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In A Better You

Self Mutilation

Not everyone knows what is self mutilation. The self mutilation definition given by the National Institutes of Health is “intentional and direct harm to one’s body without the intent of committing suicide.” This includes many types of acts causing self-harm to the body. These acts committed on the body by oneself include: cutting, burning, scratching, biting, hair-pulling, lip-biting, and picking at wounds. It extreme cases, it includes breaking bones or self-amputation. The self mutilation disorder comes along with a genetic disorder called Lesch-Nyhan syndrome where self-injurious behavior takes the form of lip biting, biting fingers, scratching the face, gouging eyes, and head-banging.

The non-genetically determined forms of self mutilation are personality disorders which typically manifest in late childhood and early teens. The most common form of this behavior is self-cutting, which is seen in self mutilation photos showing multiple cuts or scars frequently on the arms. Self mutilation is now more politely called self-injury.

History

The history of self-injury goes back at least as far as Biblical times, when Jesus encountered a man, thought to suffer from demonic possession, who was “Always, night and day, in the tombs and in the mountains, he was crying out, and cutting himself with stones.” (Mark 5:1-20)

Later, a religious practice, called flagellation appeared around the 15th century. Flagellation is the practice of harming oneself as part of a religious ritual. The concept is to punish oneself, such as whipping oneself, to simulate the punishment undergone by Jesus and suffer in such a way as to become closer to God. This practice is still used in modern times, especially around the time of Easter in such countries as Spain and the Philippines. ABC News reported modern Pope John Paul practiced self-flagellation by whipping himself with a special belt he kept for just this purpose. Religious practice differs significantly from mental health disorders, yet they are similar because both arise from a feeling of unworthiness.

In a clinical setting, self-injury was first recognized as a symptom of Borderline Personality Disorder (BPD). BPD is a mental health disorder characterized by severe emotional instability. Self-injury is one of the eight conditions used to diagnose BPD. BPD may include self-injury as a symptom; however self-injury may also exist on its own, or combined with other disorders, without the presence of BPD.

Current Status

Self-injury may also be called self-harm, self-inflicted violence, or self-injurious behavior. The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders. The most current version is the DSM-5. In DSM-5 self-injury is now classified as a separate disorder, officially called Non-Suicidal Self Injury (NSSI). The severity of self-injury must reach a certain level to achieve classification as a mental health disorder. For a diagnosis of NSSI, a person would have five or more days of self-harm over the course of one year, without intending to commit suicide. A mistaken belief is self-injury is attention seeking behavior. Most self-injurers go to great lengths to hide what they are doing.

According to a report in the New York Times it is possible self-injury is on the rise among teenagers. Empirical evidence from research reported in the Journal of the American Board of Family Medicine suggests self-injury is increasing in teenagers and young adults. The Internet has spread more information about self-injury. Famous celebrities such as the late Princess Diana, Angelina Jolie and Johnny Depp, as well as many others, gave their own personal stories about self-injury. More openness, about what was previously hidden, is a contributing factor about why self-injury statistics are increasing.

Demographics

An article which appeared in the JABFM entitled Nonsuicidal Self-Injury states 1% to 4% of Americans have experienced self-injury with about 1% of Americans having severe and reoccurring self-injury episodes. This is over 3 million people. Between 70% to 75% of patients with Borderline Personality Disorder also exhibit self-injury.

Prevalence in Teens and Young Adults

About 15% of teens report some form of self-injury. The rates in college students are even higher and are in the range of 17% to 35%. In the past, there was the mistaken belief about women being more likely than men to self-injure. Current research indicates there is no significant difference in rates among genders. However; according to the JABFM Nonsuicidal Self-Injury article, men are more likely to burn or hit themselves, where women are more likely to cut or burn themselves.

Symptoms and Warnings Signs

WebMD gives the symptoms and warning signs of self-injury. They are the damage left behind, which has no other rational explanation and the occurrences of odd behavior.

Symptoms include:

  • Wounds, marks, or scars frequently found on places like the arms, legs, and upper torso where they are made by hand and are observable while being made. It is common for cutting marks to form a pattern, which is quite distinct and unlike marks which occur from accidental injury.
  • Burn marks, especially those made with a clothes iron, cigarette, candle flame, match, or lighter
  • Damage from excessive scratching such as raw red-colored skin
  • Bruises from self-punching.
  • Poke marks from needle sticks (different from needle marks made from drug use)
  • Finger or arm bites
  • Bruises from banging the head
  • Broken bones
  • Eye damage, redness, or infection from pressing on the eyes
  • Hair pulling
  • Picking at wounds (wounds take a long time to heal or never heal)

A word of caution, self-injury mimics injury from abuse, because is it self-abuse. If another person, such as a school nurse, discovers evidence of these injuries, it may not be apparent who caused them. Self-injurers hide what they are doing. The defense mechanisms of denial or displacement (blaming others) are likely upon discovery of self-injury by another person, which often is a source of confusion about what is happening.

Warning signs include:

  • Wearing clothes to cover injuries, such as long-sleeve shirts or pants even when hot outside.
  • Reluctance or refusal to go swimming, take part in gym class, or do any activity which exposes arms and or legs.
  • Finding razors, knives, needles, lighters, safety pins, or other sharp items tucked and hidden away somewhere. Often there will be a special “cutting” kit like a box to keep all these items. Teenagers sometimes hide razor blades in a mobile phone next to the battery.

Self-injury is more common with people who have trouble expressing feelings, have low self-esteem, have problems with relationships, troubles at home, and are doing poorly at work or school.

Combination of Causes

The Mayo Clinic says a combination of things cause self-injury. One of the main causes is the lack of ability to deal with feelings. Mental anguish, anxiety, distress, sexual identity crisis, and many other kinds of psychological pain are unbearable. For the self-injurer this pain reduces by replacing it with the physical pain of self-injury. In a backwards kind of way, the physical pain replaces the emotional pain and provides a sense of relief.

Often self-injurers feel worthless, lonely, rejected, isolated or guilty. They experience these emotional states as something being done to them by others, about which they have little or no control. If guilty, they feel the need for self punishment. When pain is intentionally inflicted by themselves on themselves, they are fully in control of the process. The physical pain helps distract from the emotional pain. For those with emotional apathy, feeling little or no emotions at all, physical pain is a way to at least feel something. It allows an external expression of an inside feeling.

Contributing Factors

According to the Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults there are contributing factors which are found in many patient’s background. These include: a history of abuse during childhood including neglect, sexual abuse or more importantly emotional abuse. Low self-esteem, social isolation, and unstable homes also increase the problem. Children who internalize things going wrong as somehow being their fault, sometimes turn to self-injury as punishment they feel they deserve. Even when abused, they may feel somehow they are the cause of the problem. Cornell reports self-injury has addictive qualities because of the release of endorphins caused by physical pain. Self-injurers often report the wish to stop, but are not able to control the behavior.

Diagnosis

There is no specific protocol for diagnosis of self-injury. Sometimes a medical practitioner notices the scars and the damage. Sometimes the self-injurer, who already knows there is a problem, seeks help to overcome a condition which now causes severe distress. The technical rule of thumb for a diagnosis of NSSI is self-injury which occurs more than 5 days within a one year period. Structured and unstructured interviews with a mental health practitioner skilled in self-injury is the best way to get the proper diagnosis.

Treatment

There are no medications for the specific treatment of self-injury. If other mental disorders co-exist with self-injury, such as depression, medications such as antidepressants are helpful. Treatment includes counseling and psychotherapy.

Therapeutic Techniques

The Mayo Clinic identifies four types of therapy for self-injury, which are:

Cognitive Behavioral Therapy – This is talk therapy either structured or unstructured. Structured talk therapy is where the therapist asks the patient a series of pre-determined questions or uses psychological testing methods. Unstructured therapy is more like a guided conversation. The goal is to talk-through negative beliefs about circumstances to replace them with healthier ones.

Dialectical Behavior Therapy – This type of therapy is about learning new skills on how to deal with emotions in positive ways, handle stress more effectively, and have better communication with others.

Psychodynamic Psychotherapy – This therapy focuses on past events with the goal to uncover the root source of the problem. It may include hypnotherapy to discover repressed memories. The therapist guides the patient in thorough self-examination.

Mindfulness-based Therapy – Meditation, relaxation practice, and learning how to live in the moment reduce anxiety.

Group therapy and family counseling is also helpful.

Prognosis

Self-injury might be increasing, but the statistics as reported by the Cornell Research Program have a wide range. In America, studies of youth and young adults show between 4% to 38% who self-injure. One thing is certain, the problem of self-injury is pervasive and should be given serious consideration. By definition, self-injury is not suicidal; nevertheless it can lead to suicide if not treated properly.

Helping a Person Who Self-Injures

The Mayo Clinic gives some excellent suggestions on how to cope if someone you love is a self-injurer. Judgment and criticism are not helpful. Neither are punishment, yelling, or threats. Tell your loved one, they do not have to face the challenge by themselves, and you love them no matter what. Learn what resources are available and find support. Talk with a qualified mental health counselor or therapist. Recovery comes from therapy which takes time. In the beginning the goal is harm minimization, with the goal of achieving complete abstinence.

The National Association of School Psychologists makes the following recommendations for teachers, staff, or nurses who notice self-harm happening on school campus. If the behavior is observed, immediately stop the behavior. If self-injury is only suspected, from noticeable scars or bruises, get the student to talk with a counselor so they can get a referral to a qualified mental health practitioner. Here is a guide they created (in pdf format) called Self-Mutilation: Information and Guidance for School Personnel.

Excellent treatment programs exist for adolescents. One example is S.A.F.E. Treatment Programs.

Prevention

Reduction in serious self-injury comes from reducing the contributing factors such as sexual abuse, child abuse, and emotional abuse which occurs in childhood and adolescence. The Mayo Clinic also suggests education and training in coping skills for youth and young adults, reducing social isolation, teach others who are in a position to help how to recognize self-injury behavior, and provide information about how to get help.

Summary

Self-injury is a major concern because it is likely the symptom of other serious underlying causes, so treatment is important. Seek professional help if you, or others you know, have difficulties with self-injury.

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