Self-harm
Encyclopedia
Self-harm or deliberate self-harm (DSH) includes self-injury (SI) and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal
intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology. The older literature, especially that which predates the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR), almost exclusively refers to self-mutilation. The term is synonymous with "self-injury". The most common form of self-harm is skin-cutting but self-harm also covers a wide range of behaviors including, but not limited to, burning, scratching, banging or hitting body parts, interfering with wound healing, hair-pulling (trichotillomania
) and the ingestion of toxic substances or objects. Behaviours associated with substance abuse
and eating disorder
s are usually not considered self-harm because the resulting tissue damage is ordinarily an unintentional side effect. However, the boundaries are not always clear-cut and in some cases behaviours that usually fall outside the boundaries of self-harm may indeed represent self-harm if performed with explicit intent to cause tissue damage. Although suicide is not the intention of self-harm, the relationship between self-harm and suicide is complex, as self-harming behaviour may be potentially life-threatening. There is also an increased risk of suicide in individuals who self-harm to the extent that self-harm is found in 40–60% of suicides. However, generalising self-harmers to be suicidal is, in the majority of cases, inaccurate.
Self-harm is listed in the DSM-IV-TR as a symptom of borderline personality disorder
. However patients with other diagnoses may also self-harm, including those with depression, anxiety
disorders, substance abuse
, eating disorders, post-traumatic stress disorder
, schizophrenia
, and several personality disorder
s. Self-harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. The motivations for self-harm vary and it may be used to fulfill a number of different functions. These functions include self-harm being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness or a sense of failure or self-loathing and other mental traits including low self-esteem
or perfectionism
. Self-harm is often associated with a history of trauma
and abuse, including emotional and sexual abuse
. There are a number of different methods that can be used to treat self-harm and which concentrate on either treating the underlying causes or on treating the behaviour itself. When self-harm is associated with depression, antidepressant
drugs and treatments may be effective. Other approaches involve avoidance techniques, which focus on keeping the individual occupied with other activities, or replacing the act of self-harm with safer methods that do not lead to permanent damage.
Self-harm is most common in adolescence and young adulthood, usually first appearing between the ages of 12 and 24. Self-harm in childhood is relatively rare but the rate has been increasing since the 1980s. However, self-harm behaviour can nevertheless occur at any age, including in the elderly population. The risk of serious injury and suicide is higher in older people who self-harm. Self-harm is not limited to humans. Captive non-human animals, such as birds and monkeys, are also known to participate in self-harming behaviour.
s is a specific term associated with soldiers to describe non-lethal injuries inflicted in order to obtain early dismissal from combat. This differs from the common definition of self-harm, as damage is inflicted for a specific secondary purpose. A broader definition of self-harm might also include those who inflict harm on their bodies by means of disordered eating.
A common belief regarding self-harm is that it is an attention-seeking behaviour; however, in most cases, this is inaccurate. Many self-harmers 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. They may offer alternative explanations for their injuries, or conceal their scars with clothing. Self-harm in such individuals is not associated with suicidal
or para-suicidal
behaviour. People who self-harm are not usually seeking to end their own life; it has been suggested instead that they are using self-harm as a coping mechanism to relieve emotional pain or discomfort or as an attempt to communicate distress. Studies of individuals with developmental disabilities (such as mental retardation) have shown self-harm being dependent on environmental factors such as obtaining attention or escape from demands. Some individuals may suffer from dissociation
harbouring a desire to feel real or to fit in to society's rules.
ing, self-poisoning
, alcohol abuse
, self-embedding
of objects and forms of self-harm related to anorexia
and bulimia. The locations of self-harm are often areas of the body that are easily hidden and concealed from the detection of others. As well as defining self-harm in terms of the act of damaging the 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. Neither the DSM-IV-TR nor the ICD-10
provide diagnostic criteria for self-harm. It is often seen as only a symptom of an underlying disorder, though many people who self-harm would like this to be addressed. A formal proposal is currently under review (2010) to include Non-Suicidal Self-Injury as a distinct diagnosis in the forthcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5
).
, bipolar disorder
, depression, phobia
s, and conduct disorder
s. Schizophrenia may also be a contributing factor for self-harm. Those diagnosed with Schizophrenia have a high risk of suicide, which is particularly greater in younger patients as they may have an insight into the serious effects that the illness can have on their lives. Substance abuse is also considered a risk factor as are some personal characteristics such as poor problem-solving skills and impulsivity. There are parallels between self-harm and Münchausen syndrome
, a psychiatric disorder in which individuals feign illness or trauma. There may be a common ground of inner distress culminating in self-directed harm in a Münchausen patient. However, a desire to deceive medical personnel in order to gain treatment and attention is more important in Münchausen's than in self-harm.
is self-harm and may include biting and head-banging. Genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behaviour. However, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive.
as well as benzodiazepine withdrawal is associated with self-harming behaviour in young people. Alcohol is a major risk factor for self-harm. A study which analysed self-harm presentations to emergency rooms in Northern Ireland
found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations. A recent study in the relation between cannabis use and deliberate self-harm (DSH) in Norway and England, found that, in general, cannabis
use may not be a specific risk factor for DSH in young adolescents.
The motivations for self-harm vary as it may be used to fulfill a number of different functions. These functions include self-harm 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 also a positive statistical correlation between self-harm and emotional abuse. Self-harm may become a means of managing and controlling pain
, in contrast to the pain experienced earlier in the sufferers life of which they had no control over (e.g. through abuse).
Other motives for self-harm do not fit into medicalised models of behaviour and may seem incomprehensible to others, as demonstrated by this quotation:
"My motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. This may sound strange."
Assessment of motives in a medical setting is usually based on precursors to the incident, circumstances and information from the patient. However, limited studies show that professional assessments tend to suggest more manipulative or punitive motives than personal assessments.
The UK ONS study reported only two motives: "to draw attention" and "because of anger". For some people harming themselves can be a means of drawing attention to the need for help and to ask for assistance in an indirect way. It may also be an attempt to affect others and to manipulate them in some way emotionally. However, those with chronic, repetitive self-harm often do not want attention and hide their scars carefully.
Many people who self-harm 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-harm instead of the issues they were facing previously: the physical pain
therefore acts as a distraction from the original emotional pain. 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." 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).
Those who engage in self-harm face the contradictory reality of harming themselves while 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-harmers this relief is primarily psychological while for others this feeling of relief comes from the beta endorphins
released in the brain. 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. Many self-harmers report feeling very little to no pain while self-harming and, for some, deliberate self-harm may become a means of seeking pleasure.
Alternatively, self-harm may be a means of feeling something, even if the sensation is unpleasant and painful. Those who self-harm 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'."
As a coping mechanism, self-harm can become psychologically addictive because, to the self-harmer, it works; it enables him or 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-harm, can also create a behavioural pattern that can result in a wanting or craving to fulfill thoughts of self-harm.
(SIAD) around the world. On this day, some people choose to be more open about their own self-harm, and awareness organisations make special efforts to raise awareness about self-harm. Some people wear an orange awareness ribbon or wristband
to encourage awareness of self-harm.
and physical treatments of patients who harm themselves are most effective and as such further clinical studies are required. Psychiatric and personality disorder
s are common in individuals who self-harm and as a result self-harm may be an indicator of depression and/or other psychological problems. 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. Cognitive behavioural therapy
may also be used (where the resources are available) to assist those with Axis I diagnoses, such as depression, schizophrenia
, and bipolar disorder
. Dialectical behaviour 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-harming behaviour. Diagnosis and treatment of the causes of self-harm is thought by many to be the best approach to treating self-harm. 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-harm are sometimes psychiatrically hospitalised, based on their stability, and their ability and especially their willingness to get help.
In individuals with developmental disabilities, occurrence of self-harm 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-harm 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-harm thus is to teach an alternative, appropriate response which obtains the same result as the self-harm.
may help raise self-awareness in the sufferer of certain pre-occupations or particular mental state or mood that precede bouts of self-harming behaviour, and help the sufferer identify techniques to avoid those pre-occupations before they lead to self-harm. Any avoidance or coping strategy must be appropriate to the individual's motivation and reason for harming.
The best available research indicates that in the United States up to 4% of adults self-harm with approximately 1% of the population engaging in chronic or severe self-harm. Current research suggests that the rates of self-harm are much higher among young people with the average age of onset between 14 and 24. The earliest reported incidents of self-harm are in children between 5 and 7 years old. In the UK in 2008 rates of self-harm in young people could be as high as 33%. In addition there appears to be an increased risk of self-harm in college students than among the general population. In a study of undergraduate students in the US, 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-harm 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 Ireland, a study found that instances of hospital-treated self-harm were much higher in City and Urban Districts, than in Rural settings. The CASE (Child & Adolescent Self-harm in Europe) study suggests that the life-time risk of self-injury is ~1:7 for women and ~1:25 for men.
The WHO
/EURO Multicentre Study of Suicide, established in 1989, demonstrated that, for each age group, the female rate of self-harm 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. 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.
This gender discrepancy is often distorted in specific populations where rates of self-harm 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-harm among 428 homeless and runaway youth (age 16 to 19) with 72% of males and 66% of females reporting a past history of self-harm. However, in 2008, a study of young people and self-harm saw the gender gap close, with 32% of young females, and 22% of young males admitting to self-harm. Studies also indicate that males who self-harm may also be at a greater risk of completing suicide.
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. 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. 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.
s or natural poisons. Many people admitted for deliberate self-poisoning during a study by Eddleston et al. 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. One way of reducing self-harm would be to limit access to poisons; 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.
refined his conceptual definitions of self-mutilation. His study on self-destructiveness differentiated between suicidal behaviours 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 six types:
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. Ross and McKay (1979) categorized self-mutilators into 9 groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling and hitting and constricting.
After the 1970s the focus of self-harm shifted from Freudian psycho-sexual drives of the patients.
Walsh and Rosen (1988) created four categories numbered by Roman numerals I–IV, defining Self-mutilation as rows II, III and IV
Favazza and Rosenthal (1993) reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation. 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-harm.
Self-harm 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. A reference to the priests of Baal
"cutting themselves with blades until blood flowed" can be found in the Hebrew Bible. However, in Judaism, such self-harm is forbidden under Mosaic law.
Self-harm is also practised by the sadhu
or Hindu ascetic, in Catholic 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.
, clonidine
, amphetamine
, and very high (toxic) doses of caffeine
or theophylline
are known to precipitate self-harm in lab animals. In dogs, canine obsessive-compulsive disorder can lead to self-inflicted injuries, for example canine lick granuloma
. Captive birds are sometimes known to engage in feather-plucking
, causing damage to feathers that can range from feather shredding to the removal of most or all feathers within the bird's reach, or even the mutilation of skin or muscle tissue.
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology. The older literature, especially that which predates the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM-IV-TR), almost exclusively refers to self-mutilation. The term is synonymous with "self-injury". The most common form of self-harm is skin-cutting but self-harm also covers a wide range of behaviors including, but not limited to, burning, scratching, banging or hitting body parts, interfering with wound healing, hair-pulling (trichotillomania
Trichotillomania
Trichotillomania, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat....
) and the ingestion of toxic substances or objects. Behaviours associated with substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
and eating disorder
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s are usually not considered self-harm because the resulting tissue damage is ordinarily an unintentional side effect. However, the boundaries are not always clear-cut and in some cases behaviours that usually fall outside the boundaries of self-harm may indeed represent self-harm if performed with explicit intent to cause tissue damage. Although suicide is not the intention of self-harm, the relationship between self-harm and suicide is complex, as self-harming behaviour may be potentially life-threatening. There is also an increased risk of suicide in individuals who self-harm to the extent that self-harm is found in 40–60% of suicides. However, generalising self-harmers to be suicidal is, in the majority of cases, inaccurate.
Self-harm is listed in the DSM-IV-TR as a symptom of borderline personality disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
. However patients with other diagnoses may also self-harm, including those with depression, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
disorders, substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
, eating disorders, post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, and several personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
s. Self-harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. The motivations for self-harm vary and it may be used to fulfill a number of different functions. These functions include self-harm being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness or a sense of failure or self-loathing and other mental traits including low self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
or perfectionism
Perfectionism (psychology)
Perfectionism, in psychology, is a belief that a state of completeness and flawlessness can and should be attained. In its pathological form, perfectionism is a belief that work or output that is anything less than perfect is unacceptable...
. Self-harm is often associated with a history of trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
and abuse, including emotional and sexual abuse
Sexual abuse
Sexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
. There are a number of different methods that can be used to treat self-harm and which concentrate on either treating the underlying causes or on treating the behaviour itself. When self-harm is associated with depression, antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
drugs and treatments may be effective. Other approaches involve avoidance techniques, which focus on keeping the individual occupied with other activities, or replacing the act of self-harm with safer methods that do not lead to permanent damage.
Self-harm is most common in adolescence and young adulthood, usually first appearing between the ages of 12 and 24. Self-harm in childhood is relatively rare but the rate has been increasing since the 1980s. However, self-harm behaviour can nevertheless occur at any age, including in the elderly population. The risk of serious injury and suicide is higher in older people who self-harm. Self-harm is not limited to humans. Captive non-human animals, such as birds and monkeys, are also known to participate in self-harming behaviour.
Classification
Self-harm (SH), also referred to as self-injury (SI), self-inflicted violence (SIV), Non-Suicidal Self Injury (NSSI) or self-injurious behaviour (SIB), refers to a spectrum of behaviours where demonstrable injury is self-inflicted. The most common form of self-harm involves cutting of the skin using a sharp object, e.g. a knife or razor blade. The term self-mutilation is also sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive. Self-inflicted woundSelf-inflicted wound
A self-inflicted wound , is the act of harming oneself where there are no underlying psychological problems related to the self-injury, but where the injurer wanted to take advantage of being injured.-Reasons to self-wound:...
s is a specific term associated with soldiers to describe non-lethal injuries inflicted in order to obtain early dismissal from combat. This differs from the common definition of self-harm, as damage is inflicted for a specific secondary purpose. A broader definition of self-harm might also include those who inflict harm on their bodies by means of disordered eating.
A common belief regarding self-harm is that it is an attention-seeking behaviour; however, in most cases, this is inaccurate. Many self-harmers 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. They may offer alternative explanations for their injuries, or conceal their scars with clothing. Self-harm in such individuals is not associated with suicidal
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
or para-suicidal
Parasuicide
Parasuicide refers to suicide attempts or gestures and self-harm where there is no result in death. It is a non-fatal act in which a person deliberately causes injury to himself or ingests any prescribed or generally recognised therapeutic dose in excess...
behaviour. People who self-harm are not usually seeking to end their own life; it has been suggested instead that they are using self-harm as a coping mechanism to relieve emotional pain or discomfort or as an attempt to communicate distress. Studies of individuals with developmental disabilities (such as mental retardation) have shown self-harm being dependent on environmental factors such as obtaining attention or escape from demands. Some individuals may suffer from dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
harbouring a desire to feel real or to fit in to society's rules.
Signs and symptoms
Eighty percent of self-harm involves stabbing or cutting the skin with a sharp object. However, the number of self-harm methods are only limited by an individual's inventiveness and their determination to harm themself; this includes, but is not limited to burnBurn
A burn is an injury to flesh caused by heat, electricity, chemicals, light, radiation, or friction.Burn may also refer to:*Combustion*Burn , type of watercourses so named in Scotland and north-eastern England...
ing, self-poisoning
Poison
In the context of biology, poisons are substances that can cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism....
, alcohol abuse
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...
, self-embedding
Self-embedding
Self-embedding is a form of self-injury where foreign objects are inserted underneath the skin, and left either for a limited period of time or permanently.-History:...
of objects and forms of self-harm related to anorexia
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
and bulimia. The locations of self-harm are often areas of the body that are easily hidden and concealed from the detection of others. As well as defining self-harm in terms of the act of damaging the 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. Neither the DSM-IV-TR nor the ICD-10
ICD
The International Statistical Classification of Diseases and Related Health Problems is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease...
provide diagnostic criteria for self-harm. It is often seen as only a symptom of an underlying disorder, though many people who self-harm would like this to be addressed. A formal proposal is currently under review (2010) to include Non-Suicidal Self-Injury as a distinct diagnosis in the forthcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
).
Mental illness
Although some people who self-harm do not suffer from any forms of recognised mental illness, many people experiencing various forms of mental ill-health do have a higher risk of self-harm. The key areas of illness which exhibit an increased risk include borderline personality disorderBorderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
, bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, depression, phobia
Phobia
A phobia is a type of anxiety disorder, usually defined as a persistent fear of an object or situation in which the sufferer commits to great lengths in avoiding, typically disproportional to the actual danger posed, often being recognized as irrational...
s, and conduct disorder
Conduct disorder
Conduct disorder is psychological disorder diagnosed in childhood that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated...
s. Schizophrenia may also be a contributing factor for self-harm. Those diagnosed with Schizophrenia have a high risk of suicide, which is particularly greater in younger patients as they may have an insight into the serious effects that the illness can have on their lives. Substance abuse is also considered a risk factor as are some personal characteristics such as poor problem-solving skills and impulsivity. There are parallels between self-harm and Münchausen syndrome
Munchausen syndrome
Münchausen syndrome is a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention or sympathy to themselves. It is also sometimes known as hospital addiction syndrome or hospital hopper syndrome...
, a psychiatric disorder in which individuals feign illness or trauma. There may be a common ground of inner distress culminating in self-directed harm in a Münchausen patient. However, a desire to deceive medical personnel in order to gain treatment and attention is more important in Münchausen's than in self-harm.
Psychological factors
Abuse during childhood is accepted as a primary social factor increasing the incidence of self-harm, as is bereavement, and troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. Self-harm is frequently described as an experience of depersonalisation or a dissociative state. An estimated 30% of individuals with autism spectrum disorders engage in self-harm at some point, including eye-poking, skin-picking, hand-biting, and head-banging. Recent authors discuss the possible psychological purposes behind self-harm: it can act as a way for people to re-enact traumas experienced in the past which were possibly out of the person's control.Genetics
The most distinctive characteristic of the rare genetic condition Lesch-Nyhan syndromeLesch-Nyhan syndrome
Lesch–Nyhan syndrome , also known as Nyhan's syndrome, Kelley-Seegmiller syndrome and Juvenile gout, is a rare inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase , produced by mutations in the HPRT gene located on X chromosome. LNS affects about...
is self-harm and may include biting and head-banging. Genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behaviour. However, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive.
Drugs and alcohol
Substance misuse, dependence and withdrawal are associated with self-harm. Benzodiazepine dependenceBenzodiazepine dependence
Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...
as well as benzodiazepine withdrawal is associated with self-harming behaviour in young people. Alcohol is a major risk factor for self-harm. A study which analysed self-harm presentations to emergency rooms in Northern Ireland
Northern Ireland
Northern Ireland is one of the four countries of the United Kingdom. Situated in the north-east of the island of Ireland, it shares a border with the Republic of Ireland to the south and west...
found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations. A recent study in the relation between cannabis use and deliberate self-harm (DSH) in Norway and England, found that, in general, cannabis
Cannabis
Cannabis is a genus of flowering plants that includes three putative species, Cannabis sativa, Cannabis indica, and Cannabis ruderalis. These three taxa are indigenous to Central Asia, and South Asia. Cannabis has long been used for fibre , for seed and seed oils, for medicinal purposes, and as a...
use may not be a specific risk factor for DSH in young adolescents.
Pathophysiology
Self-harm is not typically suicidal behaviour, although there is the possibility that a self-inflicted injury may result in life-threatening damage. Although the person may not recognise the connection, self-harm often becomes a response to profound and overwhelming emotional pain that cannot be resolved in a more functional way.The motivations for self-harm vary as it may be used to fulfill a number of different functions. These functions include self-harm 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 also a positive statistical correlation between self-harm and emotional abuse. Self-harm may become a means of managing and controlling pain
Suffering
Suffering, or pain in a broad sense, is an individual's basic affective experience of unpleasantness and aversion associated with harm or threat of harm. Suffering may be qualified as physical or mental. It may come in all degrees of intensity, from mild to intolerable. Factors of duration and...
, in contrast to the pain experienced earlier in the sufferers life of which they had no control over (e.g. through abuse).
Other motives for self-harm do not fit into medicalised models of behaviour and may seem incomprehensible to others, as demonstrated by this quotation:
"My motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. This may sound strange."
Assessment of motives in a medical setting is usually based on precursors to the incident, circumstances and information from the patient. However, limited studies show that professional assessments tend to suggest more manipulative or punitive motives than personal assessments.
The UK ONS study reported only two motives: "to draw attention" and "because of anger". For some people harming themselves can be a means of drawing attention to the need for help and to ask for assistance in an indirect way. It may also be an attempt to affect others and to manipulate them in some way emotionally. However, those with chronic, repetitive self-harm often do not want attention and hide their scars carefully.
Many people who self-harm 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-harm instead of the issues they were facing previously: the physical pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
therefore acts as a distraction from the original emotional pain. 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." 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).
Those who engage in self-harm face the contradictory reality of harming themselves while 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-harmers this relief is primarily psychological while for others this feeling of relief comes from the beta endorphins
Endorphin
Endorphins are endogenous opioid peptides that function as neurotransmitters. They are produced by the pituitary gland and the hypothalamus in vertebrates during exercise, excitement, pain, consumption of spicy food, love and orgasm, and they resemble the opiates in their abilities to produce...
released in the brain. 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. Many self-harmers report feeling very little to no pain while self-harming and, for some, deliberate self-harm may become a means of seeking pleasure.
Alternatively, self-harm may be a means of feeling something, even if the sensation is unpleasant and painful. Those who self-harm sometimes describe feelings of emptiness
Emptiness
Emptiness as a human condition is a sense of generalized boredom, social alienation and apathy. Feelings of emptiness often accompany dysthymia, depression, loneliness, despair, or other mental/emotional disorders such as borderline personality disorder...
or numbness (anhedonia
Anhedonia
In psychology and psychiatry, anhedonia is defined as the inability to experience pleasure from activities usually found enjoyable, e.g. hobbies, exercise, social interaction or sexual activity....
), 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'."
As a coping mechanism, self-harm can become psychologically addictive because, to the self-harmer, it works; it enables him or 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-harm, can also create a behavioural pattern that can result in a wanting or craving to fulfill thoughts of self-harm.
Awareness
There are many movements among the general self-harm community to make self-harm itself and treatment better known to mental health professionals as well as the general public. For example, March 1 is designated as Self-injury Awareness DaySelf-injury Awareness Day
Self-injury Awareness Day is a grassroots annual global awareness event / campaign on March 1, where on this day, and in the weeks leading up to it, some people choose to be more open about their own self-harm, and awareness organizations make special efforts to raise awareness about self-harm and...
(SIAD) around the world. On this day, some people choose to be more open about their own self-harm, and awareness organisations make special efforts to raise awareness about self-harm. Some people wear an orange awareness ribbon or wristband
Gel bracelet
Gel bracelets, or jelly bracelets are an inexpensive type of wristband. They come in a variety of colors, and several can be worn on each arm. They have been popular in waves throughout the Western world and elsewhere since the 1980s...
to encourage awareness of self-harm.
Treatment
There is considerable uncertainty about which forms of psychosocialPsychosocial
For a concept to be psychosocial means it relates to one's psychological development in, and interaction with, a social environment. The individual needs not be fully aware of this relationship with his or her environment. It was first commonly used by psychologist Erik Erikson in his stages of...
and physical treatments of patients who harm themselves are most effective and as such further clinical studies are required. Psychiatric and personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
s are common in individuals who self-harm and as a result self-harm may be an indicator of depression and/or other psychological problems. Many people who self-harm suffer from moderate or severe clinical depression and therefore treatment with antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
drugs may often be effective in treating these patients. Cognitive behavioural therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
may also be used (where the resources are available) to assist those with Axis I diagnoses, such as depression, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, and bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
. Dialectical behaviour 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-harming behaviour. Diagnosis and treatment of the causes of self-harm is thought by many to be the best approach to treating self-harm. 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-harm are sometimes psychiatrically hospitalised, based on their stability, and their ability and especially their willingness to get help.
In individuals with developmental disabilities, occurrence of self-harm 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-harm 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-harm thus is to teach an alternative, appropriate response which obtains the same result as the self-harm.
Avoidance techniques
Generating alternative behaviours that the sufferer can engage in instead of self-harm is one successful behavioural method that is employed to avoid self-harm. 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. The removal of objects used for self-harm from easy reach is also helpful for resisting self-harming urges. 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-harm. 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. Using biofeedbackBiofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
may help raise self-awareness in the sufferer of certain pre-occupations or particular mental state or mood that precede bouts of self-harming behaviour, and help the sufferer identify techniques to avoid those pre-occupations before they lead to self-harm. Any avoidance or coping strategy must be appropriate to the individual's motivation and reason for harming.
Epidemiology
It is difficult to gain an accurate picture of incidence and prevalence of self-harm. This is due in a part to a lack of sufficient numbers of dedicated research centres to provide a continuous monitoring system. However, even with sufficient resources, statistical estimates are crude since most incidences of self-harm are undisclosed to the medical profession as acts of self-harm are frequently carried out in secret, and wounds may be superficial and easily treated by the individual. Recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys. About 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses. However, 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, 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.The best available research indicates that in the United States up to 4% of adults self-harm with approximately 1% of the population engaging in chronic or severe self-harm. Current research suggests that the rates of self-harm are much higher among young people with the average age of onset between 14 and 24. The earliest reported incidents of self-harm are in children between 5 and 7 years old. In the UK in 2008 rates of self-harm in young people could be as high as 33%. In addition there appears to be an increased risk of self-harm in college students than among the general population. In a study of undergraduate students in the US, 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-harm 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 Ireland, a study found that instances of hospital-treated self-harm were much higher in City and Urban Districts, than in Rural settings. The CASE (Child & Adolescent Self-harm in Europe) study suggests that the life-time risk of self-injury is ~1:7 for women and ~1:25 for men.
Gender differences
In general, the latest aggregated research has found no difference in the prevalence of self-harm between men and women. This is in contrast to past research which indicated that up to four times as many females as males have direct experience of self-harm. However, caution is needed in seeing self-harm as a greater problem for females, since males may engage in different forms of self-harm (e.g. hitting themselves) which could be easier to hide or explained as the result of different circumstances. Hence, there remain widely opposing views as to whether the gender paradox is a real phenomenon, or merely the artifact of bias in data collection.The WHO
Who
Who may refer to:* Who , an English-language pronoun* who , a Unix command* Who?, one of the Five Ws in journalism- Art and entertainment :* Who? , a 1958 novel by Algis Budrys...
/EURO Multicentre Study of Suicide, established in 1989, demonstrated that, for each age group, the female rate of self-harm 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. 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.
This gender discrepancy is often distorted in specific populations where rates of self-harm 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-harm among 428 homeless and runaway youth (age 16 to 19) with 72% of males and 66% of females reporting a past history of self-harm. However, in 2008, a study of young people and self-harm saw the gender gap close, with 32% of young females, and 22% of young males admitting to self-harm. Studies also indicate that males who self-harm may also be at a greater risk of completing suicide.
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. 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. 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.
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 by the absence of factors known to be associated with repetition, such as personality disorder and alcohol abuse. However, NICE Guidance on Self-harm in the UK suggests that older people who self-harm are at a greater risk of completing suicide, with 1 in 5 older people who self-harm going on to end their life. A study completed in Ireland showed that older Irish adults have high rates of deliberate self-harm, but comparatively low rates of suicide.Developing world
Only recently have attempts to improve health in the developing world concentrated on not only physical illness but mental health also. 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 and self-poisoning with agricultural pesticidePesticide
Pesticides are substances or mixture of substances intended for preventing, destroying, repelling or mitigating any pest.A pesticide may be a chemical unicycle, biological agent , antimicrobial, disinfectant or device used against any pest...
s or natural poisons. Many people admitted for deliberate self-poisoning during a study by Eddleston et al. 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. One way of reducing self-harm would be to limit access to poisons; 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.
Prison inmates
Deliberate self-harm is especially prevalent in prison populations. A proposed explanation for this is that prisons are often violent places, and prisoners who wish to avoid physical confrontations may resort to self-harm as a ruse, either to convince other prisoners that they are dangerously insane and resilient to pain or to obtain protection from the prison authorities.History
The term "self-mutilation" occurred in a study by L.E. Emerson in 1913 where he considered self-cutting a symbolic substitution for masturbation. The term reappeared in an article in 1935 and a book in 1938 when Karl MenningerKarl Menninger
Karl Augustus Menninger , was an American psychiatrist and a member of the famous Menninger family of psychiatrists who founded the Menninger Foundation and the Menninger Clinic in Topeka, Kansas.- Biography :...
refined his conceptual definitions of self-mutilation. His study on self-destructiveness differentiated between suicidal behaviours 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 six types:
- neurotic – nail-biters, pickers, extreme hair removal and unnecessary cosmetic surgery.
- religious – self-flagellants and others.
- puberty rites – hymen removal, circumcision or clitoral alteration.
- psychotic – eye or ear removal, genital self-mutilation and extreme amputation
- organic brain diseases – which allow repetitive head-banging, hand-biting, finger-fracturing or eye removal.
- conventional – nail-clipping, trimming of hair and shaving beards.
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. Ross and McKay (1979) categorized self-mutilators into 9 groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling and hitting and constricting.
After the 1970s the focus of self-harm shifted from Freudian psycho-sexual drives of the patients.
Walsh and Rosen (1988) created four categories numbered by Roman numerals I–IV, defining Self-mutilation as rows II, III and IV
| Classification | Examples of Behavior | Degree of Physical Damage | Psychological State | Social Acceptability |
|---|---|---|---|---|
| I | Ear-piercing, nail-biting, small tattoos, cosmetic surgery (not considered self-harm 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 | Accepted by some subgroups but not by the general population |
| IV | Auto-castration Castration Castration is any action, surgical, chemical, or otherwise, by which a male loses the functions of the testicles or a female loses the functions of the ovaries.-Humans:... , 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. 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-harm.
Society and culture
Ritual
A ritual is a set of actions, performed mainly for their symbolic value. It may be prescribed by a religion or by the traditions of a community. The term usually excludes actions which are arbitrarily chosen by the performers....
practice by cultures such as the ancient Maya civilization
Maya civilization
The Maya is a Mesoamerican civilization, noted for the only known fully developed written language of the pre-Columbian Americas, as well as for its art, architecture, and mathematical and astronomical systems. Initially established during the Pre-Classic period The Maya is a Mesoamerican...
, in which the Maya priesthood
Maya priesthood
Until the discovery that Maya stelae depicted kings instead of high priests, the Maya priesthood and their preoccupations had been a main scholarly concern. In the course of the 1960s and over the following decades, however, dynastic research marginalized interest in the subject...
performed auto-sacrifice
Sacrifice
Sacrifice is the offering of food, objects or the lives of animals or people to God or the gods as an act of propitiation or worship.While sacrifice often implies ritual killing, the term offering can be used for bloodless sacrifices of cereal food or artifacts...
by cutting and piercing their bodies in order to draw blood. A reference to the priests of Baal
Baal
Baʿal is a Northwest Semitic title and honorific meaning "master" or "lord" that is used for various gods who were patrons of cities in the Levant and Asia Minor, cognate to Akkadian Bēlu...
"cutting themselves with blades until blood flowed" can be found in the Hebrew Bible. However, in Judaism, such self-harm is forbidden under Mosaic law.
Self-harm is also practised by the sadhu
Sadhu
In Hinduism, sādhu denotes an ascetic, wandering monk. Although the vast majority of sādhus are yogīs, not all yogīs are sādhus. The sādhu is solely dedicated to achieving mokṣa , the fourth and final aśrama , through meditation and contemplation of brahman...
or Hindu ascetic, in Catholic mortification of the flesh
Mortification of the flesh
Mortification of the flesh literally means "putting the flesh to death". The term is primarily used in religious and spiritual contexts. The institutional and traditional terminology of this practice in Catholicism is corporal mortification....
, in ancient Canaanite mourning rituals as described in the Ras Shamra tablets and in the Shi'ite annual ritual of self-flagellation
Flagellant
Flagellants are practitioners of an extreme form of mortification of their own flesh by whipping it with various instruments.- History :Flagellantism was a 13th and 14th centuries movement, consisting of radicals in the Catholic Church. It began as a militant pilgrimage and was later condemned by...
, using chains and swords, that takes place during Ashura
Day of Ashura
The Day of Ashura is on the 10th day of Muharram in the Islamic calendar and marks the climax of the Remembrance of Muharram.It is commemorated by Shia Muslims as a day of mourning for the martyrdom of Husayn ibn Ali, the grandson of the Islamic Prophet Muhammad at the Battle of Karbala on 10...
where the Shi'ite sect mourne the martyrdom of Imam Hussein.
In other animals
Self-harm in non-human mammals is a well-established, although not a widely-known phenomenon; its study under zoo or laboratory conditions could lead to a better understanding of self-harm in human patients. Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self-harm in higher mammals, e.g. macaque monkeys. Lower mammals are also known to mutilate themselves under laboratory conditions after administration of drugs. For example pemolinePemoline
Pemoline was first synthesized in 1913 but it's activity was not discovered until the 1930s. Under the names it was used as a medication used to treat attention-deficit hyperactivity disorder and narcolepsy. Under the Convention on Psychotropic Substances, it is a Schedule IV drug...
, clonidine
Clonidine
Clonidine is a sympatholytic medication used to treat medical conditions, such as high blood pressure, some pain conditions, ADHD and anxiety/panic disorder...
, amphetamine
Amphetamine
Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...
, and very high (toxic) doses of caffeine
Caffeine
Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
or theophylline
Theophylline
Theophylline, also known as dimethylxanthine, is a methylxanthine drug used in therapy for respiratory diseases such as COPD and asthma under a variety of brand names. Because of its numerous side-effects, the drug is now rarely administered for clinical use. As a member of the xanthine family, it...
are known to precipitate self-harm in lab animals. In dogs, canine obsessive-compulsive disorder can lead to self-inflicted injuries, for example canine lick granuloma
Lick granuloma
A lick granuloma, also known as acral lick dermatitis, is a skin disorder in dogs resulting from an urge to lick the lower portion of the leg. The lesion from the incessant licking is a thickened, firm, oval plaque.-Causes:...
. Captive birds are sometimes known to engage in feather-plucking
Feather-plucking
Feather-plucking, sometimes termed feather-picking, feather damaging behaviour or pterotillomania, is a maladaptive, behavioural disorder commonly seen in captive birds which chew, bite or pluck their own feathers with their beak, resulting in damage to the feathers and occasionally the skin...
, causing damage to feathers that can range from feather shredding to the removal of most or all feathers within the bird's reach, or even the mutilation of skin or muscle tissue.
External links
- Information about self-harm from the Royal College of PsychiatristsRoyal College of PsychiatristsThe Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom responsible for representing psychiatrists, psychiatric research and providing public information about mental health problems...
- Men Who Self Harm BBC Radio 4BBC Radio 4BBC Radio 4 is a British domestic radio station, operated and owned by the BBC, that broadcasts a wide variety of spoken-word programmes, including news, drama, comedy, science and history. It replaced the BBC Home Service in 1967. The station controller is currently Gwyneth Williams, and the...
item discussing Self-Harm. - Understanding self-harm from Mind: A mental health charity in England and Wales
- Youth & Self Injury Information from the Canadian Mental Health AssociationCanadian Mental Health AssociationThe Canadian Mental Health Association was founded on January 26, 1918 by Dr. Clarence M. Hincks and Clifford W. Beers. Originally named the Canadian National Committee for Mental Hygiene, it is one of the oldest voluntary health organizations still operating in Canada.Each year, CMHA divisions...