Self-injury

Background
Self-injury (SI) or self-harm (SH) is deliberate injury inflicted by a person upon their own body without suicidal intent. Some scholars use more technical definitions related to specific aspects of this behavior. 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 depressive disorders, it is sometimes associated with mental illness, a history of trauma and abuse including emotional abuse, sexual abuse, eating disorders, or mental traits such as low self-esteem or perfectionism. Self harmers are often mistaken for being suicidal, but the majority of the time this is not the case. Non-fatal self-harm is common in young people worldwide and due to this prevailance the term self-harm is increasingly used to denote any non-fatal acts of deliberate self-harm, irrespective of the intention.

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. The term self-mutilation is also sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive. 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. 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. 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. Though this is not always the case, some individuals suffer from disassociation and they harbor a desire to feel real and/or to fit in to society's rules.

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". The number of self-injury methods are only limited by an individual's creativity. The bodily locations of self-injury are often areas that are easily hidden and concealed from the detection of others.

Examples of self-injury other than cutting include:


 * Punching, hitting and scratching
 * Choking or constriction of the airway
 * Biting of own body parts including the tongue, lips, hands or arms
 * Picking at or re-opening wounds (dermatillomania), ulceration, or sutures
 * Hair-pulling (trichotillomania)
 * Burning by self-incediarism, stubbing out cigarettes on skin, friction or chemical burns
 * Stabbing self with wire, pins, needles, nails, staples, pens or hair accessories
 * Pinching or clamping using, for example, clothes pins or paper clips
 * Ingesting corrosive chemicals, batteries, or pins
 * Self-poisoning; for example by over-dosing on medication and/or alcohol, without suicidal intent
 * Self-injury among individuals with developmental disabilities 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.
 * Constriction of the blood circulation via the use of rubber bands over a long period of time.
 * Self-inflicted starvation.

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. 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 voluntary organisation, LifeSIGNS.

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, though many people who self-injure would like this to be addressed.

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. This differs from the common definition of self-injury as the damage is inflicted for a specific secondary purpose.

Life style
Many teenagers who suffer from depression self harm, this can be from being emotionaly hurt or just a cry for attention. Teenagers who self harm are labled "Emo's" which is short for emotional.

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, phobias, and conduct disorders. Substance abuse is also considered a risk factor as are some personal characteristics such as poor problem resolution skills, impulsivity, hopelessness and aggression. 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. Abuse during childhood is accepted as a primary social factor, also losing a parent or loved one, along with troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. 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. However, some people who self-injure do not experience these factors.

Demographics
Accurate statistics on self-injury are hard to come by since most self-injurers conceal their injuries. Recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys. 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. 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 which suggests no gender differences were observed among skin-cutters.

The Mental Health Foundation estimates the rate in the UK to be 0.77%, 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. Many adolescents who present to general hospitals with deliberate self-harm report previous episodes for which they did not receive medical attention. A study of homeless youth (age 16 to 19) found that 69% 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.

About 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses. 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 unity for a number of years. . In a study of psychiatric morbidity carried out in the UK an overall lifetime prevalence of 2.4% was found, 2.0% of which were male and 2.7% of female.

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.

Gender differences
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 pathologised the female" and the profiling of self-injurers as female is the unsubstantiated result of social biases.

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. 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.

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.

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.

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

Self-harm in the developing world
Only recently have attempts to improve health in the developing world concentrated on not only physical illness, but mental health also. Deliberate self-harm is common in the developing world. For example, Sri Lanka has a high incidence of suicide and self poisoning with agricultural pesticides or natural poisons is an important cause of mortality in many rural areas. 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.

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."

Motives for self-injury can be different. Some feel as if they are not good enough and they might not want to take it out on the person who harmed them. It's often difficult for them to open up and tell about their "secret shame". Often when the sufferer does tell somebody there is a lack of understanding or knowledge of how to help.

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

The UK ONS study reported only two motives: “to draw attention” and “because of anger”. 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. 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).

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’." 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.

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.

Motives
Self-injury is not typically suicidal behavior, 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-injury often occurs when facing what seem like overwhelming or distressing feelings. The motivations for self-injury vary as it may be used to fulfill a number of different functions. These functions include self-injury being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness and a sense of failure or self-loathing. There is a positive statistical correlation between self-injury and emotional abuse. Intense pain can lead to the release of endorphins and so deliberate self-harm may become a means of seeking pleasure, although in many cases self-injury becomes a means to manage pain, in contrast to the pain that may have been experience through abuse earlier in the sufferers life of which they had no control over. For some people harming oneself can be a way to draw attention to the need for help and to ask for assistance in an indirect way but may also be an attempt to affect others and to manipulate them in some way emotionally. However, those with chronic, repetitive self injury often do not want attention and hide their scars carefully.

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. Self Injury Awareness Day (SIAD), 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 organisations 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. 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. 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.

Treatment
There is considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective and as such further clinical studies are required. Psychiatric and personality disorders are common in individuals who self-harm and as a result self-injury may be an indicator of depression and/or other psychological problems. Many people who self-harm suffer from moderate or severe clinical depression and therefore treatment with antidepressant drugs may often be indicated for these patients. Cognitive Behavioral Therapy may also be used (where the resources are available) to assist those with axis 1 diagnoses, such as depression, schizophrenia, and bipolar disorder. DBT, or Dialectical behavioral therapy can be very successful for those individuals exhibiting a personality disorder, and could potentially be used for those with other mental illnesses who exhibit self-injurious behavior. Diagnosis and treatment of the causes of self-harm 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, so more clinicians are starting to take a DBT approach in order to reduce the behavior itself. People who self-injure 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.

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.