Author: errinn

Psychological Impact of Infertility

This week, April 24-30, 2022, is recognized as National Infertility Awareness Week.

How common is infertility?

About 9% of men and about 11% of women of reproductive age in the United States have experienced fertility problems.1

  • In one-third of infertile couples, the problem is with the man.
  • In one-third of infertile couples, the problem can’t be identified or is with both the man and woman.
  • In one-third of infertile couples, the problem is with the woman.

To show your support for those dealing with infertility, you can wear orange. Why orange?

The color orange promotes a sense of wellness, emotional energy to be shared: compassion, passion, and warmth. Helps to recover from disappointments, a wounded heart, or a blow to one’s pride. Studies show that orange can create a heightened sense of activity, increased socialization, boost in aspiration, contentment, assurance, confidence and understanding.

What is the psychological impact of infertility?

Couples and individuals who struggle with infertility are likely to encounter many ups and downs while navigating their fertility journey. Common reactions to this process include: sadness, anger, frustration, anxiety, difficulty sleeping, changes in appetite, irritability, changes in primary relationship, loss of interest in sex, change of attitude towards sex, and feeling overwhelmed. Psychological symptoms associated with infertility are similar to those associated with other serious medical conditions. Comparative Study 

What psychological treatments are available?

Cognitive Behavioral Therapy (CBT) that includes relaxation training, restructuring, and eliminating of negative automatic thoughts and dysfunctional attitudes to depression has been shown to be effective at reducing depression in women experiencing infertility, and was superior to treatment with medication. CBT has been shown to improve the social concerns, sexual concerns, marital concerns, rejection of child-free lifestyle, and need for parenthood in women experiencing infertility more than medication alone. Thus, CBT is not only a reliable alternative to medication, but also superior to medication in resolving and reducing stress related to infertility. The positive benefits of psychotherapy and CBT in particular for treatment of psychological distress associated with infertility has been demonstrated in multiple studies. Although most of the studies focus on women, CBT is likely a good approach for men experiencing fertility challenges as well.

Treatment of depression and anxiety in infertile women: cognitive behavioral therapy versus fluoxetine

Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women? A randomized clinical trial

The effect of the cognitive behavioral therapy and pharmacotherapy on infertility stress: a randomized controlled trial

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What is Telepsychology

The pandemic has accelerated technological innovation in mental health treatment, and telehealth is one of the areas of exponential growth.

In my practice, I specialize in providing services via telehealth, also known as telepsychology. What does that mean? I screen clients before starting therapy to determine if telehealth is an appropriate modality for the type of help the client is seeking. In my opinion, telehealth is not appropriate for all psychological services and individual needs must be taken into consideration. Clients that may benefit most from telehealth services are individuals who are experiencing mild-to-moderate anxiety and depression, significant life changes, difficulty finding transportation to a traditional office, or individuals who need more flexibility. Because telehealth is conducted via the internet, a client can complete a session from wherever they are most comfortable. Once a client has been deemed appropriate for telepsychology, I send them introductory paperwork and a link for the therapy session. All sessions take place via HIPAA-compliant videoconferencing platform (all information is protected and confidential). The important part of telehealth is finding a quiet private space for the session. I see several individuals who are parked in their car on a break from work or prior to starting work.  The flexibility of not having to drive to an office helps people fit therapy into their lives, and I am strong proponent of therapy for all!

Does it work?

Ashley Batastini, PhD, an assistant professor in the Department of Counseling, Educational Psychology and Research at the University of Memphis and her colleagues recently published a large meta-analytic study (a study that takes statistics from several other studies and combines them to see the overall picture) that compared clinical interventions and assessments delivered via videoconferencing with those delivered in-person. Overall, they found that in-person and virtual interventions produced similar outcomes. Likewise, assessments produced similar opinions across modalities, she says.

The result was not a surprise, as their conclusions were in line with the existing literature on telepsychology, including a 2016 meta-analysis that focused on correctional and forensic telepsychology. Batastini and her colleagues did uncover one interesting surprise in the new study: Women appear to have better outcomes following virtual interventions than in-person interventions, something that merits further research.

Can I see any psychologist at any time?

At the moment, most psychologist are limited to seeing only patients who reside in the state where they are licensed. For my practice, this means I am limited to providing services to those who reside in the state of California. However, PSYPACT is an interstate compact that allows the practice of telepsychology across state boundaries with residents of states that have joined. Licensed Clinical Psychologists in the participating states have to apply to get permission from the PSYPACT Commission to be able to provide telepsychology services to residents in the states that have joined PSYPACT. The states that are part of PSYPACT are: Alabama, Arizona, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky,  Maine, Maryland, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Utah, Virginia, West Virginia

Resources:

Psychology Interjurisdictional Compact (PSYPACT) (site-ym.com)

Online therapy is here to stay (apa.org)

References:

Batastini, A. B., Paprzycki, P., *Jones, A. C. T., & MacLean, N. (2021). Are videoconferenced mental and behavioral health services just as good as in-person? A Meta-analysis of a fast-growing practice. Clinical Psychology Review, 83. doi: 10.1016/j.cpr.2020.101944

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Mental Health and Man’s Best Friend

Mental Health and Man’s Best Friend

Stroking a soft Yorkshire Terrier, cuddling a stubby Corgi, or even watching a YouTube video of silly Golden Retrievers, you notice a positive shift in your mood and attitude. It couldn’t be the dog affecting you, could it?

Scientist have used DNA evidence to discover that our modern-day domesticated dogs are descents of the gray wolf. Dogs are the first animal that humans domesticated, and there are a few competing theories about how this happened. Some scientists believe that humans may have begun taking in wolf pups and over time bred tamer and tamer wolves. Other scientist believe that only the tamest wolves were likely to rummage through human trash, and through natural selection they evolved into domestic dogs. However wolves became domesticated, in modern times, we are able to find virtually any type of dog to suit our unique needs. Do you have allergies? There is a hypoallergenic breed for you. Do you live in a small apartment? There is a small dog that may be just the right fit for you. Do you like to go hunting? There is a dog that can assist. Dogs perform hundreds of jobs, but an area that dogs increasingly occupy is the category of emotional support animal. What does this mean? Is it all just an excuse to take your pet into places they are typically not allowed?

An emotional support animal is an animal that a medical professional has determined provides a benefit to an individual with a disability. An individual with an emotional support animal must have a diagnosed disability, physical, intellectual, or psychiatric. This has become especially popular in recent years, as there are federal protections for individuals with disabilities, including housing protections. The Federal Fair Housing Amendments Act of 1988 states that landlords cannot discriminate against individuals with disabilities in housing if the landlord is able to provide reasonable accommodations. In many urban areas, reasonable accommodations for individuals with an emotional support animal has come to mean a waiver of the no pets policy for the emotional support animal. A tenant wishing to obtain a waiver of a “no pets” policy for an emotional support animal may meet this burden by providing a letter from his or her physician or mental health professional: stating that the tenant has a mental disability, explaining that the animal is needed to lessen the effects of the disability, and requesting that the animal be allowed in the rental unit as a reasonable accommodation for the mental disability. Landlords are entitled to ask for supporting materials which document the need for an emotional support animal. The Americans with Disabilities Act of 1990 (ADA) allows people with disabilities to bring their service animals in public places. However, the ADA only extends these protections to dogs that have been “individually trained” to “perform tasks for the benefit of an individual with a disability.” Since emotional support animals are typically not trained for an individual’s specific disability and since emotional support animals might not be dogs, they do not receive the protections of the ADA. A public place can therefore deny an emotional support animal admission.

Although humans first domesticated dogs millennia ago, only within the last few decades have we begun to scientifically study the nature of the human-canine bond. When an individual interacts with a friendly dog, his or her blood pressure lowers, heart rate slows, breathing regulates, and muscle tension reduces. These effects are felt after only a few minutes of interaction, versus up to an hour or more for pharmacological intervention. Dogs can also help with longevity. For example, in a study of individuals who were released from the hospital after a heart attack, the individuals who had a pet at home had a significantly higher survival rate than those with no pet. Dogs may also help with anxiety and depression. One of the primary causes of depression is loneliness. This is especially true for older individuals in our modern society. In a study of individuals 60 years and older living alone, those who had a pet were four times less likely to be clinically depressed and reported feeling more satisfied with their lives.

But what about individuals without significant health problems? Great news! Everyday people (individuals without significant health problems or psychiatric diagnosis) who own pets have been shown to have higher self-esteem, be more physically fit, less lonely, more conscientious, more extraverted, less fearful, and less preoccupied, when compared to everyday people who did not own pets.

Brennan, Jacquie (2014). “Service Animals and Emotional Support Animals”. ADA National Network. Retrieved 19 December 2017.

Brewer, Kate A. (2005). “Emotional Support Animals Excepted From “No Pets” Lease Provisions Under Federal Law”. The Animal Legal & Historical Center. Michigan State University College of Law. Retrieved February 28, 2014.

Coren, S. (2009, June 07). Health and Psychological Benefits of Bonding with a Pet Dog. Retrieved February 16, 2018, from https://www.psychologytoday.com/blog/canine-corner/200906/health-and-psychological-benefits-bonding-pet-dog

Mcconnell, A. R., Brown, C. M., Shoda, T. M., Martin, C. M., & Stayton, L. E. (n.d.). Friends with benefits: On the positive consequences of pet ownership. PsycEXTRA Dataset, 101(6). doi:10.1037/e683152011-002

McGrath, J. (2008, April 14). How Animal Domestication Works. Retrieved February 15, 2018, from https://animals.howstuffworks.com/animal-facts/animal-domestication3.htm

U.S. Department of Housing and Urban Development (2013). “Service Animals and Assistance Animals for People with Disabilities in Housing and HUD-Funded Programs” (PDF). Retrieved March 21, 2014.

Wisch, Rebecca (2015). “FAQs on Emotional Support Animals”. The Animal Legal & Historical Center. Michigan State University College of Law. Retrieved March 23, 2016.

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Schizophrenia and Cats

Watching a fluffy kitten saunter by or an adult cat stretch out in the sun, and it is hard to resist the urge to reach out and stroke him. Softly stroking a feline triggers the release of oxytocin, the “love” chemical, and may be one of the big reasons we feel so drawn toward cats. Humans and felines have enjoyed each other’s company for centuries. Archeological evidence suggests that feline domestication dates back over 12,000 years to early civilizations in the Fertile Crescent. It is believed that cats became domesticated after the establishment of agrarian societies and the need for secure grain stores. The grain attracted mice, and cats were happy to help out. The cats were delighted by the abundance of prey in the storehouses; people were delighted by the pest control. In the United States, cats are the most popular house pet, with 90 million domesticated cats slinking around 34 percent of U.S. homes.

Cats may produce many benefits for humans, including lower incidents of cardiovascular problems, but they also increase the risk of miscarriage and schizophrenia. The reason cats increase the risk of miscarriage and schizophrenia is because the feces of cats contain toxoplasma gondii. T. gondii is an intracellular parasite that is known to selectively infect muscle and brain tissue in humans. Schizophrenia typically does not manifest until late adolescents or early adulthood, but the disease process has its origin in earlier brain development. Toxoplasma can cause long-term infections and increases retroviral activation. In some cases, schizophrenia may have a connection to toxoplasmosis, studies indicate that individuals with schizophrenia have higher prevalence of antibodies to T. gondii, some adults with acute toxoplasmosis have developed psychotic symptoms similar to schizophrenia, antipsychotic drugs are known to inhibit T. gondii, toxoplasma has been shown to elevate dopamine levels in animals (elevated dopamine is common in individuals with schizophrenia), individuals with schizophrenia may have greater exposure to cats in childhood. However, some studies have failed to find the connection between T. gondii and schizophrenia.

How can the risk of transmission of toxoplasma from a cat to its owner be reduced?

Although the risk of transmission of infection from a cat to its owner is very low, this can be reduced further and/or its consequences minimized by adopting the following recommendations:

  1. People in ‘high risk’ groups should not have contact with the cat’s litter tray. Where possible, only non-pregnant and immunocompetent people (i.e. not those people with diseases or drug therapy suppressing their immune system) should handle cat litter trays (following all of the guidelines below).
  2. Empty litter trays daily so that oocysts do not have sufficient time to sporulate (become infective) whilst in the litter tray.
  3. Wear gloves when handling cat litter and wash hands thoroughly after cleaning the litter tray.
  4. Use litter tray liners if possible and periodically clean the litter tray with detergent and scalding water (which kills oocysts) eg fill the litter tray with boiling water and leave for 5 – 10 minutes before emptying.
  5. Dispose of cat litter safely. For example, seal it in a plastic bag before putting it with other household waste.
  6. Cover children’s sandpits when not in use to prevent cats using them as litter trays.
  7. Feed only properly cooked food or commercial cat food to your cat to avoid infection.
  8. Washing hands after contact with a cat (especially before eating) is a sensible hygiene precaution.
  9. If very concerned, ask your vet to check your cat’s Toxoplasma titre (antibody test for exposure to T gondii):
    a. Cats with a positive titre have been infected in the past and will not be a source of infection in the future as they have completed their period of oocyst shedding.
    b. Cats with a negative titre have not been infected with T gondii in the past and are likely to shed oocysts in their faeces for a short time if they become infected in the future. The risk of acquiring infection can be minimised by:

    • Avoiding feeding raw meat to the cat to reduce the risk of T gondii infection (see point 7 above).
    • Keeping the cat indoors to prevent hunting and access to intermediate hosts such as voles and mice

Amodeo, J. (2015, July 06). If You Love Cats, This May be Why. Retrieved January 16, 2018, from https://www.psychologytoday.com/blog/intimacy-path-toward-spirituality/201507/if-you-love-cats-may-be-why

Avoiding Childhood Exposure to Cats with the the T. Gondi parasite may reduce schizophrenia risk. (n.d.). Retrieved January 16, 2018, from http://www.schizophrenia.com/prevention/cats.html

Torrey, E. F., & Yolken, R. H. (2003, November). Toxoplasma gondii and Schizophrenia. Retrieved January 16, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035534/

Yolken, R. H., Dickerson, F. B., & Fuller, E. (2009, November). Toxoplasma and schizophrenia. Retrieved January 16, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/19825110

Zax, D. (2007, June 30). A Brief History of House Cats. Retrieved January 16, 2018, from https://www.smithsonianmag.com/history/a-brief-history-of-house-cats-158390681/

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Schizophrenia

“F*** you! Leave me alone!” Her wild hair, awkward posture, and anger at something or someone I could not see, made me suspect she was in the middle of a psychotic episode, possibly as part of the illness schizophrenia. I saw this middle aged woman sitting at a bus stop alone, as I was walking my dogs. This is not the first time I have seen a person in the middle of what seems like a psychotic episode, yelling at things or people I cannot see. Sometimes the person will be talking quietly to him or herself, other times they may be staring into space laughing. Psychosis can have a variety of causes, including intoxication on street drugs, physical illnesses such as neurological disorders or kidney disease, overmedication on certain prescription drugs, sleep deprivation, or a mental illness. Doctors have developed treatments for several organic causes of psychosis, but individuals who are diagnosed with schizophrenia still find themselves with few treatment options that are effective at total symptom elimination.

Schizophrenia is a mental illness that is characterized by the presence of positive, negative, and cognitive symptoms. Positive symptoms are named as such because they include things that have been added to the individual’s experience of the world, hallucinations, delusions, disorder thinking (racing and/or disorganized thoughts), and movement disorders (agitated movements). Negative symptoms are named as such because they are things that have been taken from the individual as a part of the illness, social withdrawal, flat affect, difficulty initiating and maintaining tasks, difficulty speaking, and reduced feelings of pleasure in everyday life. Cognitive symptoms affect an individual’s ability to process information, including; reduced ability to use information to make appropriate decisions (executive functioning), trouble concentrating and/or paying attention, and problems with working memory (ability to manipulate information just received).

Current treatments for schizophrenia most often combine medication with some form of psychosocial treatment. This combination has been shown to be effective at reducing positive symptoms, alleviating the effects of negative and cognitive symptoms, and reducing hospitalizations. The class of drugs most often prescribed to individuals with schizophrenia are antipsychotics. However, the majority of individuals with chronic schizophrenia discontinue medication. These drugs work by effecting the neurotransmitter dopamine, which is believed to cause many positive symptoms of schizophrenia. Antipsychotics work by blocking the effects of dopamine at the D2 receptor site, and atypical antipsychotics (newer drugs developed to treat schizophrenia) also work on the neurotransmitter serotonin. Antipsychotic medications carry the risk of tardive dyskinesia, a movement disorder characterized by involuntary, repetitive movements (such as grimacing or eye blinking).  First generation antipsychotics (older medications) have a higher risk of side effects than newer atypical antipsychotics. However, all medications have some risk of side effects, and most individuals discontinue medication prematurely.

What if a cause of schizophrenia could be found? If the root of the disease could be revealed, we may be able to develop targeted treatments that can cure and/or prevent schizophrenia. Research has been delving into causes of schizophrenia and in future posts I will examine the latest knowledge and theories on the cause.

***If you are currently taking antipsychotic medication, DO NOT abruptly stop taking your medication. This can result in withdrawal symptoms and a return of psychotic symptoms. Speak with your physician.

Cloud LJ, Zutshi D, Factor SA. Tardive dyskinesia: therapeutic options for an increasingly common disorder. Neurotherapeutics. 2014;11(1):166-176.

Jeffrey A. Lieberman, M.D., T. Scott Stroup, M.D., M.P.H., Joseph P. McEvoy, M.D., Marvin S. Swartz, M.D., Robert A. Rosenheck, M.D., Diana O. Perkins, M.D., M.P.H., Richard S.E. Keefe, Ph.D., Sonia M. Davis, Dr.P.H., Clarence E. Davis, Ph.D., Barry D. Lebowitz, Ph.D., Joanne Severe, M.S., and John K. Hsiao, M.D., for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators*   (2005). Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. New England Journal of Medicine, 53:1209-1223. September 22, 2005DOI: 10.1056/NEJMoa051688

Tardive Dyskinesia. Retrieved from https://medlineplus.gov/ency/article/000685.htm

(2013). Treating and Managing Tardive Symptoms Retrieved July 18, 2017, from https://www.aan.com/Guidelines/Home/GetGuidelineContent/614

Discontinuing Psychiatric Medications: What You Need to Know

https://psychcentral.com/lib/discontinuing-psychiatric-medications-what-you-need-to-know/

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Protecting Transgender Adult Psychiatric Patients

Most transgender individuals will find themselves interacting with the mental healthcare system at some point in their lives. However, many psychiatric hospitals and general healthcare facilities do not have clear written policies to address the unique needs of transgender patients. This is extremely problematic because it can lead to discriminatory practices, inadequate care, trauma, and/or aversion to seeking needed healthcare services in the future.

The most common DSM-V diagnosis given to transgender individuals is gender dysphoria. The criteria for this diagnosis is:

In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:

  1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
  2. A strong desire to be rid of one’s primary and/or secondary sex characteristics
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender
  4. A strong desire to be of the other gender
  5. A strong desire to be treated as the other gender
  6. A strong conviction that one has the typical feelings and reactions of the other gender

However, it is possible for transgender individuals to have a concurrent psychiatric diagnosis, and in fact, it is quite common. Many transgender individuals to experience anxiety, depression, and substance abuse. This may have a large connection to societal attitudes towards gender and discrimination transgender individuals often face. Transgender individuals face discrimination in employment, housing, and healthcare. Many transgender individuals contemplate suicide and 41 percent of transgender individuals make a suicide attempt. Therefore, it is highly likely that a transgender person will become a patient in a psychiatric hospital in his or her lifetime.  It is critical that psychiatric hospitals, both public and private, have clear policies to guarantee that transgender patients are treated with dignity, respect, and appropriate care. However, most psychiatric hospitals do not have written policies to address transgender patients.

How can psychiatric hospitals protect transgender patients?

Congress passed the Prison Rape Elimination Act (PREA) in 2003 and published standards in June 2009 that outline how transgender individuals within the justice system should be treated to safeguard from sexual violence, both from becoming a victim or perpetrator.  Psychiatric hospitals are very similar to prisons; individuals are denied free access to the outside, often are segregated based upon gender, and must conform to authority. Therefore, the standards issued in the PREA are a great place to start when creating a written policy to addressing the needs of transgender psychiatric patients.

The specific parts of the policy that psychiatric hospitals should focus upon are screening and classification, and housing. The PREA states: Facilities must screen all individuals at admission and upon transfer to assess their risk of experiencing or perpetrating abuse, including identifying those who may be at risk because of their transgender status, gender nonconformity, sexual orientation, or intersex condition. The individual’s own perception of their vulnerability must also be considered.

Individuals may not be disciplined for any refusal or nondisclosure during screening regarding gender identity, sexual orientation, intersex condition, disability status, or prior sexual victimization.

Facilities must use this information to make appropriate, individualized decisions about an individual’s security classification and housing placement.

Housing transgender people

Decisions about where a transgender person, or a person with an intersex condition, is housed must be made on a case-by-case basis; they cannot be made solely on the basis of a person’s anatomy or gender assigned at birth. This means that, for example, every transgender woman must be assessed individually to determine whether she would be best housed with other women instead of in a men’s facility. An individual’s views regarding their personal safety must be seriously considered.

These decisions must be reassessed at least twice per year to consider changed circumstances such as incidents of abuse or changes in an individual’s appearance or medical treatment.

All transgender people and people with intersex conditions must be given the opportunity to shower separately from other inmates if they wish, regardless of where they are housed.

Hospitals may access resources from the National Institute of Corrections to create a written policy for their specific patient population. https://static.nicic.gov/Library/026702.pdf

It is critical that mental health practitioners and healthcare facilities create an environment of acceptance, compassion, dignity, and respect to ensure that transgender individuals receive the care they need. Creating a written policy will assist in this mission and hopefully foster an atmosphere of trust between the transgender community and the healthcare community.

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My approach to therapy

As human beings we have learned the pain is bad and pleasure is good, but we run into
difficulties when we apply these principles universally to our life. For example, we must occasionally experience pain or annoyance to accomplish things, sitting at the DMV or changing a diaper. Often
people run into problems in their life because they are unwilling to experience temporary discomfort or
pain. Acceptance and Commitment Therapy (ACT) teaches clients that their emotions are normal
reactions to the environment, and that they choose how to react to their emotions.

I worked with a female client with Obsessive-Compulsive Disorder who feared contamination by
germs and dirt, resulting in cleaning rituals of 8 or more hours per day. Through the course of therapy,
she was able to acknowledge that her fears were preventing her from living according to her values and
kept her stuck in a cycle of thought removed from the present moment. I created a strong therapeutic
alliance with this client by asserting my commitment to her and her treatment, making it known that I
would not ask her to do anything I was not myself willing to do. During one of our first sessions, I proved
this commitment by licking the door knob to my office. In order to live, you must be willing to face the
possibility of sickness. As we completed exposure exercises, she began to get more comfortable sitting
with her uncomfortable feelings, and eventually was able to live closer to her values.

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My Dissertation

THE EMOTION REGULATION EFFECT OF EXPERIMENTALLY INDUCED PAIN ON INDIVIDUALS WITH A HISTORY OF NON-SUICIDAL SELF-INJURY

Abstract

 

Individuals who engage in nonsuicidal self-injury (NSSI) are at high risk for suicide, hospitalization, and many other serious life problems. Two studies have demonstrated that physical pain leads to a reduction in negative emotion, and two studies suggest that high levels of self-criticism and self-punishment may explain why physical pain helps these individuals regulate their emotions. This study examined the distraction hypothesis of NSSI, which states that NSSI functions to distract from negative thoughts about the self, and the self-punishment theory, which states that NSSI functions to confirm negative self-concepts. Participants were adult members of the community (N = 24) who reported engaging in NSSI at least twice in their lifetime, with the most recent NSSI occurring in the past year, and reported having a current treatment provider. Participants experienced two counter-balanced experimental procedures, the cold pressor pain induction task and a cognitive-tactile distraction task, each proceeded by a mood induction procedure. There were no statistically significant interactions between condition and time for shame, guilt, anxiety, and urges to punish the self, which suggests that pain may not uniquely contribute to the emotion regulation effect of NSSI beyond its distracting properties. The statistically insignificant interaction effects in this study do not support the hypothesis that confirmation of self-punishing beliefs leads to emotion relief, even though self-punishing beliefs may contribute to NSSI in other ways.

Keywords: non-suicidal self-injury, heart rate variability, shame, self-punishment

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