Depression and Risky Behavior

Why self-destructive behavior may accompany depression and what to do about it.

From the WebMD Archives

Depression poses many dangers, burdening people with hopelessness and raising their risk of suicide. But in attempts to quell the pain, some turn to alcohol, drugs, and other harmful behaviors that endanger them even further, psychologists say.

“There is a strong relationship between depression and high-risk behaviors,” says Pamela Cantor, PhD, a psychologist and lecturer at Harvard Medical School.

“Excessive drinking, drug abuse, unsafe sex, and cutting are all self-injurious behaviors that individuals may use to provide temporary relief from intense emotional pain,” she says -- a pain that some experts have labeled “psychache.”

It’s a fairly common scenario in therapists’ offices across the country. Cara Gardenswartz, a clinical psychologist in private practice in Beverly Hills, Calif., and a lecturer at UCLA, estimates that roughly 30% of her depressed clients engage in some type of “self-injurious or harmful behavior,” she says.

Often, there’s more than one problem. “Someone with one self-injurious behavior is more likely to have two or three,” Gardenswartz says.

At Fordham University in New York, assistant psychology professor and researcher Peggy Andover, PhD, studies young people who engage in “nonsuicidal self-injury.” In other words, when they’re distressed, they cut, burn, carve, or scratch their skin in an attempt to make themselves feel better.

There’s not much data on how often depressed people will engage in nonsuicidal self-injury, Andover says. But researchers have studied those with self-injury for symptoms of depression. “What we know is that people who engage in nonsuicidal self-injury generally have higher levels of depressive [symptoms],” she says. Furthermore, newer research suggests that depression comes first and the self-injury follows, not vice versa, she says.

Reasons for Self-Destructive Behavior

Depression can unearth unbearable feelings that many people try to escape. For example, a depressed man who grew up in a violent and neglectful home may turn to drinking to bury the feelings of rage and poor self-esteem.

“For all of these high-risk behaviors, there’s a part of them that’s trying to numb themselves ... from really difficult and significant feelings of loss, anger, shame, or anxiety,” Gardenswartz says.

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But there are secondary reasons, too: Self-destructive behaviors can communicate one’s misery, experts say.

“If they’re depressed and feel that nobody cares -- ‘Nobody loves me and I’m not important to anybody’ -- those behaviors can be a way of saying to themselves and others that ‘I deserve nothing. I don’t deserve to be healthy or happy or whole,’” says Mary Carole Curran, PhD, a psychologist in St. Louis. “Or sometimes, they say, ‘Pay attention to me.’ It’s a cry for help.”

Some turn to harmful coping methods because their families modeled such behavior, Gardenswartz says. For example, if one’s parents dealt with problems through drinking, an adult child might do the same.

The Costs

When depressed people resort to self-destructive behaviors, the physical damage is obvious: liver damage from alcoholism, sexually transmitted diseases or HIV from unprotected sex, or infections and scarring from cutting one’s skin.

Psychologically, the attempts to avoid or soothe painful emotions with self-destructive behaviors usually backfire, experts say.

“Drinking numbs the brain, drugs obliterate pain for a while by altering perception, sex provides distraction and a temporary feeling of connection which, however, almost always results in greater feelings of isolation and aloneness,” Cantor says. “These behaviors are all maladaptive coping mechanisms.”

Gardenswartz says she once treated a woman who became drunk repeatedly, sometimes on as many as four bottles of wine per night. The woman said that after men had sexually assaulted her, she would wake up feeling ashamed. But beyond the woman's understanding, the vicious cycle continued.

Powerful, unconscious forces and past traumas often drive such self-destructive behavior, according to Gardenswartz. For example, some women who engage in high-risk sex may have been molested as children and learned unconsciously to disrespect themselves and their bodies, she says. “Unfortunately, that was the message put into them.”

“The person has a void inside. They just feel so much pain from the past,” Gardenswartz adds. “They end up harming themselves instead of helping themselves.”

Besides the physical and emotional costs, high-risk behaviors also make suicide or accidental death more likely.

“These behaviors are usually a means of avoiding suicide and relieving pain, yet individuals who self-harm have a greater risk of suicide and suicidal behaviors than individuals who do not,” Cantor says. “Thus, these symptoms of distress, if left untreated, may lead to suicidal gestures, attempts, or plans to commit suicide.”

Or, as Gardenswartz notes, a person might not have suicidal intentions but may die accidentally from a drug overdose or car crash.

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Treating Harmful Behaviors

Treatment for self-destructive behaviors should focus on the underlying causes, experts say.

“You have to find out, where is that coming from?” Curran says. “A lot of those behaviors come from having experienced trauma, either witnessing it or experiencing it personally. There’s all this pent-up energy, and it comes out in the anxiety, depression, and risky behaviors. Dealing directly with the trauma helps.”

Besides supportive psychotherapy, antidepressant medications can be useful, says Cantor.

Therapists can also teach avoidance techniques, she says. “If you can avoid a trigger, you can avert the behavior. One has to take oneself away from situations that prompt self-destructive behaviors.” For example, a person who clears alcohol or blades from his or her surroundings will find it harder to drink or to cut.

Depressed people can also learn to substitute activities that don’t cause damage. For instance, relaxation techniques or meditation can help them to manage their feelings, rather than resorting to harmful behaviors, Curran says.

Dialectical Behavior Therapy (DBT)

For anyone who's depressed, therapy is a key part of treatment. One form of therapy, called dialectical behavior therapy (DBT), offers promise for some self-destructive behaviors, experts tell WebMD.

DBT is a form of cognitive behavioral therapy that was originally developed to treat borderline personality disorder, which often involves self-destructive behaviors. Now, some therapists use DBT to treat substance abuse, eating disorders, anger, and other problem behaviors.

According to Gardenswartz, a depressed person with a substance addiction still needs an inpatient rehab program, but DBT could help address other self-injurious behaviors.

“It’s a fantastic treatment,” Andover says of DBT. But she adds that it is a highly intensive approach that requires lots of resources and may not be right for everyone.

The cornerstones of DBT include: addressing dangerous and impulsive behaviors in order to improve control, learning how to deal with distress and manage extreme emotions, training in interpersonal skills, and finding effective and socially acceptable ways to handle life’s problems.

It’s called dialectical behavior therapy because it combines two seemingly opposite ideas: fully accepting people in their current condition while actively helping them to change problem behaviors. According to DBT proponents, acceptance and empathy -- not rejection -- help motivate people to change.

WebMD Feature Reviewed by Laura J. Martin, MD on June 23, 2011

Sources

SOURCES:

Peggy Andover, PhD, assistant professor of psychology and researcher, Fordham University, New York.

Pamela Cantor, PhD, psychologist and lecturer, Harvard Medical School.

Mary Carole Curran, PhD, LMFT, ABPP, psychologist; executive directory, Catholic Family Services, St. Louis.

Cara Gardenswartz, clinical psychologist, Beverly Hills, Calif.; lecturer, UCLA.

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