Self mutilation, a feature of self harm or self injury, is intentional injury to one’s own body tissues without an accompanying, conscious intention to commit suicide. Although this behavior can appear similar to a suicide attempt, the phrase “deliberate self harm” is preferred rather than “suicide attempt” because the reasons and motivation behind self harm or mutilation are generally quite different from those that underlie attempted suicide. Self mutilation is considered a coping mechanism.
Self mutilation and self harm are not explicitly listed as disorders in the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM, although some clinicians argue that they should be. The 2000 edition of the DSM (the Fourth Edition Text Revision, also known as DSM-IV-TR) mentions self-injury as a symptom or criterion for diagnosis of borderline personality disorder (abbreviated as BPD), stereotypic movement disorder, which can be a co-morbidity of autism or mental retardation, and
factitious disorder (specifically factitious disorder with predominantly physical signs and symptoms), in which the person fakes a physical illness. For example, the self-mutilation behavior in factitious disorder might involve pulling out hair or purposely exacerbating a healing wound to mimic disease symptoms. Self harm, including self mutilation, also can be associated with other disorders listed in the DSM-IV, including post-traumatic stress disorder, known as PTSD.
Self mutilation can take different forms and have different functions depending on the individual. In some nonpsychiatric subpopulations, self mutilation is a sanctioned activity; for example, among adolescents, some forms of mutilation of tissues are socially acceptable and done as a group. Self harm or self mutilation also can accompany cognitive deficits or psychosis, and in the most severe expression of the practice, can manifest as auto-castration or even self-immolation.
The focus of this entry is self mutilation that occurs in the absence of cognitive deficits or psychosis. In general, self mutilation remains poorly understood and comparatively little explored, especially in empirical studies. What is known is that this behavior can be a manifestation of anguish that the person cannot otherwise express, or it can be a way for the person to cope with and relieve tension. In some cases, it has been construed as a method of self punishment. In general, self mutilation results in so little actual harm to the body that medical professionals and even family members often do not know that the mutilation is taking place. In addition, the person who engages in self mutilation may go to great lengths to hide the resulting physical signs. The usual forms of self mutilation are sticking with needles, scratching, or cutting.
In general, the incidence of self harm has received more attention in clinical populations rather than in community or nonclinical groups. Groups at risk of self harm include depressed adolescents, those experiencing an interpersonal crisis, and those who have done it before. Although reported incidence in the research literature can vary from study to study, there is some overlap. Some studies report a rate of 4% in the general adult population and 21% in the adult clinical population. Adolescents make up the group at greatest risk: in the community, rates have been reported ranging from 14 to 39% of respondents and a range of 14 to 21% among high school students; in adolescent psychiatric inpatient samples, rates are as high as 40 to 61%. Studies have identified self-harm behaviors in 4% of military recruits and 14 to 35% of psychology students at public universities. Research indicates that self-mutilating behavior occurs among nonclinical populations at rates greater than previously thought.
Rates of frequent self-mutilation activity are significantly higher among lesbian and bisexual women, and the behavior was long thought to be more prevalent among females, although recent findings indicate a similar prevalence in both sexes. Although the function of self mutilation usually differs from the motivations underlying a suicide attempt, one study suggests that 20 to 45% of those who engage in self harm think about suicide. In addition, someone who experiences one episode of self harm may be likely to engage in another: as many as 30% of adolescents who report a previous incident of self harm will do it again.
Self injury is closely linked to dysfunctions of emotional expression. For some who self mutilate, the physical pain of cutting or scratching provides a distraction from emotional pain. Others may use self mutilation as a way to punish themselves or relieve a feeling of “evil,” while for others who engage in the practice, it offers a relief from tension or a way to “feel
real” through the physical pain or the visible evidence of physical injury. Causing physical pain to one’s body through self mutilation may also provide an outlet for a person who has difficulty communicating emotions like anger or emotional pain. In addition, people who engage in self mutilation may be trying, either consciously or subconsciously, to alter the behavior of someone near them or seek help, although many people who self harm go to great lengths to conceal the signs of the behavior.
The immediate triggers for self mutilation often center on some kind of interpersonal crisis. A person may have just experienced a separation from a partner or a major confrontation with a parent, or have just run away from home, for example.
The immediate causes of self mutilation in the absence of psychosis or social sanction can differ, and the risk factors also can differ based on the population subgroup studied and association with other psychiatric disorders. Because of this emerging variety of risk factors, some experts believe that focusing too much on a specific type of mistreatment or risk factor may result in overlooking the association of other factors.
There is a correlation between self harm and suicide attempts, feelings of hopelessness and other symptoms of depression, anxiety, external expectations of perfection, and most often, a history of abuse. Risk factors can be classified into two categories: those associated with the individual’s environment and those that are intrinsic to the individual. In addition, risk factors from one category can influence those of the other, and vice versa.
Environmental risk factors
Some of the most commonly seen environmental risk factors in self mutilation are associated with abuse experienced in childhood. Most research into the phenomenon of self harm has focused on sexual abuse, but there are some indications that self harm can also be associated with physical abuse and even emotional abuse, and it is strongly associated with low self esteem. Almost any discussion about factors directly related to self harm, however, is theoretical because of the paucity of actual experimental or empirical data.
In what may be a blurring of the distinction between socially sanctioned self mutilation and the kind of self mutilation discussed here, another risk factor for engaging in this behavior is awareness that others in one’s peer group are doing it. Substance abuse also can be a contributing factor, and depression may also lead a someone to turn to self mutilation as a coping mechanism. Perfectionism may also be a risk factor. Perfectionism consistently correlates with thoughts and behaviors related to self injury, but at least one study indicates that the type of perfectionism related to self mutilation arises from social requirements rather than from an individual’s self-requirements.
Individual risk factors
The interaction of environmental factors and personal factors arises because of the individual ways people respond to environmental risk factors. Researchers have identified alexithymia, which is the inability to express feelings verbally, as an individual risk factor. The importance of this inability to express emotion as a risk factor in self mutilation is underscored by research that suggests that self-harmers who learn to express their feelings verbally exhibit a decrease in the self-harming behavior.
The signs that a self-mutilation event has occurred are obvious, but less obvious are the symptoms that one will occur. A recent study found that individuals engaging in self-mutilating behavior usually thought about it for only a few minutes or even less time before doing the act; almost half reported not thinking about it at all before doing it. This association of impulse with self mutilation could be related to the specifics of the population studied, which was a group of adolescents who had previously self mutilated. High levels of dissociation—a defense mechanism to isolate and protect the psyche from thoughts, emotions, or physical sensations that cause anxiety—can accompany self-mutilating behavior.
There are some signs that may precede an impulsive act of self mutilation. These signs include trouble with parents, school, partners, or siblings, health problems, trouble with peers, including being bullied, depression, and low self esteem. Again, knowing that others in the peer group are doing it can also be a precipitating factor.
Many cases of self mutilation may never come to the attention of a clinician, parent, or caregiver. Often, identified self mutilation has occurred in the context of a personality disorder, such as BPD. It may also appear as a manifestation of other psychiatric disorders, including substance abuse, intermittent explosive disorder, and eating disorders. Below, specific information about self harm in the context of BPD and suicide is presented.
Self mutilation and borderline personality disorder
For a person with BPD, self-mutilating behavior offers relief during a dissociative episode by functioning as an affirmation of the ability to feel or by relieving the person’s personal feeling of being bad. Clinical populations with BPD have been the target of most studies focusing on self harm, and in these populations, emotional vulnerability appears to play a strong role in whether or not an individual will self harm and in the development of BPD itself. Emotional vulnerability involves two aspects: emotional reactivity, which is high sensitivity to stimuli, and emotional intensity, which is an extreme reaction to those stimuli. These factors are among the individual characteristics that might interact with environmental factors to elicit self-mutilating behaviors. Persons with BPD may have feel empty or detached to the point of anhedonia, an inability to experience pleasure from things that most people find pleasurable, such as eating good food. In addition, they may exhibit a narrow range of affect, the mood that a person displays to others. These signs of emotional inexpressivity may, according to some research, increase the possibility that a person with BPD will engage in self mutilating behavior.
Self mutilation and suicide
Because self mutilation can be interpreted as a “cry for help,” suicide can be a concern for those who become aware that an individual is self mutilating. Research suggests that there appears to be a distinction between the risk of suicide and impulsive self mutilation compared to self mutilation that is deliberate and well thought out. Statistically, 20 to 25% of self harmers think about suicide, and the risk of suicide after self harm ranges from 0.24 to 4.3%. Among the self-harming population, suicide risk factors include being an adolescent male, using a violent method for self harming, and a history of being an inpatient at a psychiatric facility. Some other features also are associated with conscious suicidal intent in a person who self mutilates: self mutilation performed alone, attempts to hide the behavior, preparations made for death, such as a plan for disposition of effects, or an act of self harm that was planned considerably in advance (i.e., it was not impulsive).
Treatments for self mutilation include dialectical behavioral therapy, problem-solving therapy, and cognitive behavioral therapy.
Dialectical behavioral therapy
This relatively new approach to therapy was developed by Marsha Linehan at the University of Washington. It focuses on teaching alternative ways to manage emotion and handle distress. The relationship between emotional inexpressivity and self harm suggests that those who engage in self-mutilating behaviors to express emotions might benefit from a clinical approach involving tutoring in other methods of emotional expression. Dialectical behavioral therapy, or DBT, which involves individual therapy and group skills training, was originally developed for individuals with BPD who engage in self-harm, but it is now used for self-harming individuals with a wide variety of other psychological issues, including eating disorders and substance dependence. Research indicates that the approach is helpful in reducing self-harm.
This form of therapy involves developing and rehearsing coping strategies for the situations that may precipitate self harm. The approach can involve the entire family, using structured family interventions over five or six sessions. There is a focus on improved cognitive and social skills to facilitate sharing feelings, controlling emotion, and family negotiation. Group treatment can also be a facet of problem-solving therapy. Briefly, this therapeutic approach identifies problems, prioritizes them, defines goals, and establishes and executes a strategy to achieve the goals, addressing any psychological issues that become obstacles along the way.
Cognitive behavioral therapy
In cases of self mutilation accompanied by depression, a suggested approach is cognitive behavioral therapy, which involves identifying patterns of destructive or negative behaviors or thinking and modifying them to be more realistic and pragmatic.
Other potential treatments for self mutilation in the context of other disorders include treatment for any substance abuse, anger management therapy, or environmental changes. There are no drugs specifically designated for treating self-mutilation behavior, but antidepressants might be prescribed if the behavior is accompanied by depression.
Some studies indicate that following self harm, some adolescents see improvement in their relationship with their parents. In addition, research suggests
Affect —the mood a person displays to others
Alexithymia —The inability to express some feelings verbally.
BPD —Borderline personality disorder, a mental disorder characterized by disturbed and unstable interpersonal relationships and self-image, along with impulsive, reckless, and often self-destructive behavior.
Dissociation —A defense mechanism to isolate and protect the psyche from thoughts, emotions, or physical sensations that cause anxiety
PTSD —Post-traumatic stress disorder, a psychiatric disorder precipitated by witnessing or experiencing an event involving serious injury or death. Those suffering from PTSD may experience such symptoms as nightmares, insomnia, flashbacks, and anxiety.
Self mutilation, self harm, self injury —Intentional injury to one’s own body tissues without an accompanying, conscious intention to commit suicide.
that self harm may result in more support from social networks. In terms of decreasing the incidence of self harming, self-harmers who learn to express their feelings verbally see a decrease in self-mutilating behaviors.
Due to the lack of research on the disorder, self mutilation remains a poorly understood phenomenon, and prevention measures have not been thoroughly explored. In addition, the mixed and varied development pathways that lead to self harm may complicate efforts at prevention. The risk factors for self harm are often associated with other pathologies, and an awareness of this association might be a potential aid in targeting prevention.
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National Center for PTSD, 1116D V.A. Medical Center, 215 N. Main Street, White River Junction, VT 05009-0001. (802)296-5132. http://www.ncptsd.org
Emily Jane Willingham, Ph.D.