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May 23, 2012

Self-Harm

What is self-harm?

Self-harm" refers to the deliberate, direct destruction of body tissue that results in tissue damage. When someone engages in self-harm, they may have a variety of intentions; these are discussed below. However, the person's intention is NOT to kill themselves. You may have heard self-harm referred to as "parasuicide," "self-mutilation," "self-injury," "self-abuse," "cutting," "self-inflicted violence," and so on.

How common is self-harm?

Self-harm is not well-understood and has not yet been extensively studied. The rates of self-harm revealed through research vary tremendously depending on how researchers pose their questions about this behavior.


One widely cited estimate of the incidence of impulsive self-injury is that it occurs in at least 1 person per 1,000 annually (Favazza, 1996). A recent study of psychiatric outpatients found that 33% reported engaging in self-harm in the previous 3 months (Zlotnick, Mattia, & Zimmerman, 1999). A recent study of college undergraduates (Gratz, Conrad, & Roemer, 2002) asked study participants about specific self-harm behaviors and found alarmingly high rates. Although the high rates may have been due in part to the broad spectrum of self-harm behaviors that were assessed (e.g., severe scratching and interfering with the healing of wounds were included), the numbers are certainly cause for concern:
  • 18% reported having harmed themselves more than 10 times in the past,
  • 10% reported having harmed themselves more than 100 times in the past, and
  • 38% endorsed a history of deliberate self-harm.
  • The most frequently reported self-harm behaviors were needle sticking, skin cutting, and scratching, endorsed by 16%, 15%, and 14% of the participants, respectively.
It is important to note that research on self-harm is still in the early stages, and these rates may change as researchers begin to utilize more consistent definitions of self-harm and more studies are completed.

Who engages in self-harm?

Only a handful of empirical studies have examined self-harm in a systematic, sound manner. Self-harm appears to be more common in females than in males, and it tends to begin in adolescence or early adulthood. While some people may engage in self-harm a few times and then stop, others engage in it frequently and have great difficulty stopping the behavior (Simeon & Hollander, 2001). Several studies (e.g., Gratz et al., 2002; Van der Kolk, Perry, & Herman, 1991; Zlotnick et al., 1996) have found that individuals who engage in self-harm report unusually high rates of histories of:
  • Childhood sexual abuse
  • Childhood physical abuse
  • Emotional neglect
  • Insecure attachment
  • Prolonged separation from caregivers
At least two studies have attempted to determine whether particular characteristics of childhood sexual abuse place individuals at greater risk for engaging in self-harm as adults. Both studies reported that more severe, more frequent, or a longer duration of sexual abuse was associated with an increased risk of engaging in self-harm in one's adult years (Boudewyn & Liem, 1995; Turell & Armsworth, 2000).

Also, individuals who self-harm appear to have higher rates of the following psychological problems (Simeon & Hollander, 2001; Zlotnick et al., 1999; Zlotnick et al., 1996):
  • High levels of dissociation
  • Borderline personality disorder
  • Substance abuse disorders
  • Posttraumatic stress disorder
  • Intermittent explosive disorder
  • Antisocial personality
  • Eating disorders
Why do people engage in self-harm?

While there are many theories about why individuals harm themselves, the answer to this question varies from individual to individual (Conterio & Lader, 1998; Favazza, 1998).

Some reasons why people engage in self-harm:
  • To distract themselves from emotional pain by causing physical pain
  • To punish themselves
  • To relieve tension
  • To feel real by feeling pain or seeing evidence of injury
  • To feel numb, zoned out, calm, or at peace
  • To experience euphoric feelings (associated with release of endorphins)
  • To communicate their pain, anger, or other emotions to others
  • To nurture themselves (through the process of healing the wounds)
How is self-harm treated?

Self-harm is a problem that many people are embarrassed or ashamed to discuss. Often, individuals try to hide their self-harm behaviors and are very reluctant to seek needed psychological or even medical treatment.

Psychological Treatments

Because self-harm is often associated with other psychological problems, it tends to be treated under the umbrella of a co-occurring disorder like a substance abuse problem or an eating disorder. Sometimes the underlying feelings that cause the self-harm are the same as those that cause the co-occurring disorder. For example, a person's underlying feelings of shame may cause them to abuse drugs and cut themselves. Often, the self-harm can be addressed in the context of therapy for an associated problem. For example, if people can learn healthy coping skills to help them deal with their urges to abuse substances, they may be able to apply these same skills to their urges to harm themselves.

There are also some treatments that specifically focus on stopping the self-harm. A good example of this is Dialectical Behavior Therapy (DBT; Linehan, 1993), a treatment that involves individual therapy and group skills training. DBT is a therapy approach that was originally developed for individuals with borderline personality disorder who engage in self-harm or "parasuicidal behaviors." Now the treatment is also being used for self-harming individuals with a wide variety of other psychological problems, including eating disorders and substance dependence. The theory behind DBT is that individuals tend to engage in self-harm in an attempt to regulate or control their strong emotions. DBT teaches clients alternative ways of managing their emotions and tolerating distress. Research has shown that DBT is helpful in reducing self-harm.

Pharmacological Treatments

It is possible that psychopharmacological treatments would be helpful in reducing self-harm behaviors, but this has not yet been rigorously studied. As yet, there is no consensus regarding whether or not psychiatric medications should be used in relation to self-harm behaviors. This is a complicated issue to study because self-harm can occur in many different populations and co-occur with many different kinds of psychological problems. If you are wondering about the use of medications for the emotions related to your self-harm behaviors, we recommend that you discuss this with your doctor or psychiatrist.

How to find a qualified psychologist or psychiatrist

If you are trying to find a psychologist or psychiatrist, we advise you to ask them whether they are familiar with self-harm. Consider which issues are important to you and make sure you can talk to the potential therapist about them. Remember that you are the consumer-you have the right to interview therapists until you find someone with whom you feel comfortable. You may want to ask trusted friends or medical professionals for referrals to psychologists or psychiatrists. Consider asking your potential provider questions, such as:
  • How do you treat self-harm?
  • What do you think causes self-harm?
  • Do you have experience in treating self-harm?
Self-help Resources

There are a variety of self-help books on the market for people who engage in self-harm. Most of these provide practical advice, support, and coping skills that may be helpful to individuals who engage in self-harm. These approaches have not been studied in research trials, so it is not known how effective they are for individuals who self-harm. Two books that may be useful to individuals who self-harm are:

Alderman, T. (1997). The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland, CA: New Harbinger Publications.

Conterio, K., & Lader, W. (1998). Bodily Harm: The Breakthrough Healing Program for Self-Injurers. New York: Hyperion.

My friend or relative self-harms. What should I do to be supportive?

If you have a friend or relative who engages in self-harm, it can be very distressing and confusing for you. You may feel guilty, angry, scared, powerless, or any number of things. Both of the books mentioned above contain chapters for friends and family members. Some general guidelines are:
  • Take the self-harm seriously by expressing concern and encouraging the individual to seek professional help.
  • Don't get into a power struggle with the individual-ultimately they need to make the choice to stop the behavior. You cannot force them to stop.
  • Don't blame yourself. The individual who is self-harming initiated this behavior and needs to take responsibility for stopping it.
  • If the individual who is self-harming is a child or adolescent, make sure the parent or a trusted adult has been informed and is seeking professional help for them.
  • If the individual who is engaging in self-harm does not want professional help because he or she doesn't think the behavior is a problem, inform them that a professional is the best person to make this determination. Suggest that a professional is a neutral third party who will not be emotionally invested in the situation and so will be able to make the soundest recommendations.
References

Boudewyn, A.C., & Liem, J.H. (1995). Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood. Journal of Traumatic Stress, 8, 445 - 459.

Conterio, K., & Lader, W. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York: Hyperion.

Favazza, A. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry (2nd ed.). Baltimore, MD: The Johns Hopkins University Press.

Favazza, A. (1998). The coming of age of self-mutilation. Journal of Nervous and Mental Disease, 186, 259 - 268.

Gratz, K.L., Conrad, S.D., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128 - 140.

Linehan, M.M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: The Guilford Press.

Simeon, D., & Hollander, E. (Eds.). (2001). Self injurious behaviors: Assessment and treatment. Washington, DC: American Psychiatric Press.

Turell, S.C., & Armsworth, M.W. (2000). Differentiating incest survivors who self-mutilate. Child Abuse & Neglect, 24, 237 - 249.

Van der Kolk, B.A., Perry, J.C., & Herman, J.L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665 - 1671.

Zlotnick, C., Mattia, J.I., & Zimmerman, M. (1999). Clinical correlates of self-mutilation in a sample of general psychiatric patients. The Journal of Nervous and Mental Disease, 187, 296 - 301.

Zlotnick, C., Shea, M.T., Pearlstein, T., Simpson, E., Costello, E., & Begin, A. (1996). The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive Psychiatry, 37, 12 - 16.

Source: National Center for PTSD Fact Sheet
Author: Laura E. Gibson, Ph.D., The University of Vermont

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