Information about Self Harm

Self-injury
Classification & external resources

ICD-10	X84.
DiseasesDB	30605 29126

Self-injury (SI) or self-harm (SH) is deliberate injury inflicted by a person upon his or her own body without suicidal intent. Some scholars use more technical definitions related to specific aspects of this behaviour. These acts may be aimed at relieving otherwise unbearable emotions, sensations of unreality and numbness. It is listed in the DSM-IV-TR as a symptom of borderline personality disorder and is sometimes associated with mental illness, a history of trauma and abuse, eating disorders, or mental traits such as low self-esteem or perfectionism. There is a positive statistical correlation between self-injury and emotional abuse.^[1][2]

Definition

Self-injury, sometimes referred to as self-harm (SH), self-inflicted violence (SIV) or self-injurious behavior (SIB), refers to a spectrum of behaviors where demonstrable injury is self-inflicted. ^[3] The term self-mutilation is also sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive. ^[3] A broader definition of self-injury might also include those who inflict harm on their bodies by means of disordered eating, as well as tattooing or body piercing that goes beyond the limits of culturally accepted body modification.

A common belief regarding self-injury is that it is an attention-seeking behavior; however, in most cases, this is untrue. Most self-injurers are very self-conscious of both their wounds and scars, and go to great lengths to conceal their behavior from others. They may offer alternative explanations for their injuries, or conceal their scars with clothing.^[4][5] Self-injury in such individuals is not associated with suicidal or para-suicidal behavior. The person who self-injures is not usually seeking to end his or her own life; it has been suggested instead that he or she is using self-injury as a coping mechanism to relieve emotional pain or discomfort.^[6] However, 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.^[7]

Methods of injury

A common form of self-injury involves making cuts in the skin of the arms, legs, abdomen, inner thighs, etc. This is colloquially referred to as "cutting"; a person who routinely does this may be colloquially called a "cutter".^[8] The number of self-injury methods are only limited to an individual's creativity. The bodily locations of self-injury are often areas that are easily hidden and concealed from the detection of others.^[9]

Examples of self-injury other than cutting include:

• Punching, hitting and scratching
• Choking, constricting of the airway
• Self-biting of hands, limbs, tongue, lips, or arms
• Picking at wounds (dermatillomania), ulceration, or sutures
• Hair-pulling (trichotillomania)
• Burning, including cigarette burns, and self-incendiarism (as well as eraser burns)
• Stabbing self with wire, pins, needles, nails, staples, pens, or hair accessories
• Ingesting corrosive chemicals, batteries, or pins^[10]
• Self-poisoning; for example by over-dosing on medication and/or alcohol, without suicidal intent^[4]
• Self-injury among individuals with developmental disabilites often involves relatively simple actions, such as banging one's head against a hard surface, punching hard surfaces, biting oneself (usually hands or arms), or picking wounds. It may also include pica, the swallowing of nonfood items, which can be extremely dangerous and sometimes fatal.

Other definitions

Strictly speaking, self-harm is a general term for self-damaging activities (which could include such activities as alcohol abuse or bulimia). Self-injury refers more specifically to the practice of cutting, bruising, poisoning, over-dosing (without suicidal intent), burning, or otherwise directly injuring the body.^[12] 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 is provided by the self-injury awareness charity, LifeSIGNS.^[13]

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,<ref name="fox_hawton" /> though many people who self-injure would like this to be addressed.<ref name= "pembroke" />

Self-inflicted wounds is a specific term associated with soldiers, where they inflicted harm on themselves (commonly a shot in the foot or hand) in order to obtain early dismissal from combat.^[14][15]This differs from the common definition of self-injury as the damage is inflicted for a specific secondary purpose.

Demographics

Accurate statistics on self-injury are hard to come by since most self-injurers conceal their injuries. 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-injurers who do not need or seek hospital treatment for their injuries.<ref name="fox_hawton" /> Many of these statistics show that more women seem to self-injure than men, and that it is more common among young people. This most likely explains the female bias that the media seems to portray in its attitude to self-injury, despite research in 2006 by Marchetto ^[16] which suggests otherwise.

"No gender differences were observed among skin-cutters, most of whom reported experiences of trauma. Borderline Personality Disorder (BPD) was recorded for a minority of those skin-cutters without a history of trauma. PBI scores discriminated between non-BPD skin cutters and non-BPD comparison participants without a history of trauma." Marchetto, 2006

• One of the earliest studies into self-injury 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.^[17] It should be noted that more recent studies show the numbers of self-injurers 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-injury 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-injury 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-injury with cutting may account for this belief.^[18]
  • The WHO/EURO Multicentre Study of Suicide estimated that the average European rate of self-injury 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.^[19]
  • The Mental Health Foundation estimates the rate in the UK to be 0.77%,^[20] 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 .
  • A 2003 study commissioned by Samaritans found that more than one in ten 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.^[21]
  • 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.^[22]
  • 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, however the majority of these are for drug overdoses, with only 5 to 15% of this number being caused by cutting.^[20]
  • 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.^[24]
    • A discourse analysis of self-injury research demonstrates methodological and sampling errors that explain the disproportional representation of females that practice self-injury. Brickman argues "Medical discourse has again pathologized the female (99)" and the profiling of self-injurers as female is the unsubstantiated result of social biases. ^[25]
    • A study of homeless youth (age 16 to 19) found that 69% of the youth practiced self-injury on at least one occasion with 12% receiving medical attention for the self-inflicted wounds. There was no significant difference in frequency between gender (72% of males vs. 66% females), however gender correlations may be made between the methods of self-injury with the exception of cutting being most common for both. ^[26]

    Risk factors

    A number of social or psychological factors can be seen to have a positive statistical correlation with self-injury or its repetition.
    
    People experiencing various forms of mental ill-health can be considered to be at higher risk of self-injuring. Key issues are depression,<ref name="meltzer" />^[27] phobias,<ref name="meltzer" /> conduct disorders^[28] Substance abuse is also considered a risk factor<ref name="fox_hawton" /> as are some personal characteristics such as poor problem resolution skills, impulsivity, hopelessness and aggression.<ref name="fox_hawton" /> 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 ^[29]. Abuse during childhood is accepted as a primary social factor,^[30] also losing a parent or loved one,<ref name="BBC" /> along with troubled parental or partner relationships.<ref name="fox_hawton" />.<ref name="rea" /> Factors such as war, poverty, and unemployment may also contribute.<ref name="meltzer" />^[31][32] In addition, some individuals with pervasive developmental disabilities, more popularly known as autism, engage in self injury, while is debated whether it is a form of self stimulation or for the purpose of harming one's self. [1]
    
    However, some people who self-injure have no experience of these factors.<ref name="spandler" />

    Psychology

    
    
    Attempts to understand self-injury fall broadly into either 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 quote:

    "My motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. This may sound strange."[33]

    
    
    Motives for self-injury can be different. Some feel as if they are not good enough. It's often difficult for them to open up and tell about their "secret shame". When they do tell somebody often that person does not understand.
    
    Assessment of motives in a medical setting is usually based on precursors to the incident, circumstances and information from the patient<ref name="fox_hawton" /> however the limited studies comparing professional and personal assessments show that these differ with professionals suggesting more manipulative or punitive motives.^[34]
    
    The UK ONS study reported only two motives: “to draw attention” and “because of anger”.<ref name="meltzer" /> 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 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.<ref name="spandler" /> 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 persons well being. (e.g., responses to child sexual abuse)
    
    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."^[3]
    
    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’."<ref name="lifesigns" /> A flow diagram of these two theories accompanies this section.
    
    It is also important to note that many self-injurers report feeling very little to no pain while self-harming.^[30]
    
    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 (the same chemicals that are thought to be responsible for the "runner's high"). These act to reduce tension and emotional distress and may lead to a feeling of calm.
    
    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-injury 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.^[37]

    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. SIAD (Self Injury Awareness Day) which is set for March 1 of every year, is one such movement. On this day some people choose to be more open about their own self-injury, and awareness organizations make special efforts to raise awareness about self-injury. Some people wear ribbons to show awareness; commonly orange ribbons are used for this. Sometimes a red and black ribbon is also used, generally signifying a person who self-injures.^[38] Sometimes orange is used to represent those who self-injure, white for those who don't injure but show support and white and orange together show someone who is trying to stop or has stopped self-injury.^[39] A single white bead on an orange bracelet may sometimes be used for those who want to stop and several mixed white and orange beads is for those who have stopped.^[40]

    Treatment

    Self-injury may be an indicator of depression and/or other psychological problems. Therapy and skills training can be very useful for those who self-injure. 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-injurious 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-injury; 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-injury are sometimes psychiatrically hospitalised, based on their stability, and their ability and especially their willingness to get help.^[41]
    
    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.^[42][43][44]

    See also

    • Clinical depression
    • Suicide
    • Mental illness

    Further reading

    • Bogdashina, Olga. (2003). Sensory Perceptual Issues in Autism and Asperger Syndrome, Different Sensory Experiences, Different Perceptual Worlds
    • Farber, S. (1995).A psychoanalytically informed understanding of the association between binge-purge behavior and self-mutilating behavior: A study comparing binge-purgers who self-mutilate severely with binge-purgers who self-mutilate less severely or not at all. Doctoral dissertation, New York University school of Social Work.
    • 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.
    • Griffin, J. & Tyrrell, I. (2000) The Shackled Brain: How to release locked in patterns of psychological trauma. Organising Idea Monograph, No.5. European Therapy Studies Institute. ISBN 1-899398-11-2.
    • 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 0-691-11721-7 (Game-theoretic examination of various types of self-injury by a former political prisoner.)
    • Miller, Dusty (1994). Women Who Hurt Themselves. Basic Books
    • Nicole, Tara L. (2006). Dancing in the Rain: the Final Cut. Pneuma Springs Publishing.
    • 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.
    • Steven Levenkron (1998). Cutting. New York, NY: W. W. Norton and Company.
    • Strong, Marilee (1999). A Bright Red Scream. G P Putnam's Sons ISBN 0140280537
    • Suyemoto, K. L. & MacDonald, M. L. (1995). Self-cutting in female adolescents. Psychotherapy, 32(1), 162-171.
    • Whittenhall, Elaina (2006). Cutting: Self-Injury and Emotional Pain. InterVarsity Press.
    • 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.

    References

    1. ^ 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. ^ 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 3 Mar. 01, 2007 from Self Injury Awareness Booklet, LifeSIGNS ISBN 0955550602
    4. ^ Spandler, H (1996) Who's Hurting Who? Young people, self-harm and suicide, Manchester: 42nd Street ISBN 1-900782-00-6
    5. ^ Pembroke, L R (ed.)(1994) Self-harm. Perspectives from personal experience, Survivors Speak Out ISBN 1-904697-04-6
    6. ^ "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 142370987X
    7. ^ Iwata, B. A., et al. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197–209.
    8. ^ [2]
    9. ^ Hodgson, Sarah. 2004. “Cutting Through the Silence: A Sociological Construction of Self-Injury.” Sociological Inquiry, Vol. 74, No. 2. pp. 162-179
    10. ^ Burrows, S (1992) Nursing management of self-mutilation, British Journal of Nursing 17:138-148
    11. ^ Spandler, H (1996) Who's Hurting Who? Young people, self-harm and suicide, Manchester: 42nd Street ISBN 1-900782-00-6
    12. ^ Harrsion, D (1994) There is a strikingly high correlation between self-injury and disordered eating (Farber 1995, 1997, 2000, 2003, 2007). 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)
    13. ^ What self-injury is
    14. ^ Example of Self-inflicted woundin World War I
    15. ^ Reasons for Self inflicted wounds
    16. ^ Marchetto, M. J., Psychology and Psychotherapy: Theory, Research and Practice, Volume 79, Number 3, September 2006 , pp. 445-459(15)
    17. ^ What kinds of people self-injure?
    18. ^
  Whitlock, J.L., Eckenrode, J.E. & Silverman, D. (2006). The epidemiology of self-injurious behavior in a college population. Pediatrics, 117(6).
  19. ^ World Health Organisation Europe Multicentre Study of Suicide, retrieved Jul. 20, 2004 from Women and Parasuicide: a Literature Review, Women's Health Council
  20. ^ Self-injury at the BBC
  21. ^ Teenage self-harm widespread
  22. ^ Vanderhoff & Lynn, 2000
  23. ^ 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
  24. ^

Retrieved Jul. 20, 2004 from Hospitalisation for intentional self-harm, New Zealand Health Information Service
25. ^ Brickman, Barbara Jane. 2004. “’Delicate’ Cutters: Gendered Self-mutilation and Attractive Flesh in Medical Discourse.” Body and Society, Vol. 10, No. 4. pp. 87-111.
26. ^ Tyler, Kimberly A., Les B. Whitbeck, Dan R. Hoyt, Kurt D. Johnson. 2003. “Self Mutilation and Homeless Youth: The Role of Family Abuse, Street Experiences, and Mental Disorders.” Journal of Research on Adolescence, Vol. 13, No. 4. pp. 457-474.
27. ^ 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.
28. ^ Wessely et al. (1996) Deliberate self-harm and the probation service: An overlooked public health problem?, Journal of Public Health Medicine, 18, 129-32
29. ^ [3]
30. ^ Strong, M., (1998, 2000) A Bright Red Scream: Self-mutilation and the Language of Pain, London: Virago.
31. ^ Third World faces self-harm epidemic
32. ^ The deportation machine: unmonitored and unimpeded
33. ^ Pembroke, L R (ed.)(1994) Self-harm. Perspectives from personal experience (P. 18), Survivors Speak Out ISBN 1-904697-04-6
34. ^ 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
35. ^ Retrieved Jul. 28, 2005 from LifeSIGNS: Precursors to Self Injury
36. ^ Strong, M. (1999). A Bright Red Scream: Self-Mutilation and the Language of Pain.
37. ^ Self-injury - types, causes and treatment
38. ^ American Self-harm Information Clearing-House
39. ^ Bracelet colours
40. ^ Bracelet colours 2
41. ^ Self-help - how do I stop right now?
42. ^ Bird, F., Dores, P.A., Moniz, D., & Robinson, J. (1989). Reducing severe aggressive and self-injurious behaviors with functional communication training. American Journal on Mental Retardation, 94, 37-48.
43. ^ Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111-126.
44. ^ Sigafoos, J. (1996). Functional Communication Training for the Treatment of Multiply Determined Challenging Behavior in Two Boys with Autism. Behavior Modification, 20, 60-84.