Self-Harm Behavior Among Chronic Pain Patients

To the Editor: Chronic pain is fairly prevalent in both developed and developing countries.1 However, few studies have examined self-harm behavior in this unique clinical population. Among chronic pain patients in an inpatient rehabilitation unit in a psychiatric service, Fisher and colleagues2 reported the prevalence of suicidal intent at 6.5%. In a large Canadian community sample, Ratcliffe and colleagues3 found that the presence of 1 or more chronic pain conditions was associated with both suicidal ideation and attempts. However, other forms of self-harm have received little attention (ie, we could locate no published reports in the literature). Given that the broad spectrum of self-harm behavior has received little attention in the empirical literature, in this study, we examined the prevalence of 22 self-harm behaviors in a cohort of chronic pain patients being seen by a pain specialist. Method. The study was conducted from December 2005 through August 2007. Participants were 117 general pain patients (response rate: 94.4%; 43 men, 73 women; 1 participant did not designate his or her sex) who were insured and referred to a pain management specialist by physicians predominantly in the areas of physical medicine and rehabilitation, orthopedics, and primary care. The sample ranged in age from 18 to 69 years (mean = 44.50, SD = 11.50). With regard to race/ethnicity, 105 (89.7%) were white, 6 (5.1%) Hispanic, 3 (2.6%) African American, 1 (0.9%) Asian, and 2 (1.7%) other. The majority were currently married (n = 60; 51.3%); 26 (22.2%) were never married, 26 (22.2%) were divorced, 4 (3.4%) were separated, and 1 (0.9%) was widowed. Nine (7.7%) did not graduate from high school, 25 (21.4%) graduated from high school only, 39 (33.3%) attended some college, 27 (23.1%) had a college degree, and 17 (14.5%) had a graduate degree. Each participant was recruited during his or her initial clinical evaluation for chronic pain. Each completed a research booklet that explored demographics as well as self-harm behaviors using the Self-Harm Inventory (SHI).4 The SHI is a 22-item, yes/no, self-report inventory that explores participants’ lifetime histories of self-harm behavior. Each item is preceded by the phrase, “Have you ever intentionally, or on purpose…” Items include “overdosed,” “cut yourself on purpose,” “burned yourself on purpose,” and “hit yourself.” Each endorsement is in the pathological direction, and the SHI total score is the summation of “yes” responses. The project was approved by an Institutional Review Board, and completion of the booklet was assumed to function as informed consent. Results. The number and percentage of respondents endorsing each SHI item are shown in Table 1. The number and percentage of respondents who endorsed 0, 1, 2, 3, 4, or 5 or more SHI items were 56 (47.9%), 8 (6.8%), 10 (8.5%), 9 (7.7%), 9 (7.7%), and 25 (21.4%), respectively. Note that each item was endorsed by some participants, with a substantial minority reporting the abuse of alcohol (about one third). In addition, more than 20% of the sample reported driving recklessly, being promiscuous, and engaging in emotionally abusive relationships. Finally, the prevalence rates of overdoses and suicide attempts in this cohort (7% for each) were nearly identical to the rate of “suicide intent” reported by Fisher and colleagues.2 Table 1 Rates of Endorsement of Items on the Self-Harm Inventory (SHI) (N = 117 chronic pain patients) These data indicate that, among patients with chronic pain, there are likely to be a number of aberrant behaviors, characterized by underlying themes of impulsivity and self-harm. While the relationships between pain, depression, and other potential contributory factors (eg, Axis II disorders) are not clarified by these data, there are likely to be complex associations that warrant further investigation. The potential limitations of this study include the small sample size, the self-report nature of the data, and the lack of control for pain intensity and depressive symptoms. However, this is the first study, to our knowledge, to explore a broad array of self-harm behaviors in an outpatient chronic pain population. Our findings indicate that there may be some psychopathological currents in a substantial minority.

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