that are psychologically experienced as exposures, there isn't enough time to teach skills before the interventions begin.  Further, even intelligent people with malnourished brains are much more likely to think inflexibly, and therefore, skills such as flexible & dialectical thinking may not be absorbed even if taught well to smart folks.

Now with a greater understanding of the individual disorders, let's return to the problem: focusing on treatment of an eating disorder in which intense exposure is needed can exacerbate the emotion dysregualtion inherent in borderline personality disorder, increasing the odds for impulsive behavior, self-injurious behavior, and suicide; alternatively, focusing primarily on skill building to treat the borderline personality disorder would does not allow for the rapid weight gain needed to ensure medical stability in the treatment of anorexia nervosa. 

To increase understanding of this problem even further, let's combine the above concepts with understanding a bit about how the brain is impacted by both disorders. A patient with anorexia nervosa has a malnourished brain that will result in inflexible thinking, further obsessionally, increased irritability, and other cognitive deficits.  If this person also has borderline personality disorder, not only is the brain malnourished, but the system in the brain in charge of emotion regulation is malfunctioning.  As such, the brain is malnourished - and needs nourishment to function properly - but the process by which re-nourishment occurs involves intense, all-day, multiple exposures that predictably result in rather severe emotion dysregulation, which is efficiently calmed by the immediate escape of negative emotion through the sabotage of the re-nourishment process (e.g. purging).  Big problem.

The problem is so big, in fact, that I do not think that simply treating someone with both outpatient gold standards of treatment - Family Based Therapy for anorexia nervosa and Dialectical Behavior Therapy for borderline personality disorder - will be helpful.  I do, however, have some strategies for fighting the two-headed monster that is comorbid anorexia nervosa and borderline personality disorder.

When clinicians finally see a patient with anorexia nervosa and borderline personality disorder in treatment, the complex interplay of psychological and physical pathology has already seriously compromised the patient's overall health.  Without any time for fostering full understanding of our rationale, the only thing to do in the moment is push the person into the deep end of the pool.  As clinicians we must also, however, dive in after them.  In the pool, we can hold them up until they learn how to swim.

I don't believe there is much hope of recovering from comorbid anorexia nervosa and borderline personality disorder without massive amounts of support.  Inherent in the disorder of anorexia nervosa, the person with this diagnosis cannot reach the conclusion that consuming large volumes of food and gaining weight will result in recovery.  We have to show them this.  As such, an outpatient level of care is very rarely enough.  It makes sense to me that most people who are severely underweight with anorexia nervosa and borderline personality disorder must be hospitalized on a psychiatric unit with staff and structure that can limit dangerous behaviors.  Because re-nourishment will inevitably be an awfully triggering experience, we must be as emotionally supportive as possible  We must also must be practically supportive and help the person learn as many coping skills as possible.  When someone is very underweight, we don't have the medical luxury of spending time focusing on skills, nor is it likely that most people can effectively learn the skills with a malnourished brain and body.  I think we must focus on re-nourishment while mitigating as many destructive behaviors as possible and teaching skills.  Once the person is stabilized, going to a structured program, likely makes the most sense.  

Unfortunately, in 2017 America, people with anorexia nervosa do not stay on inpatient units until they are 100% weight restored, even without the added complications that borderline personality disorder brings.  On a larger scale, I intend to advocate for a return to a time when patients stay until they have truly weight restored, especially if there is co-morbid borderline personality disorder.  In short, a presentation of both anorexia nervosa and borderline personality disorder really seems to call for the highest levels of care that you can get for the longest amount of time that you can get.  Whether you are a provider, patient, or loved one: I urge you to convey the information in this post to foster an understanding of the serious problem the comorbidity that anorexia nervosa & borderline personality disorder presents to advocate for more time in higher levels of care.

*Please note: there is evidence that PTSD & BPD can be treated simultaneously (Harned and colleagues; for more info: http://bit.ly/2cCrbiy).   But let's think about the treatment of borderline personality disorder and co-morbid PTSD v.s. anorexia nervosa a bit more. In the treatment of PTSD, "prolonged exposure" typically refers to about an hour of exposure once per week, the intensity of which is selected based on the psychological readiness of the patient.  From the perspective of someone who has undergone treatment for anorexia nervosa, the term "prolonged" is likely to seem sarcastically adorable.  I can imagine my patients saying "Wait, that is considered prolonged?  Ha!"  Although PTSD might be able to be treated in the context of BPD with careful consideration, the challenge of treatment anorexia nervosa is much greater.

New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

The French Paradox

The French Paradox:

Why The French Eat Fatty Food & Are Skinnier Than Us

It is official.  The French enjoy food more than Americans. And they are thinner with less health issues.  Awesome.

As it turns out, this phenomenon is so well documented,  even has a name - The French Paradox.

But what if it wasn't actually a paradox?  Maybe it all makes perfect sense.

Studies have shown that the French stop eating when they're full.  Americans stop eating when their plate is empty (Wansink,  2006).  Interestingly, the larger a person is, the more likely they were to rely on external cues to stop eating (e.g. portion size).

Frankly, this isn't too surprising.   We all understand that the plate sizes in the States are big, some of us have an inclination to eat everything on the plate, and subsequently, we gain weight.  But this begs a more interesting million dollar question:  If relying on external cues like plate size can cause weight gain, what is the answer to weight stablization?

Well, the answer is resoundingly NOT self-control, restraint, effort, pressuring yourself, and/or punishing yourself.  These methods also rely on external cues or rules that you set for yourself.  These types of eating guidelines are largely ineffective in practice too.  Consider how many times you've tried to restrain your eating, only to eat a ton.  You may even binge after trying to restrict.

I would go so far as to say that restricting food intake with any type of diet may actually be just as much a part of long-term weight gain as overeating.  For so many people, restricting food intake is simply just the first step in a sequence that eventually leads to unstoppable eating.

Take a moment to chew on that concept a bit: restricting is the opening act for a grande finale binge.  If this cycle repeats over time, the overall effect could actually be weight gain.  Shortening the message, restricting may = weight gain for some.

[Turns out there is this whole psychological component to dieting practically no one has been considering!  But I digress.]

Now, returning to the million dollar question.  The correct answer is this: the opposite of relying on external cues to stop eating is relying on internal cues of hunger and fullness.  In short, if you go by external cues like your plate size, you could be heavier over time.  Conversely, if you go by internal cues, your weight is likely to be more stable over time (e.g. Augustus-Hovarth & Tylka, 2011)

Interestingly, Rozin et al (1999) found that American's associated "chocolate cake" with guilt, while the French associated it with "celebration."  The French can actually enjoy cake and they're still thinner.

After all of that dieting, could it be that thinking more like a hedonist shrinks your waistline?  Tell me what you think with a comment below.

P.S. As usual, this post is only a sliver of my thoughts on the matter.  More generally, not only does one need to start paying attention to hunger/satiety cues, but also 1) decrease fear about weight gain, 2) try to curb the desperate desire to be thin, 3) stop mentally obsesses over calories, 4) curb efforts to compensate for calories, and 5) very importantly, being "thin" doesn't equal good health in the same way being "overweight" doesn't equal bad health.  But these issues are fodder for another post!  We'll get there.

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References

Augustus-Hovarth, C. & Tylka. T.  (2011). The Acceptance Model of Intuitive Eating: A Comparison of Women in emerging adulthood, early adulthood, and middle adulthood. The Journal of Counseling Psychology, 58, 110-125.

Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to Food and the Role of Food in Life in the U.S.A., Japan., Flemish Belgium, and France: Possible Implications for the Diet-Health Debate.  Appetite, 1999, 33, 163-180.

Wansink,  B. (2006).  Mindless Eating: Why We Eat More Than We Think.  New York: Bantam Books.

You can read more about The French Paradox here: http://en.wikipedia.org/wiki/French_paradox

Is Multiple Personality Disorder Real? - The Response

In April 2011, I wrote a post called "Is Multiple Personality Disorder Real?"   It is the third most popular post I've written here and certainly generates the most polarized comments / emails.   While I encourage you to read the original if you're interested in the following response, the gist is that Dissociative Identity Disorder (DID) - which was once called Multiple Personality Disorder (MPD) -  could potentially be Borderline Personality Disorder peppered with some delusional qualities. 

One very interesting & thought-provoking comment from 9/25/2012 inspired me to write this (belated) response.

Comment:
This blog post reads like it was written by someone who's never read a book or an article on DID, who's never worked with people with DID, who's just making wild assumptions. There are people dx'ed with both DID and BPD. There are also people dx'ed with BPD who don't have BPD at all, but have DID. You also make no mention of PTSD which all DID patients have, but not all BPD patients have. Look at somewhere that actually treats DID and PTSD specifically like the trauma Ward at Sheppard Pratt. But your theories seem a little half cocked.

This is my response:
Fair enough - I've admittedly not had much experience with DID - however; allow me a belated response (apologies for the delay).

First, I was generally very impressed when visiting Sheppard Pratt in May 2012.  My impression was that they offer top-of-the-line treatment.

As for DID though, I have read a bit about it.  For a summary, I would see Prof. Rich McNally's book "What is Mental Illness?" from 2011, copyright, President and Fellows at Harvard College.

In short, the book explains right after the book Sybil was published, "from near-nonexistence, MPD spread throughout North America, with the number of diagnosed cases soaring to 50,0000."  And then the "epidemic of MPD ended abruptly" because a study showing that asking leading questions is more likely to "create false memories than to recover them" (Ceci & Loftus, 1994).

The book also reads "MPD therapists inadvertently undermined the credibility of their own field when they began helping patients recall alleged memories of satanic ritual abuse" (McNally, Remembering Trauma). And that the FBI failed to uncover any physical evidence of these types of abuses (Lanning, 1992).

Interestingly enough, stories about abuse and trauma Sybil herself endured were also unfounded.  What seems to be the (even more disturbing) truth is that Sybil sought treatment with Dr. Cornelia Wilbur, who appears to have implanted false memories with the (unwitting) use of leading questions and social positive reinforcement.  When treatment tapes of the sessions between Wilbur and Sybil were researched, convincing evidence of this was revealed.  The book also states "indeed, Sybil admitted in writing to Wilbur that she had manufactured her MPD symptoms."

As such, while the symptoms of DID are in the DSM-IV, this does not mean that the disorder is not socially constructed, at least for the vast majority of cases.

[By the way, I'm not saying that there was never an organic (non-socially constructed) case of DID out there.  Saying that 100% of DID cases are socially constructed is a bit like meeting 50,000 Elvis impersonators in the year 2013 and then concluding Elvis Presley never existed. It stands though, that the ratio of hypothetical Elvis impersonators to Elvis Presley himself is still 50,000:1.] 

If someone presents with a case of DID, undoubtedly the situation is severe; however, I would argue that give the citations provided above, the idea  that the etiology (or cause) of the disorder is organic seems dubious at best.  Of course, understanding etiology is extremely important for treatment - especially if the treatment itself is indicated as a possible cause of the disorder, as was in the case of Dr. Cornelia Wilbur and Sybil.

For the cases that are not organic, but socially-constructed - which the evidence seems to suggest is most of them - perhaps a BPD identity disturbance / delusional quality may be present.  That's all.

Dysregulation of the Anxiety System & Bipolar

As per usual, I'm trying to focus on work now, but get completely derailed with a thought I feel the need (compulsively) to blog about.

I saw that someone somewhere on a remote part of the globe was reading a post I wrote a while ago postulating that fear was the first emotion to appear on the evolutionary scene. I decided to revisit it. Here's the link: http://taradeliberto.blogspot.com/2011/03/first-emotion-fear.html

While rereading the post, I had the thought that bipolar disorder may result from a dysregulation of the anxiety system. Long story short, in depression, we see that prolonged anxiety can lead to chronic sadness (via chronic exposure to cortisol and what I conceptualize as over-use of the hypothalamus-pituitary-adrenal axis). We can also see that exhilaration and anxiety are quite similar emotions. Combining these two thoughts, perhaps bipolar disorder could arise out of the dysregulation of a primary anxiety system - sometimes leading to chronic sadness and other times leading to chronic exhilaration.

Interestingly, bipolar is pretty hereditary, but like most psychiatric disorders, it is thought to be prompted by none other than stress, perhaps indicating that it stems directly from some a dysregulation of the anxiety system.

I realize that this is being done already, but the fact that stress / anxiety can trigger the onset of disorders might be a signal to look at how anxiety relates to the course of the illness (with the consideration that anxiety could be the ultimate primary emotion). In this case, while stress may trigger bipolar disorder, lack of ability to regulate anxiety may maintain the behavior. While research in which I am involved examines reward sensitivity in bipolar, I'm wondering if a layer beneath reward sensitivity is anxiety sensitivity, being that we're conceptualizing anxiety as the ultimate primary emotion in this post.

I also realize that to say anxiety dysregulation may prompt bipolar disorder because stress prompts the onset utilizes circular reasoning. But circular reasoning notwithstanding (lol), I still think this is interesting to consider anxiety sensitivity as it relates to two separate constructs of bipolar - both onset and course of the illness.

Ok, back to work.

Triggers - Avoid or Expose?

I was just thinking about the practice of identifying and avoiding triggers in therapy. Sure, inherently harmful triggers are best avoided... but what about triggers that are what we call "conditioned stimuli?"

[For the non-psychologists out there: some of us are triggered by certain things that are actually harmless, but during the course of our lives, we somehow came to associate them with feeling like crap. For instance, walking by a restaurant you used to frequent with an ex could trigger negative emotions. The restaurant itself is harmless, but you've been conditioned to feel sad when walking by it. As such, the restaurant is now a trigger.]

Some therapists may urge their patients to simply avoid all triggers. Sure, this sounds like a good idea, but is it truly helpful? If the patient is in acute / reactive pain, then throwing some more negative experiences their way probably isn't a good idea. But typically, I think that systematically exposing people to triggers, just like you would to anxiety provoking stimuli, would lead to habituation.

While this may be common practice for treating some disorders, it doesn't seem to be the case for all of them (i.e. eating disorders). For instance, when a particular food may trigger a binge, the general advice simply seems to be to avoid that food. Well, I'm just not so sure.

Sensory Integration and Self-Injury

I spent the last semester working with children who have autism.  During this time, I heard the term "sensory issue" a bunch of times, but had no clue what it really meant.  Even after asking questions about it, I never felt like I really understood it.

I ended up learning the most about sensory integration issues at an unsuspecting event - at a writer's conference in NYC.  There, I so happen to have met Nancy Peske, the co-author of the book, Raising a Sensory Smart Child, and a mother of a child with the conceptually elusive sensory integration issue.  I figured she'd be the perfect person to ask about this stuff.

I ended up learning that some people are prone to either seek out intense stimulation or find even the most mild sensations aversive.  For instance, some children have an extremely high tolerance for what would cause most of us pain.  Conversely, the same child may find light tickling painful or aversive.  Although many people with autism have these types of sensory integration issues, we also see this in people who don't happen to have autism.

Relevant to my past research, we find that children who engage in self-injury are more likely to have a high pain tolerance and engage in repetitive behaviors.  While we previously thought that having a high pain tolerance was caused by repeated episodes of self-injury, I'm wondering if actually there is an underlying sensory integration issue here.  [In fact, we're finding that the traditional tolerance theory is not supported.]

On top of that, we have been conceptualizing repetitive behaviors as a precursor to self-injury; however, now I'm thinking that perhaps they both emerge out of the same sensory integration issue that may have been present from before / soon after birth.

And speaking of birth, in Deliberto & Nock, 2008, we report that in utero complications are seen more in children who engage in self-injury than in controls.  Like repetitive behaviors and in utero complications, these findings are also seen in people who have autism.  Although these data are correlational, the relationship among in utero complications and repetitive behaviors, self-injury, and autism is worth considering in my opinion.

In short, I'd bet that both self-injury and some of the underlying commonalities between this behavior and autism are sensory integration issues relating to touch.


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Why Do People Talk about Cutting Themselves?

I just received the following inquiry: I know some one thats very public about cutting themselves. Is this normal? And why do you think this is?

Here's my answer:

Good question. Although I cannot assume I understand this specific person, I can speak generally about the topic of openly discussing one's own self-injurious behavior.

My first inclination is that the person may be seeking what we call "social reinforcement." There are two types of social reinforcement - positive and negative.

What we call "positive social reinforcement" is what people not in the biz call "getting attention." This would come in the form of sympathy, interest, concern, or even people expressing shock. Particularly if a person feels disconnected / a lack of social support (and want these things), they may be prone to be seeking interaction with other people in this way.

So what we call "negative social reinforcement" does actually not mean punishment. In my experience, people in the public misuse the term "negative reinforcement" quite frequently. Negative reinforcement simply means to remove something aversive or to get out of a responsibility. For instance, an adolescent working on a boring group project might tell her peers that she's a "cutter" so they put less of a workload on her. In this example, if the teen gets out of doing something boring, she is negatively reinforced for telling people she cuts.

This brings us to an interesting point. It is my opinion - which is not shared among people with whom I've worked - that when people are socially reinforced (either negatively or positively) for telling people they self-injure, it isn't necessarily the cutting itself that is affected. What I think is more influenced is the actual disclosure of the behavior. This would mean that if someone is socially reinforced for telling people they cut, the actual act of cutting wouldn't necessarily increase, but the number of times self-injury is discussed would increase. To be crystal clear, I think that social reinforcement may shape the largely impulsive behavior of cutting itself, but not as strongly as the seemingly more deliberate act of discussing the behavior.

It is my opinion that people primarily engage in self-injury for emotion regulation purposes. In other words, to decrease their anxiety or to pull them out of a disoriented state (to learn more, I posted a link about this at the bottom of the page). It doesn't make sense to me that people engage in self-injury just so that they can receive attention for it later. My intuition tells me that the reinforcer of social approval is too far removed from that actual act of cutting to be incredibly potent. To my knowledge though, no research has been conducted to support this. In fact, self-report studies show that people report thinking they engage in self-injury to gain approval, therefore, it is advisable to take this into consideration when considering the thoughts previously expressed.

Perhaps self-injury can start out so that one may gain approval (positive social reinforcement) or even get out of something (negative social reinforcement). It could also be the case that someone starts cutting just for the emotional effects, but then starts telling people about it. I just can't buy into the idea that the only reason someone would cut is for social reinforcement.

Anyhow! I digress. Back to your question. It could be the case that this person is trying to connect with people, shock them, or remove his/herself from responsibility. On the other hand, perhaps he/she is just trying to work through previous shame about the behavior and finds it liberating to talk about it. I really don't know. But these are my best guesses!

Speaking to your question regarding whether or not it is normal: based on no data but my experience, about half of people who cut themselves report telling other people, while the other half don't tell anyone but maybe a mental health professional. While I'm not sure how normative it is for people to talk at length about their self-injury, I have some thoughts about this.

We can't make assumptions that talking about engaging in self-injury is necessarily a maladaptive / bad thing. For instance, perhaps the person will end up getting into the right treatment and get support for stopping the behavior. And as previously mentioned, perhaps the person used to feel much shame about the behavior and is working through it by speaking about cutting. Who knows?

On the other hand, one could make the case that if the person is socially reinforced for disclosing that he/she self-injures, the behavior could be maintained. I'm just not sure exactly why this person may be openly discussing engaging in self-injury.

As you can imagine, it is quite complicated!

Great question though. I've never been asked this.

To read more check this out: http://taradeliberto.blogspot.com/2011/02/why-do-people-cut-themselves.html