Self-harm

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Self-harm (SH) or Self-injury (SI) is deliberate injury inflicted by a person upon his or her own body. Some scholars use more technical definitions related to specific aspects of behavior. This injury may be aimed at relieving otherwise unbearable emotions, sensations of unreality and numbness, or for other reasons. Self-harm is generally a social taboo. It is listed in the DSM-IV-TR as a symptom of Borderline Personality Disorder and is sometimes associated with mental illness, with a history of trauma and abuse, with eating disorders, or with mental traits such as perfectionism. There is a positive statistical correlation between self-harm and emotional abuse.[1] [2]

Note that this article focuses on repetitive self-harm, not severe self-harm inflicted during psychosis, such as eye enucleation and amputation.

Definition

Self-harm has traditionally been known as self-injury (SI), self-inflicted violence (SIV), self-injurious behavior (SIB), and self-mutilation[3], although this last term has connotations that some people find worrisome, inaccurate, or offensive. However, a broader definition can also include the phenomenon of those who inflict harm on their bodies by means of disordered eating, or compulsive tattooing or body piercing. When discussing self-harm with someone who engages in it, it is suggested to use the same terms and words which that person uses, e.g. "cutting".[4] Self-harm is usually dissociated from an attempt at suicide; the person who self-harms is not usually seeking to end his or her own life, but is instead hoping to cope with or relieve unbearable emotional pressure or some kind of discomfort.[5]

A common form of self-injury involves making shallow cuts to the skin of the arms or legs, and this is casually referred to as "cutting"; a person who routinely does this may be colloquially referred to as "a cutter". Localized multiple cuts, especially those similar in appearance, are sometimes characteristic of cutting, but are not reliable indicators of self-harm. Less frequently, this behaviour may involve cutting other parts of the body, including the breasts and sexual organs. Other examples include:

  • Punching, hitting and scratching
  • Self-biting: hands, limbs, tongue, lip, arms
  • Picking: wounds, ulceration, sutures or blemishes
  • Burning: cigarette burns, self-incendiarism
  • Insertion damage: wire, pins, nails, pens etc.
  • Ingestion damage: swallowing corrosive chemicals, batteries, pins etc. [6]

Some people also report self-poisoning as a form of repetitive self-harm with no suicidal intent. [4]

A popular misconception of self-harm is that it is an attention seeking behavior. In truth, many people who self-harm are very self-conscious of their wounds and scars and go to great lengths to conceal their behavior from others. They may offer alternate explanations for their injuries or conceal their scars with clothing. [4] [7]

In the strictest terms, self-harm is a general term for self-damaging activities (which could include alcohol abuse, bulimia, etc), while self-injury refers more specifically to the practice of cutting, bruising, self poisoning, over-dosing (without suicidal intent), burning or otherwise directly injuring the body. [8] Many people, including Health Care Workers, define self-harm based around the act of damaging one's own body. It may be more accurate to define self-harm based around the intent, and the emotional distress that the person wishes to deal with. An example of this form of definition can be seen in those provided by the support group LifeSIGNS [1].

Neither the DSM-IV-TV or the ICD-10 provide diagnostic criteria for self-harm and it is often seen as only a symptom of an underlying disorder [9] though many people who self-harm would like this to be addressed. [7]

Demographics

Accurate statistics on self-harm are hard to come by. Recorded figures tend to be based on hospital admissions, though more recently researchers have attempted to document the topography and correlates of the behavior in the general population. Studies based only on hospital admissions may hide the larger group of self-harmers who do not need or seek hospital treatment for their injuries.[9] Many of these statistics show that more women seem to self-harm than men, and that it is more common among young people.

  • One of the earliest studies into self harm was carried out in 1986 by Conterio and Favazza, who estimated that 0.75% of the population exhibit self-injurious behavior. Half the sample had been hospitalised for the problem, and 97% of were female. [10] It should be noted that more recent studies show the numbers of self-harmers to be more evenly split between female and male.
  • A study of self-injurious behavior in college students published by Cornell University researchers in 2006 found that the most common methods of self-harm reported by both male and female subjects were scratching or pinching with fingernails or other objects to the point that bleeding occurred or marks remained on the skin (51.6%), banging or punching objects to the point of bruising or bleeding (37.6%), cutting (33.7%), and punching or banging oneself to the point of bruising or bleeding (24.5%). Female subjects were 2.3 times more likely to scratch or pinch and 2.4 times more likely to cut. Male subjects were 2.8 times more likely than female subjects to punch an object with the intention of injuring themselves. Male subjects were 1.8 times more likely to injure their hands, whereas female subjects were 2.3 times more likely to injure their wrists and 2.4 times more likely to injure their thighs. Self-harm is popularly assumed to represent a female phenomenon, and although there is some disputed support to this claim, the authors of the study believe that the popular association of self-harm with cutting may account for this belief.[11]
  • The WHO/EURO Multicentre Study of Suicide estimated that the average European rate of self-harm for persons over 15 years is 0.14% for males and 0.193% for females. For each age group the female rate exceeded that of the males, with the highest rate among females in the 15-24 age group and the highest rate among males in the 12-34 age group. Recently, however, it has been found that the female to male ratio, previously thought to be around 2:1, is diminishing – in Ireland it has been close to parity for a number of years.[12]
  • The Mental Health Foundation estimates the rate in the UK to be 0.77% [13], and that the majority of people who self-harm are aged between 11 and 25 years, with between 1 in 12 and 1 in 15 young people self-harming [14].
  • A 2003 study commissioned by the Samaritans found that more than 1 in 10 15-16 year olds in the UK have deliberately harmed themselves, and that girls of this age were nearly four times more likely to have self-harmed than boys [15].
  • 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. This suggests that this problem is not associated only with severely disturbed psychiatric patients but is not uncommon among young adults. [16]
  • In a study of psychiatric morbidity carried out in the UK, respondents were asked the question: "Have you ever harmed your-self in any way, but not with the intention of killing yourself?" This survey found an overall lifetime prevalence of 2.4%, this being 2.0% of males and 2.7% of females. [1]
  • About 10% of admissions to medical wards in the UK are as a result of self-harm. [17]
  • 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 hospitalization.[18]

Risk factors

A number of social or psychological factors can be seen to have a positive statistical correlation with self-harm or its repetition.

People experiencing various forms of mental ill-health can be considered to be at higher risk of self-harming. Key issues are depression [1] [19], phobias [1], conduct disorders [20] Substance abuse is also considered a risk factor [9] as are some personal characteristics such as poor problem resolution skills, impulsivity, hopelessness and aggression. [9]

Abuse during childhood is accepted as a primary social factor [21], also losing a parent or loved one[22], along with troubled parental or partner relationships. [9] [2]. Factors such as war, poverty, and unemployment may also contribute [1] [23] [24].

However, some people who self-harm have no experience of these factors. [4]

Psychology

Attempts to understand self-harm fall broadly into either attempts to interpret motives, or application of psychological models.

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

"My motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. This may sound strange." [25]

Assessement of motives in a medical setting is usually based on precursors to the incident, circumstances and information from the patient [9] 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”.[1] Many people who self-harm state that self-injury is a way to "go away" or dissociate, separating the mind from feelings that are causing anguish. This may be achieved by tricking the mind into believing the pain felt at the time is caused by self-injury instead of the issues they were facing before: the physical pain therefore acts as a distraction from emotional pain.[4] The sexual organs may be deliberately hurt as a way to deal with unwanted feelings of sexuality. [citation needed]

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." [27]

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, 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’." [27] A flow diagram of these two theories accompanies this section.

It is also important to note that some self-injurers report feeling very little to no pain while self-harming. [21]

Those who engage in self-harm 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 (the same chemicals responsible for the "runner's high"). These act to reduce tension and emotional distress and may lead to a feeling of calm. A similar rush of endorphins is triggered when someone receives a tattoo. In this way, one can become psychologically addicted to getting tattoos.

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 behavioral pattern that can result in a wanting or craving to fulfill thoughts of self-injury.

Another possible source of self-harm can be self-loathing, often as a means of punishment for having strong feelings that they were expected to suppress when they were children, or because they feel bad and undeserving, having previously been physically or emotionally abused and feeling that they were deserving of the abuse. [28]

Another often overlooked area that can result in self-harming behavior is processing disorders. Autistic-spectrum disorders, especially when undiagnosed, or misdiagnosed, can result in severe depression, anxiety and fluctuating behavior. The rising depression rates in the UK teenage population could be accounted for by the fact that there is no testing being carried out on the NHS for such disorders. If a person is diagnosed with depression and anxiety, the help available is most often medication and (arguably pre-scientific) therapy (such as psychodynamic therapy). This could mean that a large proportion of people with various processing disorders are unable to be diagnosed as such. It is arguable that the stress resulting from living with no support for an undiagnosed disorder, or being given inappropriate therapy, could lead to self-harming behavior.

Often, people with disorders such as autism are unable to feel certain stimulation, such as temperature, hunger and pain, in the same way as someone without a processing disorder usually would. In his book The Ultimate Stranger: The Autistic Child, Carl Delacato (1974) classified each sensory channel as being either hyper (too much stimulation gets in through the sensory channel for the brain to cope with) hypo (too little stimulation gets in through the sensory channel causing the brain to be deprived) and "white noise" (the faulty channel creates its own stimulus).

A person with autism often displays behaviors to balance their sensory dysfunction. If, for example, a person was hypo-tactile, they may attempt to stimulate themselves by using methods that could be categorized as self-harm.

Self-harm awareness

There are many movements among the general self harm community to make self harm and treatment better known to mental health professionals as well as the general public. SIAD (Self Injury Awareness Day) which is set for March 1 of every year, is the widest known movement. On this day some people choose to be more open about their own self harm, and awareness organizations make special efforts to raise awareness about self harm. Some people wear ribbons to show awareness; commonly orange ribbons are used for this. [2]

Treatment

Self-harm may be an indicator of depression and / or other psychological problems. Therapy and skills training can be very useful for those who self-harm. The therapy module used will vary depending on the person's diagnosis and their individual needs.

DBT, or Dialectical behavioral therapy can be very successful for those with a personality disorder, and could potentially be used for those with other mental illnesses who exhibit self-harm behavior. Cognitive Behavioral Therapy is generally used to assist those with axis 1 diagnoses, such as depression, schizophrenia, and bipolar disorder. Diagnosis and treatment of the causes is thought by many to be the best approach to self-harm; but in some cases, particularly in clients with a personality disorder, this is not very effective, which is why more clinicians are starting to take a DBT approach in order to reduce the behavior itself. A person who is injuring themselves may be advised to use coping skills, such as journaling or taking a walk, when they have the urge to harm themselves. They may also be told to avoid having the objects they use to harm themselves within easy reach. People who rely on habitual self-harm are sometimes psychiatrically hospitalised, based on their stability, and their ability and especially their willingness to get help. [29]

Music

See also

Further reading

  • Farber, S. (1997). Self-medication, traumatic reenactment, and somatic expression in bulimic and self-mutilating behavior. Journal of Clinical Social Work, 25,1: 87-106.
  • Farber, S. (2000). When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments.Northvale, NJ: Jason Aronson.
  • Farber, S. (2003). Ecstatic stigmatics and holy anorexics, medieval and contemporary.Journal of Psychohistory,31,2:183-204.
  • Favaro, A. & Santonastaso, P. (2000). Self-injurious behavior in anorexia nervosa. The Journal of Nervous and Mental Disease, 188(8), 537-542.
  • Favazza, A.R. (1996). Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry. Johns Hopkins University Press (May be seminal work on self-injury.)
  • Favazza, A.R. & Rosenthal, R. J. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.
  • Groves, A. L. (1998). Cutting a Knowledge. Unpublished Masters thesis: School of Cultural Studies, Australian National University, Canberra.
  • Marek M. Kaminski (2004) Games Prisoners Play. Princeton University Press. ISBN 0691117217 (Game-theoretic examination of various types of self-injury by a former political prisoner.)
  • Levenkron, S. (1998). Cutting. New York, NY: W. W. Norton and Company.
  • Miller, Dusty (1994). Women Who Hurt Themselves. Basic Books
  • Smith, Carolyn (2006). Cutting it Out: a journey through psychotherapy and self-harm. Jessica Kingsley Publishers
  • Stanley, B., Gameroff, M. J., Michalsen, V., & Mann, J. J. (2001). Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, 158(3), 427-432.
  • Suyemoto, K. L. & MacDonald, M. L. (1995). Self-cutting in female adolescents. Psychotherapy, 32(1), 162-171.
  • Zila, L. M. & Kiselica, M. S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling & Development, 79, 46-52.
  • Strong, Marilee (1999). A Bright Red Scream. G P Putnam's Sons
  • Sensory Perceptual Issues in Autism and Asperger Syndrome, Different Sensory Experiences, Different Perceptual Worlds - Olga Bogdashina
  • The European Therapy Studies Institute, Organising Ideas, The Shackled Brain - Joe Griffin and Ivan Tyrrell
  • Whittenhall, Elaina (2006). Cutting: Self-Injury and Emotional Pain. InterVarsity Press.

References

  1. ^ a b c d e f Meltzer, Howard, et. al., (2000), Non Fatal Suicidal Behaviour Among Adults aged 16 to 74 in Great Britain, The Stationary office ISBN 0-11-621548-8
  2. ^ a b Rea, K., Aiken, F., and Borastero, C., (1997) Building Therapeutic Staff: Client Relationships with Women who Self-Harm, Women's Health Issues, 7, 2, p121-125.
  3. ^ LifeSIGNS Self Injury Awareness Booklet, Version 2 Mar. 01, 2005 from Self Injury Awareness Booklet, LifeSIGNS
  4. ^ a b c d e Spandler, H (1996) Who's Hurting Who? Young people, self-harm and suicide, Manchester: 42nd Street ISBN 1-900782-00-6
  5. ^ "Sometimes it's nice to see that it is me hurting, instead of somebody else". Fox, C & Hawton, K (2004) Deliberate Self-Harm in Adolescence, London: Jessica Kingsley ISBN 18431022366
  6. ^ Burrows, S (1992) Nursing management of self-mutilation, British Journal of Nursing 17:138-148
  7. ^ a b Pembroke, L R (ed.)(1994) Self-harm. Perspectives from personal experience, Survivors Speak Out ISBN 1-904697-04-6
  8. ^ Harrsion, D (1994) Understanding self harm, Peterborogh, MIND (Cited in Greenwood, S & Bradley, P (1997) Managing deliberate self-harm: the A&E perspective Accident and Emergency Nursing 5: 134-136)
  9. ^ a b c d e f Cite error: The named reference fox_hawton was invoked but never defined (see the help page).
  10. ^ http://www.selfharm.net/who.html
  11. ^ Whitlock, J.L., Eckenrode, J.E. & Silverman, D. (2006). The epidemiology of self-injurious behavior in a college population. Pediatrics, 117(6).
  12. ^ World Health Organisation Europe Multicentre Study of Suicide, retrieved Jul. 20, 2004 from Women and Parasuicide: a Literature Review, Women's Health Council
  13. ^ http://news.bbc.co.uk/1/hi/health/medical_notes/4067129.stm
  14. ^ http://www.mentalhealth.org.uk/html/content/selfharm.cfm
  15. ^ http://news.bbc.co.uk/1/hi/health/2884119.stm
  16. ^ Vanderhoff & Lynn, 2000
  17. ^ http://www.bbc.co.uk/health/conditions/mental_health/emotion_selfharm.shtml
  18. ^ Retrieved Jul. 20, 2004 from Hospitalisation for intentional self-harm, New Zealand Health Information Service
  19. ^ Hawton, K., Kingsbury, S., Steinhardt, K., James, A., and Fagg, J., (1999) Repetition of deliberate self-harm by adolescents: the role of psychological factors, Journal of Adolescence, 22, 369-378.
  20. ^ Wessely et. al. (1996) Deliberate self-harm and the probation service: An overlooked public health problem?, Journal of Public Health Medicine, 18, 129-32
  21. ^ a b Strong, M., (1998, 2000) A Bright Red Scream: Self-mutilation and the Language of Pain, London: Virago. Cite error: The named reference "strong" was defined multiple times with different content (see the help page).
  22. ^ http://news.bbc.co.uk/1/hi/health/medical_notes/4067129.stm
  23. ^ http://news.bbc.co.uk/1/hi/health/129684.stm
  24. ^ http://www.irr.org.uk/2005/april/ha000011.html
  25. ^ Pembroke, L R (ed.)(1994) Self-harm. Perspectives from personal experience (P. 18), Survivors Speak Out ISBN 1-904697-04-6
  26. ^ Hawton, K., Cole, D., O'Grady, J., Osborn, M. (1982) Motivational Aspects of Deliberate Self Poisoning in Adolescents, British Journal of Psychiatry, 141, 286-291
  27. ^ a b Retrieved Jul. 28, 2005 from LifeSIGNS: Precursors to Self Injury
  28. ^ http://www.helpguide.org/mental/self_injury.htm
  29. ^ http://www.selfinjury.org/docs/selfhelp.html
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