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This article focuses on repetitive self-injury, not on severe self-injury inflicted during psychosis. For forms of self-injury related to body image, sexuality and wartime, see Body modification, Algolagnia and Self-inflicted wound respectively.
Self-harm
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata

Self-injury (SI), self-harm (SH) or deliberate self-harm (DSH) is deliberate infliction of tissue damage or alteration to oneself without suicide. Although the terms self-injury or self-harm have been used to refer to infliction of harm to the body's surface, the term self-harm may be used to include the harm inflicted on the body by those with eating disorders.[1] Some scholars use more technical definitions related to specific aspects of this behaviour. These acts may be aimed at relieving otherwise unbearable emotions, and/or sensations of unreality and numbness. Self-harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a symptom of borderline personality disorder and depressive disorders. It is sometimes associated with mental illness, a history of trauma and abuse including emotional abuse, sexual abuse, eating disorders, or mental traits such as low self-esteem or perfectionism, but a statistical analysis is difficult, as many self-injurers conceal their injuries.

The relationship between self-harm and suicide is a complex one, as self-harm behaviour may be potentially life-threatening, with or without the intent of suicide.[2] However, attributing self harmers as suicidal is, in the majority of cases, inaccurate.[3][4] Non-fatal self-harm is common in young people worldwide[5] and due to this prevalence the term self-harm is increasingly used to denote any non-fatal acts of deliberate self-harm, irrespective of the intention.[6]

There are a number of different treatments available for self-injurers which concentrate on either treating the underlying causes or on treating the behaviour itself. When self-injury is associated with depression, antidepressant drugs and treatments may be effective.[7] Other approaches involve avoidance techniques, which focus on keeping the self-injurer occupied with other activities, or replacing the act of self-harm with safer methods that do not lead to permanent damage.[8]

Definition

Self-injury (SI), also referred to as self-harm (SH), self-inflicted violence (SIV) or self-injurious behaviour (SIB), refers to a spectrum of behaviours where demonstrable injury is self-inflicted.[9] The term self-mutilation is also sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive.[9] Self-inflicted wounds is a specific term associated with soldiers to describe non-lethal injuries inflicted in order to obtain early dismissal from combat.[10][11] This differs from the common definition of self-injury, as damage is inflicted for a specific secondary purpose. A broader definition of self-injury might also include those who inflict harm on their bodies by means of disordered eating.

A common belief regarding self-injury is that it is an attention-seeking behaviour; however, in most cases, this is inaccurate. Many self-injurers are very self-conscious of their wounds and scars and feel guilty about their behaviour leading them to go to great lengths to conceal their behaviour from others.[12] They may offer alternative explanations for their injuries, or conceal their scars with clothing.[13][14] Self-injury in such individuals is not associated with suicidal or para-suicidal behaviour. A person who self-injures is not usually seeking to end their own life; it has been suggested instead that they are using self-injury as a coping mechanism to relieve emotional pain or discomfort.[3][4] Studies of individuals with developmental disabilities (such as mental retardation) have shown self-injury being dependent on environmental factors such as obtaining attention or escape from demands.[15] Though this is not always the case, some individuals suffer from disassociation and they harbor a desire to feel real and/or to fit in to society's rules. A common form of self-injury involves making cuts in the skin of the arms, legs, abdomen, inner thighs, etc. However, the number of self-injury methods are only limited by an individual's inventiveness and their determination to harm themselves; this includes, but is not limited to compulsive skin picking (dermatillomania), hair pulling (trichotillomania), burning, stabbing, poisoning, alcohol abuse, self-embedding of objects and forms of self harm related to anorexia and bulimia. The locations of self-injury are often areas of the body that are easily hidden and concealed from the detection of others.[16] As well as defining self-harm in terms of the act of damaging one's own body, it may be more accurate to define self-harm in terms of the intent, and the emotional distress that the person is attempting to deal with.[17] Neither the DSM-IV-TR nor the ICD-10 provide diagnostic criteria for self-injury. It is often seen as only a symptom of an underlying disorder,[3] though many people who self-injure would like this to be addressed.[14]

History

Research on this type of behavior began in the 1880's but were not generally differentiated from other behavioral problems.[citation needed] The term "Self-mutilation" occurred in a study by Emerson in 1913[18] where he considered self-cutting a symbolic substitution for masturbation. The term reappeared in an article in 1935 and a book in 1938 when Menninger refined his conceptual definitions of self-mutilation. His study on self-destructiveness differentiated between suicidal behaviors and self-mutilation. For Menninger, self-mutilation was a non-fatal expression of an attenuated death wish and thus coined the term partial suicide. He began a classification system of 6 types:

  • (1) neurotic - nail biters, pickers, extreme hair removal and unnecessary cosmetic surgery.
  • (2) religious - self-flagellants and others.
  • (3) puberty rites - hymen removal, circumcision or clitoral alteration.
  • (4) psychotic - eye or ear removal, genital self-mutilation and extreme amputation
  • (5) organic brain diseases - which allow repetitive head banging, hand biting, finger fracturing or eye removal.
  • (6) conventional - nail clipping, trimming of hair and shaving beards.[19]

Pao (1969) differentiated between delicate (low lethality) and coarse (high lethality) self-mutilators who cut. The 'delicate' cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. The 'coarse' cutters were older and generally psychotic.[20] Ross and McKay (1979) categorized self-mutilators into 9 groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling and hitting and constricting[21]

After the 1970s the paradigm of self-harm shifted from a focus on Freudian psycho-sexual drives of the patients.[22]

Walsh and Rosen (1988) created four categories numbered by Roman Numerals I-IV, defining Self-mutilation as rows II, III and IV[23]

Classification Examples of Behavior Degree of Physical Damage Psychological State Social Acceptability
I Ear piercing, nail biting, small tattoos, cosmetic surgery (not considered self injury by the majority of the population) Superficial to mild Benign Mostly accepted
II Piercings, saber scars, ritualistic clan scarring, sailor and gang tattoos Mild to moderate Benign to agitated Subculture acceptance
III Wrist or body cutting, self-inflicted cigarette burns and tattoos, wound excoriation Mild to moderate Psychic crisis However accepted by some subgroups, it is not accepted by the general population, nor the medical community.
IV Autocastration, self-enucleation, amputation Severe Psychotic decompensation Unacceptable

Favazza and Rosenthal (1993) reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation[24]. Favazza also created two subcategories of sanctioned self-mutilations; rituals and practices. The rituals are mutilations repeated generationally and “reflect the traditions, symbolism, and beliefs of a society” (p. 226). Practices are historically transient and cosmetic such as piercing of earlobes, nose, eyebrows as well as male circumcision (for non-Jews) while Deviant self-mutilation is equivalent to self-injury.[22][25]

Cause

Psychological explanations

A flow diagram of two theories of self-injury.

Attempts to understand self-injury fall broadly into two categories: attempts to interpret motives, or application of psychological models.

Motives for self-injury are often personal, often do not fit into medicalised models of behaviour and may seem incomprehensible to others, as demonstrated by this example:

My motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. This may sound strange.[14]

It's often difficult for people who self harm to talk about their condition. Often when the sufferer does tell somebody there is a lack of understanding or knowledge of how to help.

Assessment of motives in a medical setting is usually based on precursors to the incident, circumstances and information from the patient[3] however the limited studies comparing professional and personal assessments show that these differ with professionals suggesting more manipulative or punitive motives.[26]

The UK ONS study reported only two motives: "to draw attention" and "because of anger".[27] Many people who self-injure state that it allows them to "go away" or dissociate, separating the mind from feelings that are causing anguish. This may be achieved by tricking the mind into believing that the present suffering being felt is caused by the self-injury instead of the issues they were facing previously: the physical pain therefore acts as a distraction from the original emotional pain.[13] To complement this theory, one can consider the need to 'stop' feeling emotional pain and mental agitation. "A person may be hyper-sensitive and overwhelmed; a great many thoughts may be revolving within their mind, and they may either become triggered or could make a decision to stop the overwhelming feelings."[9] The sexual organs may be deliberately hurt as a way to deal with unwanted feelings of sexuality, or as a means of punishing sexual organs that may be perceived as having responded in contravention to the person's wellbeing. (e.g., responses to childhood sexual abuse).[4]

Alternatively, self-injury may be a means of feeling something, even if the sensation is unpleasant and painful. Those who self-injure sometimes describe feelings of emptiness or numbness (anhedonia), and physical pain may be a relief from these feelings. "A person may be detached from himself or herself, detached from life, numb and unfeeling. They may then recognise the need to function more, or have a desire to feel real again, and a decision is made to create sensation and 'wake up'."[28]

It is also important to note that many self-injurers report feeling very little to no pain while self-harming.[29] Those who engage in self-injury face the contradictory reality of harming themselves whilst at the same time obtaining relief from this act. It may even be hard for some to actually initiate cutting, but they often do because they know the relief that will follow. For some self-injurers this relief is primarily psychological whilst for others this feeling of relief comes from the beta endorphins released in the brain.[30] Endorphins are endogenous opioids that are released in response to physical injury, act as natural painkillers, and induce pleasant feelings and would act to reduce tension and emotional distress.[31]

As a coping mechanism, self-injury can become psychologically addictive because, to the self-injurer, it works; it enables him/her to deal with intense stress in the current moment. The patterns sometimes created by it, such as specific time intervals between acts of self-injury, can also create a behavioural pattern that can result in a wanting or craving to fulfill thoughts of self-injury. [32]

Motives

Self-injury is not typically suicidal behaviour, although there is the possibility that a self-inflicted injury may result in life-threatening damage.[33] Although the person may not recognise the connection, self-injury often becomes a response to profound and overwhelming emotional pain that cannot be resolved in a more functional way.[12] The motivations for self-injury vary as it may be used to fulfill a number of different functions.[30] These functions include self-injury being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness and a sense of failure or self-loathing. There is a positive statistical correlation between self-injury and emotional abuse.[27][34] Intense pain can lead to the release of endorphins[30] and so deliberate self-harm may become a means of seeking pleasure, although in many cases self-injury becomes a means to manage pain, in contrast to the pain that may have been experienced through abuse earlier in the sufferer's life over which they had no control.[33] For some people harming oneself can be a way to draw attention to the need for help and to ask for assistance in an indirect way but may also be an attempt to affect others and to manipulate them in some way emotionally.[30][33] However, those with chronic, repetitive self-injury often do not want attention and hide their scars carefully.[35]

Cultural motives

Self-injury is known to have been a regular ritual practice by cultures such as the ancient Maya civilization, in which the Maya priesthood performed auto-sacrifice by cutting and piercing their bodies in order to draw blood. It is also practiced by the sadhu or Hindu ascetic, in Catholic and Jewish mortification of the flesh, in ancient Canaanite mourning rituals as described in the Ras Shamra tablets and in the Shi'ite annual ritual of self flagellation, using chains and swords, that takes place during Ashura where the Shi'ite sect mourne the martyrdom of Imam Hussein.[citation needed]

Risk factors

Although some people who self-injure do not suffer from any forms of recognised mental illness,[13] many people experiencing various forms of mental ill-health do have a higher risk of self-injury. The key areas of illness which exhibit an increased risk include depression,[27][36] phobias,[27] and conduct disorders.[37] Substance abuse is also considered a risk factor[3] as are some personal characteristics such as poor problem solving skills and impulsivity.[3] Emotionally invalidating environments where parents punish children for expressing sadness or hurt can attribute to a lack of trust in oneself and difficulty experiencing intense emotions.[38] Abuse during childhood is accepted as a primary social factor,[29] as is bereavement,[39] and troubled parental or partner relationships.[3][34] Factors such as war, poverty, and unemployment may also contribute.[27][40][41] In addition, some individuals with pervasive developmental disabilities such as autism engage in self-injury, although whether this is a form of self-stimulation or for the purpose of harming oneself is a matter of debate.[42]

Drugs and diet

Many factors influencing compulsive self-injury are related to purine metabolism. A very severe form of self-injury is associated with Lesch-Nyhan syndrome, which results from a genetic flaw in hypoxanthine phosphoribosyltransferase (HPRT), a gene which allows the salvage and recycling of purines in cellular metabolism. Drugs such as pemoline, clonidine, amphetamine, and very high (toxic) doses of caffeine or theophylline can precipitate self-injury in animal models.[43][44] 300 mg daily allopurinol, which inhibits purine degradation, seemed promising in preventing self-injury in two human patients.[45]

These findings relate to self-injury as a primary disorder, and may or may not be applicable to individuals who self-injure in response to other emotional or psychological disturbances.

Treatment

There is considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective and as such further clinical studies are required.[46] Psychiatric and personality disorders are common in individuals who self-harm and as a result self-injury may be an indicator of depression and/or other psychological problems.[7] Many people who self-harm suffer from moderate or severe clinical depression and therefore treatment with antidepressant drugs may often be effective in treating these patients.[7] Cognitive Behavioural Therapy may also be used (where the resources are available) to assist those with axis 1 diagnoses, such as depression, schizophrenia, and bipolar disorder. Dialectical behavioural therapy (DBT) can be very successful for those individuals exhibiting a personality disorder, and could potentially be used for those with other mental illnesses who exhibit self-injurious behaviour. Diagnosis and treatment of the causes of self-harm is thought by many to be the best approach to treating self-injury.[4] But in some cases, particularly in clients with a personality disorder, this is not very effective, so more clinicians are starting to take a DBT approach in order to reduce the behaviour itself. People who rely on habitual self-injury are sometimes psychiatrically hospitalised, based on their stability, and their ability and especially their willingness to get help.[47]

In individuals with developmental disabilities, occurrence of self-injury is often demonstrated to be related to its effects on the environment, such as obtaining attention or desired materials or escaping demands. As developmentally disabled individuals often have communication or social deficits, self-injury may be their way of obtaining these things which they are otherwise unable to obtain in a socially appropriate way (such as by asking). One approach for treating self-injury thus is to teach an alternative, appropriate response which obtains the same result as the self-injury.[48][49][50]

Avoidance techniques

Generating alternative behaviours that the sufferer can engage in instead of self-injury, and shaping the use of such behaviours, is one successful behavioural method that is employed to avoid self-harm.[51] Techniques, aimed at keeping busy, may include journaling, taking a walk, participating in sports or exercise or being around friends when the sufferer has the urge to harm themselves.[8] The removal of objects used for self-injury from easy reach is also helpful for resisting self-injurious urges.[8] The provision of a card that allows sufferers to make emergency contact with counselling services should the urge to self-harm arise may also help prevent the act of self-injury.[46] Alternative and safer methods of self-harm that do not lead to permanent damage, for example the snapping of a rubber band on the wrist, may also help calm the urge to self-harm.[8] Using biofeedback may help raise self-awareness in the suffer of certain pre-occupations or particular mental state or mood that precede bouts of self-harming behavior.[52], and help the sufferer identify techniques to avoid those pre-occupations before they lead to self harm.

Self-injury awareness

There are many movements among the general self-injury community to make self-injury itself and treatment better known to mental health professionals as well as the general public. For example, Self-injury Awareness Day (SIAD) is set for March 1 of every year, where on this day, some people choose to be more open about their own self-injury, and awareness organisations make special efforts to raise awareness about self-injury. Some people wear an orange awareness ribbon or wristband to encourage awareness of self-harm. [53]

Epidemiology

Accurate statistics on self-injury are hard to come by since most self-injurers conceal their injuries. Recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys.[6] About 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses.[39] However, studies based only on hospital admissions may hide the larger group of self-injurers who do not need or seek hospital treatment for their injuries,[3] instead treating themselves. Many adolescents who present to general hospitals with deliberate self-harm report previous episodes for which they did not receive medical attention.[6] Current research on self-harm suggests that the rates are much higher among young people [12] with the average age of onset around 12 years old.[3] The earliest reported incidents of self-harm are in children between five and seven years old.[12]

In a study of undergraduate students in the United States, 9.8% of the students surveyed indicated that they had purposefully cut or burned themselves on at least one occasion in the past. When the definition of self-injury was expanded to include head-banging, scratching oneself, and hitting oneself along with cutting and burning, 32% of the sample said they had done this. In other words, while this problem is often associated with severely disturbed psychiatric patients, it is fairly common among young adults.[54]

Gender differences

The best available evidence to date indicates that four times as many females than males have direct experience of self-harm.[3] Caution is however needed in seeing self-harm as a greater problem for females, since males may well engage in different forms of self-harm which may be easier to hide or explained as the result of different circumstances.[12] The WHO/EURO Multicentre Study of Suicide, established in 1989 demonstrated that, for each age group, the female rate of self-injury exceeded that of the males, with the highest rate among females in the 13–24 age group and the highest rate among males in the 12–34 age group. However, this discrepancy has been known to vary significantly depending upon population and methodological criteria, consistent with wide-ranging uncertainties in gathering and interpreting data regarding rates of self-harm in general.[55] Such problems have sometimes been the focus of criticism in the context of broader psychosocial interpretation. For example, feminist author Barbara Brickman has speculated that reported gender differences in rates of self-harm are due to deliberate socially biased methodological and sampling errors, directly blaming medical discourse for pathologising the female.[56]

This gender discrepancy is often distorted in specific populations where rates of self-injury are inordinately high, which may have implications on the significance and interpretation of psychosocial factors other than gender. A study in 2003 found an extremely high prevalence of self-injury among 428 homeless and runaway youth (age 16 to 19) with 72% of males and 66% of females reporting a past history of self-mutilation.[57]

There does not appear to be a difference in motivation for self-harm in adolescent males and females. For example, for both genders there is an incremental increase in deliberate self-harm associated with an increase in consumption of cigarettes, drugs and alcohol. Triggering factors such as low self-esteem and having friends and family members who self-harm are also common between both males and females.[6] One limited study found that, among those young individuals who do self-harm, both genders are just as equally likely to use the method of skin-cutting.[58] However, females who self-cut are more likely than males to explain their self-harm episode by saying that they had wanted to punish themselves. In New Zealand, more females are hospitalised for intentional self-harm than males. Females more commonly choose methods such as self-poisoning that generally are not fatal, but still serious enough to require hospitalisation.[59]

In the elderly

In a study of a district general hospital in the UK, 5.4% of all the hospital's self-harm cases were aged over 65. The male to female ratio was 2:3 although the self-harm rates for males and females over 65 in the local population were identical. Over 90% had depressive conditions, and 63% had significant physical illness. Under 10% of the patients gave a history of earlier self-harm, while both the repetition and suicide rates were very low, which could be explained due to the absence of factors known to be associated with repetition, such as personality disorder and alcohol abuse.[60]

In the Developing world

Only recently have attempts to improve health in the developing world concentrated on not only physical illness, but mental health also.[61] Deliberate self-harm is common in the developing world. Research into self harm in the developing world is however still very limited although an important case study is that of Sri-Lanka, which is a country exhibiting a high incidence of suicide[62] and self poisoning with agricultural pesticides or natural poisons.[61] Many people admitted for deliberate self-poisoning during a study by Eddleston et al.[61] were young and few expressed a desire to die, but death was relatively common in the young in these cases. The improvement of medical management of acute poisoning in the developing world is poor and improvements are required in order to reduce mortality.

Some of the causes of deliberate self-poisoning in Sri Lankan adolescents included bereavement and harsh discipline by parents. The coping mechanisms are being spread in local communities as people are surrounded by others who have previously deliberately harmed themselves or attempted suicide.[61] One way of reducing self-harm would be to limit access to poisons;[63] however many cases involve pesticides or yellow oleander seeds, and the reduction of access to these agents would be difficult. Great potential for the reduction of self-harm lies in education and prevention, but limited resources in the developing world make these methods challenging.

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Further reading

  • Bogdashina, O. (2003), Sensory Perceptual Issues in Autism and Asperger Syndrome, Different Sensory Experiences, Different Perceptual Worlds., Jessica Kingsley, ISBN 978-1-84310-166-6
  • Farber, S. (2002), When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments, Jason Aronson Inc, ISBN 978-0-76570-371-2
  • Favazza, A.R (1996), Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry., Johns Hopkins University Press, ISBN 978-0-80185-300-5
  • Griffin, J. & Tyrrell, I. (2000), The Shackled Brain: How to release locked in patterns of psychological trauma., Organising Idea Monograph: 5, European Therapy Studies Institute, ISBN 1-899398-11-2{{citation}}: CS1 maint: multiple names: authors list (link)
  • Hawton, K. and Rodham, K. (2006), By Their Own Young Hand: Deliberate Self-harm and Suicidal Ideas in Adolescents, Jessica Kingsley, ISBN 978-1-84310-230-4{{citation}}: CS1 maint: multiple names: authors list (link)
  • Kaminski, M.M. (2004), Games Prisoners Play., Princeton University Press, ISBN 0-691-11721-7
  • Kern, J. (2007), Scars That Wound: Scars That Heal, Standard Publishing, ISBN 978-0-7847-2104-9
  • Levenkron, S. (1998), Cutting: Understanding and Overcoming Self-Mutilation, W. W. Norton and Company., ISBN 978-0-39302-741-9
  • McVey-Noble, M.; Khemlani-Patel, S.;Neziroglu, F (2006). When Your Child is Cutting: A Parent's Guide to Helping Children Overcome Self Injury. California: New Harbinger. ISBN 978-1572244375.{{cite book}}: CS1 maint: multiple names: authors list (link)
  • Miller, D. (1994), Women Who Hurt Themselves., Basic Books, ISBN 978-0-46509-219-2
  • Plante, L. G. (2007), Bleeding to Ease the Pain: cutting. self-injury, and the adolescent search for self., Praeger Publishers, ISBN 978-0-27599-062-6
  • Smith, C. (2006), Cutting it Out: a journey through psychotherapy and self-harm., Jessica Kingsley Publishers, ISBN 978-1-84310-266-3
  • Whittenhall, E. (2006), Cutting: Self-Injury and Emotional Pain, InterVarsity Press, ISBN 978-0-83084-990-1
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