To help people who perform non-lethal self-harm, such as cutting and burning themselves, we need a better understanding of the thoughts and feelings that contribute to them resorting to this behaviour. Risk factors are already known, including depression and a history of sexual abuse. However, Noelle Smith and her colleagues wondered if these factors increase the risk of self-harm because they lead people to experience self-disgust. Viewed this way, the researchers believe “self-disgust may serve as an emotional trigger” for self-harm.
Over five hundred undergrads, men and women, answered questions about whether they’d ever intentionally harmed themselves (including cutting, burning and scratching); when they’d last performed such an act; their depression symptoms; any history of physical or sexual abuse; their anxiety; and crucially, their feelings of self-disgust, as measured by 18 items, such as “I find myself repulsive”.
Consistent with the researchers’ predictions, the more self-disgust a student reported, the greater the likelihood that they had previously performed self-harm (statistically speaking, a one standard deviation increase in self-disgust was associated with a two-fold increase in the odds of reporting self-harm).
Levels of self-disgust were the highest in those students who said they’d performed self-harm in the last year. These were also the same students who tended to report depression symptoms and a history of physical or sexual abuse. It’s notable though, that depression was no longer associated with self-harm once self-disgust was taken into account, suggesting that self-disgust is the key mediating factor.
These findings jibe with past research on the more cognitive aspects of self-disgust – for example, there’s evidence that self-harm is associated with being self-critical and having an excessive focus on one’s own mistakes. Other studies have highlighted reductions in self-disgust after acts of self-harm, but also increases. Smith and her colleagues suggested the link could be bi-directional: self-harm may assuage feelings of disgust with self, but performing a self-harming act may then trigger feelings of shame with one’s own actions.
The cross-sectional nature of this study means it can’t shed light on the direction of causality – whether self-disgust contributes to self-harm behaviours, or if the reverse is true. Self-disgust was also measured as trait, rather than as an acute state of mind. The researchers acknowledged these issues, but they note theirs is the first study to look at the emotion of self-disgust as a precipitating factor for self-harm, and they call for more research. For now, they said their results suggest reducing self-disgust may help people who are at risk of self-harm.
_________________________________ Smith, N., Steele, A., Weitzman, M., Trueba, A., & Meuret, A. (2015). Investigating the Role of Self-Disgust in Nonsuicidal Self-Injury Archives of Suicide Research, 19 (1), 60-74 DOI: 10.1080/13811118.2013.850135
Edgar Allan Poe’s fictional detective C. Auguste Dupin warns against tackling questions that are too complicated to test, but too fascinating to give up. Whether psychotherapy or medication can reduce suicidality is probably such a question. Particularly if we are really interested in whether treatments can reduce attempted suicides, not whether they change patients’ answers in an interview or on a questionnaire.
There is no doubt about the clinical and public health significance of the question. After all, psychotherapy and medication are treatments of choice for suicidal patients. The logic is that many, even if not all, suicidal persons are depressed; we know about effective treatments for depression; and so we can generalise from knowledge about what works for depression to what works for suicidality. However, we must hope for more definitive evidence, and a new study attempts to provide it.
The authors include suicide expert Ad Kerkhof, and Pim Cuijpers, who has done some of the most influential meta-analyses and systematic reviews on the treatment of depression. Together with doctoral student Erica Weitz and depression expert Steven Hollon, they analyzed data from the US National Institute of Mental Health Treatment for Depression Collaborative Research Project (TDCRP). Conducted in the 1980s, it was then the largest ever comparison of psychotherapy and medication for treatment of depression. Two hundred and fifty patients with major depression were randomized to cognitive therapy, interpersonal psychotherapy, antidepressant medication, or a pill-placebo plus clinical management as a control group.
The original study did not specifically target suicidality. It actually excluded patients with moderate to severe suicidality. However, the two primary depression outcome measures for the study, the self-report Beck Depression Inventory (BDI) and the interview-administered Hamilton Rating Scale for Depression (HRSD), each contained a single item inquiring about suicidal thoughts and behaviour:
Suicidal ideation/suicidality is rated on the HRSD on a 5-point scale: 0—absent, 1—feels life is not worth living, 2—wishes he were dead or any thoughts of possible death to self, 3—suicide ideas or gesture. 4—attempts at suicide (any serious attempt rates a 4).
The suicidality question on the BDI is measured on a 4-point scale: 0—I do not have any thoughts of killing myself, 1—I have thoughts of killing myself, but I would not carry them out, 2—I would like to kill myself, 3—I would like to kill myself if I had the chance.
The new analysis required that patients have at least some suicidal ideation on either measure. Of the 250 patients, 146 met this criterion. At the start of treatment, patients scored a mean of 1.15 on the HRSD suicide item and .74 on the BDI’s item. The sample included one person who had made a suicide attempt. This case proved to be an outlier and was removed from the analysis. Thus, this study captures mostly mild to moderate suicidal thoughts.
Based on measures taken pre- and post-treatment, the authors found that all treatments, including the pill placebo with clinical management, significantly reduced scores on both the interview and self-report measures of suicidality, with all having a medium effect size. According to the interview measure, interpersonal psychotherapy and antidepressant medication reduced suicidality more than the pill placebo with clinical management. No differences were found between treatments using the self-report measure.
The authors recognised that because the comparison-control group (pill placebo plus clinical management) significantly reduced suicidality, no conclusions could be drawn about specific components of the treatments being essential. It is important to note that pill placebo plus clinical management was not an inert control condition. Neither patients nor therapist knew that any antidepressant was not given, and there were considerable positive expectations, support and encouragement. I am sure that outcomes would have been better in this group than for a waiting list control condition, but there was none included the study.
Recall that the items measuring suicidal ideation were part of depression scales. Did these specific items decrease simply as a result of overall improvements in depression? The authors state they ruled that out with complex multivariate analyses, but I was left unconvinced.
Suicidal ideation is a surrogate outcome. That is, it serves as a proxy for the more interesting, but less frequent outcomes of suicide gestures and attempts and completed suicides. However, the problem with a proxy outcome is the treatment can have a positive effect that is insufficient to change the clinical variables of interest. There was a time when pharmaceutical companies relied on surrogate outcomes like reduction in blood pressure when rates of heart attack were the actual variable of interest. In that context, many treatments affected surrogate outcomes without changing the real variables of interest. The same could be happening here.
Overall, the study demonstrates a dilemma. Mild suicidal ideation is common among depressed patients seeking treatment, but overall is a poor predictor of suicide attempts, which are comparatively infrequent. While many of the patients who ultimately attempt suicide present with serious suicidal ideation, most of them start off with signs of only mild to moderate suicidality. The seeming paradox is due to having to predict later infrequent events from imperfect and nonspecific risk indicators.
We can certainly study treatment of patients at high risk because of a recent suicide attempt, but what we learn then is not readily generalisable to the more common clinical situation of patients expressing only mild to moderate suicidality when they enter treatment. On the other hand, if we study the treatment of this moderate suicidality seen in the clinic, we can’t measure the impact on actual attempts or death by suicide, because to do so would involve a prohibitively large sample.
We are left with the uncomfortable situation of attempting to address a clinical problem in studies with poor measures and inadequate sample size. Or simply having to settle for answering the question “Do depression treatments reduce suicidality?” with “Probably: they reduce depression.”
_________________________________ Weitz E, Hollon SD, Kerkhof A, & Cuijpers P (2014). Do depression treatments reduce suicidal ideation? The effects of CBT, IPT, pharmacotherapy, and placebo on suicidality. Journal of affective disorders, 167C, 98-103 PMID: 24953481
Post written by James Coyne (@Coyneoftherealm) for the BPS Research Digest. James Coyne, PhD is Professor of Health Psychology, University Medical Center, Groningen and the 2015 Carnegie Centenary Professor at University of Stirling.
Public surveys show many people view suicide as morally wrong. When you ask them why, they usually refer to the harm caused to the deceased’s family and friends, and to the victim themselves. However, a fascinating new study uncovers evidence suggesting that a more important reason people feel suicide is morally wrong is because they see it as tainting the victim’s soul. This is the case even for liberal non-religious people. The finding is another example of how our implicit moral judgments are often at odds with our conscious, explicitly stated moral reasoning.
Joshua Rottman and his colleagues presented 174 US participants (114 women; average age 21) online with eight fabricated obituaries that had the appearance of a real obituary published in a paper. The participants were mostly non-religious liberals. Half of them read obituaries about people killed by murder; the other half read obituaries for people killed by suicide. The wording for the obituaries began with a simple statement (e.g. “Louise Parker, who was 68 years old, died on January 11, 2008 due to [suicide/homicide]”). Apart from that single word difference at the end of the opening statement, the remainder of each obituary – a respectful description of the deceased – was the same for participants in the two conditions.
After reading each obituary, the participants were asked to rate the death according to how morally wrong it was; how angry it made them feel; how disgusted it made them feel; how much harm had been done; and whether the victim’s soul had been tainted. The order of the questions was randomised. The participants were also asked to state explicitly why each suicide/homicide is morally wrong.
Overall, homicides were judged more morally wrong than suicides, as you’d expect. However, on average the suicides were also rated as morally wrong, consistent with previous public surveys. The most revelatory finding is that the participants’ ratings for the moral wrongness of suicides was not correlated with their ratings of the harm caused. Rather, their judgment of moral wrongness was correlated with their ratings of how much the victim’s soul was tainted. Consistent with this, the participants’ feelings of disgust predicted their ratings for the moral wrongness of suicide, but their feelings of anger did not.
In contrast, to the findings for suicide, ratings for the moral wrongness of homicide were associated with judgments about harm, but not ratings about the tainting of victims’ souls. “These results support our principal hypothesis,” the researchers said, “suicide, but not homicide, is considered immoral when there are elevated concerns about spiritual taint (impurity), while the same is not true for concerns about harm.” Intriguingly, this result was at odds with the participants’ explicitly stated reasons for finding suicide morally wrong, which tended to focus on harm caused.
What about the participants’ religious and political beliefs? As you might expect, those who were more conservative and religious tended to judge suicide as more morally wrong. But perhaps the most astonishing result from this research is that the link between seeing the victim’s soul as tainted and seeing a suicide as morally wrong was just as strong for the non-religious and liberal as for the religious and conservative.
“These results suggest that even if people explicitly deny the existence of religious phenomena, natural tendencies to at least implicitly believe in souls can underlie intuitive moral judgments”, the researchers said. The research has some limitations, as the researchers acknowledged – for example, all the participants were from the US, and there’s a need to examine other forms of suicide, such as suicide bombers. Also, the causal role of beliefs about purity has not yet been proven.
However, the authors are to be credited for publishing several replications of their main finding (not detailed here). “A greater understanding of the processes that are relevant to the condemnation of suicide victims may prove useful for the millions worldwide who are affected by this widespread tragedy”, the researchers concluded.
_________________________________ Rottman J, Kelemen D, and Young L (2014). Tainting the soul: Purity concerns predict moral judgments of suicide. Cognition, 130 (2), 217-26 PMID: 24333538
The number of teenagers deliberately hurting themselves is on the increase. For example, the latest data for England show that over 13,000 15- to 19-year-old girls and 4,000 boys were admitted to hospital for this reason in the 12-month period up to June this year, an increase of 10 per cent compared with the previous 12-month period. More than ever we need to understand why so many young people are resorting to this behaviour.
A common motivation teenagers give is that non-suicidal self-harm provides a way to escape unpleasant thoughts and emotions. Another motive, little explored before now, is that self-harm is a way to deliberately provoke a particular desired feeling or sensation. A new paper from US researchers has explored this aspect of self-harm, known as “automatic positive reinforcement” (APR).
Edward Selby and his colleagues gave 30 teenagers who self-harm (average age 17; 87 per cent were female) a digital device to carry around for two weeks. Twice a day, the device beeped and the teens were asked to record their recent thoughts of self-harm, any episodes of self-harm, their motives, their actual experiences of what it felt like, as well as answering other questions.
Just over half the sample reported engaging in at least one instance of self-harm that was motivated by wanting to experience a particular sensation (and 35 per cent of all self-harm behaviours had this motive). The most common sensation the teenagers sought was “satisfaction” (45 per cent of them), followed by “stimulation” (31 per cent) and “pain” (24 per cent). Those were the hoped for sensations. In fact, pain was experienced more often than it was sought; stimulation was experienced as often as it was sought; and satisfaction was experienced less often than the teenagers wanted.
There were differences between the teenagers who self-harmed in order to produce a particular feeling and those who didn’t have this motive. The former group self-harmed more often during the study (and in the past) and they thought about self-harm more often and for longer. Those seeking a particular feeling from self-harm also engaged in more other risky behaviours including using alcohol, binge eating and impulsive spending. Zooming in on the different sensation motives, those teens seeking pain and stimulation tended to self harm more than those who sought satisfaction.
This study has made an important contribution to an under-researched aspect of self-harm, although it leaves many questions unanswered. For instance, one explanation for the more frequent self-harming observed among those who say they self-harm because they want to experience pain, is that the act triggers pain-relief mechanisms in the brain – a form of euphoria. And yet, self-harming was less frequent among those who said they self-harmed for satisfaction. This potential contradiction could be due to vagueness in the meanings of the words used – is the pursuit of euphoria (via pain) different from the pursuit of satisfaction? Such ambiguities will have to be addressed by future research.
Despite this, and the small sample size, Selby and his team said their novel findings already have clinical implications. “If alternative healthy behaviours can be identified that might induce a similar reinforcing sensation, then those healthy behaviours may be able to be harnessed as a more effective alternative to non-suicidal self-injury (NSSI),” they concluded. “For example if one purpose of NSSI is to derive pain, then exercise might function as an effective alternative as moderate levels of exercise might have a similarly painful or distracting effect that can help cope with upsetting emotions.”
Edward A. Selby, Matthew K. Nock, and Amy Kranzler (2013). How Does Self-Injury Feel? Examining Automatic Positive Reinforcement in Adolescent Self-Injurers with Experience Sampling. Psychiatry Research DOI: 10.1016/j.psychres.2013.12.005
In 2010 more people died by suicide than were killed in war, by murder, or in natural disasters. In Norway, the location of a heart-rending new study of suicide notes left by children and young teens, suicide is the second leading cause of death for this age group. We need urgently to do more to understand why so many young people are taking their own lives.
The researchers Anne Freuchen and Berit Grøholt predicted that, given their immaturity, the young authors of suicide notes would show signs of confusion. Also, because diagnoses of mental illness are lower in children and young teens, the researchers predicted that the notes would show fewer signs of inner pain compared with notes left by older teens and adults.
In all, Freuchen and Grøholt had access to 23 suicide notes left by 18 youths (average age 14; 5 girls) who took their own lives between 1993 and 2004. They also interviewed the children’s parents and referred to police reports. For comparison, the researchers also interviewed the parents of 24 youths who died by suicide during the same period but did not leave a note.
Analysing the notes revealed ten themes, each of which was present in three or more of the notes: they were addressed to someone (most often parents); the author gave reasons for the suicide; they declared their love; expressed a settlement with themselves (e.g. “it’s better for me to be dead”); expressed a settlement with someone else (e.g. “I do this for you, dad”); asked for forgiveness; expressed good wishes (e.g. “good luck in the future”); expressed aggression (e.g. “you bastards”); over half included instructions (e.g. “give Peter Playstation 2”); and just under half expressed inner pain.
Contrary to their predictions, Freuchen and Grøholt said that “the notes are coherent and do not reveal confusion or overwhelming emotions. The children and young adolescents emphasise their consciousness of what they are about to do and they take full responsibility.”
According to the parental interviews, the children and teens who left the notes had not sought help with the issues that led to their suicide. At the same time, they had communicated their thoughts about suicide more often than those who didn’t leave notes. One has to wonder why this did not trigger more effective preventive action. Similarly, three of the notes took the form of school essays, and yet none of them were acted upon by school authorities.
The fact that many of the notes conveyed declarations of love and gave explanations suggests, the researchers said, that the authors were well aware of the implications of their actions. “These children and adolescents somehow retain their dignity,” the researchers said. “They act like decent people do, they bear their pain alone, and even manage to take care of others by leaving detailed instructions with respect to giving away their assets.”
The researchers do not extract many practical lessons from their findings, other than calling for more research into parent-child/teen relationships in the hope of developing preventative strategies. Moreover, they cautioned that it is not possible to generalise or draw conclusions from this small sample. Another methodological limitation is that the suicide notes are from an era that pre-dates the rise of social media (which can be a source of threat, a support, and an outlet), so it’s not clear how relevant insights from this study are for young people today.
_________________________________ Anne Freuchen, and Berit Grøholt (2013). Characteristics of suicide notes of children and young adolescents: An examination of the notes from suicide victims 15 years and younger. Clinical Child Psychology and Psychiatry DOI: 10.1177/1359104513504312
Among the various risk factors for suicide, psychologists have recognised for some time that a person’s occupation plays an important part. Suicide rates have tended to be unusually high in professions that provide ready access to guns, drugs, or open water, such as in farming, medicine, dentistry and maritime careers.
A new analysis has examined whether this still holds true. Stephen Roberts and his colleagues accessed the UK suicide rates for dozens of occupations in 1979 to 1983 and compared these with similar data recorded between 2001 and 2005.
Consistent with the ready access theory, vets, pharmacists, dentists, doctors, and farmers were all among the top 15 occupations with the highest suicide rates back in the late 70s, early 80s. But this had all changed when looking at the more recent data. In the early noughties, none of these professions were in the top 30 occupations in terms of suicide rates. Instead, the occupations with the highest rates of suicide were largely manual, including coal miners, builders, window cleaners, plasterers and refuse collectors.
Stated differently, of 55 high-risk occupations, 14 had shown reductions in suicide rate in the noughties compared with the late seventies, and these were almost exclusively highly educated professional roles like doctors, radiographers and judges, as well as farmers, actors and authors. In contrast, five of the 55 high-risk professions showed an increased rate of suicide in the later data, and these were exclusively manual professions – coal miners, labourers, plasterers, fork-lift drivers and carpenters.
The new findings are published at a time when arguments are raging over the relative prominence that should be given to biological or social explanations of mental illness.
According to this new analysis, socio-economic forces appear to have become an increasingly major factor in occupational suicide risk. The percentage of variation in suicide rates explained by an occupation’s socioeconomic grouping (e.g. managerial, trade, admin etc) almost doubled from 11.4 per cent in the early data to 20.7 per cent in the early noughties. Bear in mind these figures were from before the recession, so if anything it seems likely this trend will have intensified in more recent years.
The data also showed that suicide rates were much higher among men than women, and that among men, the most at-risk occupations tended to be manual, whereas in women they were more often (non-manual) professional.
If the pattern of these results are replicated in other European and Western countries, the researchers said this “could help in developing new suicide prevention interventions that can be targeted at specific occupational groups.”
_________________________________ Roberts, S., Jaremin, B., and Lloyd, K. (2013). High-risk occupations for suicide Psychological Medicine, 43 (06), 1231-1240 DOI: 10.1017/S0033291712002024
The sight of their own blood plays a key role in the comfort that some non-suicidal people find in deliberately cutting themselves. That’s according to a new study by Catherine Glenn and David Klonsky that suggests it is those self-harmers who have more serious psychological problems who are more likely to say the sight of blood is important.
There are plenty of anecdotal reports hinting at the importance of the sight and taste of blood to self-harmers, as well as references in popular music. ‘Yeah you bleed just to know you’re alive,’ sing the Goo Goo dolls in Iris. ‘I think it’s time to bleed I’m gonna cut myself and Watch the blood hit the ground,’ sings Korn on Right Now. However, this is the first systematic investigation on the topic.
Glenn and Klonsky recruited 64 self-harmers from a mass screening of 1,100 new psychology students. With an average age of 19, and 82 per cent being female, the students answered questions about their self-harming and other psychological problems and specifically reported on the importance of the sight of blood.
Just over half the participants said that it was important to see blood when they self-harmed, with the most common explanation being that it helps relieve tension and induces calmness. Other explanations were that it ‘makes me feel real’ and shows that ‘I did it right/deep enough’.
The participants who said blood was important didn’t differ in terms of age and gender from those who said it wasn’t. However, the blood-important group reported cutting themselves far more often (a median of 30 times compared with 4 times) and they were more likely to say they self-harmed as a way of regulating their own emotions. The blood-important group also reported more symptoms consistent with bulimia nervosa and borderline personality disorder.
‘Overall, these results suggest that self-injurers who report it is important to see blood are a more clinically severe group of skin-cutters,’ the researchers said. ‘Therefore, a desire to see blood during non-suicidal self-injury may represent a marker for increased psychopathology.’
Glenn and Klonsky said more research was needed to find out why the sight of blood has the significance it does for some people who self-harm. However, they surmised that the sight of one’s own blood could, after an initial rise in heart-rate, lead to a rebound effect characterised by reduced heart-rate and feelings of calmness. _________________________________
Glenn, C., & Klonsky, E. (2010). The Role of seeing blood in non-suicidal self-injury. Journal of Clinical Psychology DOI: 10.1002/jclp.20661
Some people say cutting their skin brings them relief from emotional pain – an act usually referred to as self-harm. Others enjoy having their body pierced with metal and their skin inscribed with permanent ink. Is there a link between these acts? According to the German psychologists AglajaStirn and Andreas Hinz, in some cases there might well be.
The researchers collaborated with the body modification magazine Taetowiermagazin, recruiting 432 of their readers to complete a comprehensive questionnaire about their tattooing and piercing practices and motives.
One hundred and nineteen of the participants admitted to cutting themselves in childhood. That’s 27 per cent of the sample – a much higher proportion than is found among the general population of Germany: 0.75 per cent.
Compared with the readers who said they had never self-harmed, those who had were more likely to report “bad things” having happened in their lives, and to say they had previously had a bad relationship with their own body.
Moreover, the self-harmers reported that they often had their skin tattooed or body pierced to help overcome a negative experience, or simply to experience physical pain. Another clue that self-harm and piercing/tattooing might, in some cases, be linked, derives from the fact that many of the self-harmers said they had ceased cutting themselves after obtaining their first piercing or tattoo.
Stirn and Hinz concluded that most people who partake in body modification clearly do not do it because they have any psychological problems. “However,” they continued, “because body modifications have become so common and accessible, they are also used with probably increasing frequency as a convenient means to either realise psychopathological inclinations, such as self-injury, or to overcome psychological traumas.” _________________________________
Stirn, A., Hinz, A. (2008). Tattoos, body piercings, and self-injury: Is there a connection? Investigations on a core group of participants practicing body modification. Psychotherapy Research, 18(3), 326-333. DOI: 10.1080/10503300701506938
Only a minority of people who think about committing suicide actually go ahead and make a suicide attempt. Is there something different about these people – some way, perhaps, to identify those suicidal people who are at most risk?
Kate Fairweather and colleagues identified 522 people (aged between 20 and 44) from a massive community survey who said they had thought about taking their own life in the last year. Among these people, just under 10 per cent also reported that they had made an attempt on their life.
The researchers found those individuals who had actually attempted suicide, rather than just thinking about it, were more likely to have serious ill-health, to be unemployed and to have poor relationships with their friends and family. And these factors had a cumulative effect – a participant with two of these factors was three times more likely to have attempted suicide; someone with all three factors was 11 times more likely to have made an attempt.
Surprisingly perhaps, rates of self-reported depression and anxiety were no greater among the suicide attempters than among those who only thought about suicide.
There were also gender- and age-specific associations. For example, among men only, those reporting high levels of ‘mastery’ (feeling in control of the forces affecting their lives) were 20 per cent less likely to attempt suicide. “…[T]he male role prescribes autonomy, self-confidence and being goal-orientated. Accordingly, males who believe they are lacking in these domains may feel socially marginalised or incompetent”, the researchers said.
Among people aged between 40 and 44, unemployment was a particular risk, increasing the likelihood of a suicide attempt nine-fold. Perhaps people in this age group were particularly dependent on their workplace for social support.
“Contrary to the view that mental health differentiates suicide attempters from ideators…”, the researchers concluded, “…This [research] suggests that mental health professionals may be able to intervene in the progression of ideation into attempt if they identify recent instances of upsetting social interactions, diagnosis of a disabling physical illness or recent job losses”. __________________________________
“From the Archives”, first published in the Digest 05.01.04.
Psychologists in America have documented what they believe to be the first report of tattooing used as a form of emotional self-regulation. Michael Anderson (Wright State University, USA) and Randy Sansone (Kettering Medical Centre, USA) reported the case of Mr. B, a 19-yr-old who was hospitalised voluntarily following acute suicidal thoughts. Diagnosed with major depressive disorder, Mr. B explained to the clinicians that he had dealt with his emotional pain in the past through acquiring tattoos. “Physical pain helps to take my mind of it” he said. He had considered cutting himself but “people would see the cuts and it would be pretty embarrassing”. The greater his emotional pain at a given time, the more sensitive the body area he selected for tattooing.
Anderson and Sansone interpreted this behaviour as a form of mood regulation, distracting Mr. B from his intolerably depressive feelings. Physiologically, the pain of the tattoos might have resulted in the release of naturally occurring opioids in the brain and had a therapeutic effect that way. The authors concluded that the question of how often tattooing is used in this way “warrants further investigation”. _________________________________