Self-harm

Self-harm refers to intentional behaviors that cause harm to oneself. This is most commonly regarded as direct injury of one's own skin tissues, usually without suicidal intention.^[1][2][3] Other terms such as cutting, self-injury, and self-mutilation have been used for any self-harming behavior regardless of suicidal intent.^[2][4] Common forms of self-harm include damaging the skin with a sharp object or scratching with the fingernails, hitting, or burning. The exact bounds of self-harm are imprecise, but generally exclude tissue damage that occurs as an unintended side-effect of eating disorders or substance abuse, as well as more societally acceptable body modification such as tattoos and piercings.^[5]

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This article needs more reliable medical references for verification or relies too heavily on primary sources. (August 2023)

Quick Facts Other names, Specialty ...

Self-harm
Other names	Deliberate self-harm (DSH), self-injury (SI), nonsuicidal self-injury (NSSI), cutting
Healed scars on the forearm from prior self-harm
Specialty	Psychiatry, surgery, or emergency medicine if serious injuries occur

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Although self-harm is by definition non-suicidal, it may still be life-threatening.^[6] People who do self-harm are more likely to die by suicide,^[3][7] and self-harm is found in 40–60% of suicides.^[8] Still, only a minority of those who self-harm are suicidal.^[9][10]

The desire to self-harm is a common symptom of some personality disorders. People with other mental disorders may also self-harm, including those with depression, anxiety disorders, substance abuse, mood disorders, eating disorders, post-traumatic stress disorder, schizophrenia, dissociative disorders, psychotic disorders, as well as gender dysphoria or dysmorphia. Studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions.^[2] Self-harm can also occur in high-functioning individuals who have no underlying mental health diagnosis.

The motivations for self-harm vary; some use it as a coping mechanism to provide temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness, or a sense of failure. Self-harm is often associated with a history of trauma, including emotional and sexual abuse.^[11][12] There are a number of different methods that can be used to treat self-harm, which concentrate on either treating the underlying causes, or on treating the behavior itself. 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.^[13]

Self-harm tends to begin in adolescence. Self-harm in childhood is relatively rare, but the rate has been increasing since the 1980s.^[14] Self-harm can also occur in the elderly population.^[15] The risk of serious injury and suicide is higher in older people who self-harm.^[16] Captive animals, such as birds and monkeys, are also known to harm themselves.^[17]

This section possibly contains synthesis of material that does not verifiably mention or relate to the main topic. (August 2023)

Although the 20th-century psychiatrist Karl Menninger is often credited with the initial clinical characterization of self-harm, self-harm is not a new phenomenon.^[18] There is frequent reference in 19th-century clinical literature and asylum records which make a clear clinical distinction between self-harm with and without suicidal intent.^[19] This differentiation may have been important to both safeguard the reputations of asylums against accusations of medical neglect and to protect patients and their families from the legal or religious consequences of a suicide attempt.^[19] In 1896, the American ophthalmologists George Gould and Walter Pyle categorized self-mutilation cases into three groups: those resulting from "temporary insanity from hallucinations or melancholia; with suicidal intent; and in a religious frenzy or emotion".^[20]

Self-harm was, and in some cases continues to be, a ritual practice in many cultures and religions.

The Maya priesthood performed auto-sacrifice by cutting and piercing their bodies in order to draw blood.^[21] A reference to the priests of Baal "cutting themselves with blades until blood flowed" can be found in the Hebrew Bible.^[22] However, in Judaism, such self-harm is forbidden under Mosaic law.^[23] It occurred in ancient Canaanite mourning rituals, as described in the Ras Shamra tablets.

Self-harm is practised in Hinduism by the ascetics known as sadhus. In Catholicism, it is known as mortification of the flesh. Some branches of Islam mark the Day of Ashura, the commemoration of the martyrdom of Imam Hussein, with a ritual of self-flagellation, using chains and swords.^[24]

Dueling scars such as those acquired through academic fencing at certain traditional German universities are an early example of scarification in European society.^[25] Sometimes, students who did not fence would scar themselves with razors in imitation.^[25]

Constance Lytton, a prominent suffragette, used a stint in Holloway Prison during March 1909 to mutilate her body. Her plan was to carve 'Votes for Women' from her breast to her cheek, so that it would always be visible. But after completing the V on her breast and ribs she requested sterile dressings to avoid blood poisoning, and her plan was aborted by the authorities.^[26] She wrote of this in her memoir Prisons and Prisoners.

Kikuyu girls cut each other's vulvas in the 1950s as a symbol of defiance, in the context of the campaign against female genital mutilation in colonial Kenya. The movement came to be known as Ngaitana ("I will circumcise myself"), because to avoid naming their friends, the girls said they had cut themselves. Historian Lynn Thomas described the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.^[27][28]

Self-harm (SH), self-injury (SI), nonsuicidal self-injury (NSSI) and self-injurious behavior (SIB) are different terms to describe tissue damage that is performed intentionally and usually without suicidal intent.^[36] The adjective "deliberate" is sometimes used, although this has become less common, as some view it as presumptuous or judgmental.^[37] Less common or more dated terms include parasuicidal behavior, self-mutilation, self-destructive behavior, self-inflicted violence, self-injurious behavior, and self-abuse.^[38] Others use the phrase self-soothing as intentionally positive terminology to counter more negative associations.^[39] Self-inflicted wound or self-inflicted injury refers to a broader range of circumstances, including wounds that result from organic brain syndromes, substance abuse, and autoeroticism.^[40]

Different sources draw various distinctions between some of these terms. Some sources define self-harm more broadly than self-injury, such as to include drug overdose, eating disorders, and other acts that do not directly lead to visible injuries.^[41] Others explicitly exclude these.^[37] Some sources, particularly in the United Kingdom, define deliberate self-harm or self-harm in general to include suicidal acts.^[42] (This article principally discusses non-suicidal acts of self-inflicted skin damage or self-poisoning.) The inconsistent definitions used for self-harm have made research more difficult.^[43]

Nonsuicidal self-injury (NSSI) has been listed in section 2 of the DSM-5-TR under the category "other conditions that may be a focus of clinical attention".^[44] While NSSI is not a separate mental disorder, the DSM-5-TR adds a diagnostic code for the condition in-line with the ICD. The disorder is defined as intentional self-inflicted injury without the intent of dying by suicide. Criteria for NSSI include five or more days of self-inflicted harm over the course of one year without suicidal intent, and the individual must have been motivated by seeking relief from a negative state, resolving an interpersonal difficulty, or achieving a positive state.^[45]

A common belief regarding self-harm is that it is an attention-seeking behavior; however, in many cases, this is inaccurate. Many self-harmers are very self-conscious of their wounds and scars and feel guilty about their behavior, leading them to go to great lengths to conceal their behavior from others.^[46][47] They may offer alternative explanations for their injuries, or conceal their scars with clothing.^[47][48][49] Self-harm in such individuals may not be associated with suicidal or para-suicidal behavior. 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.^[9][10]

Studies of individuals with developmental disabilities (such as intellectual disability) have shown self-harm being dependent on environmental factors such as obtaining attention or escape from demands.^[50] Some individuals may have dissociation harboring a desire to feel real or to fit into society's rules.^[51]

The most common form of self-harm for adolescents, according to studies conducted in six countries, is stabbing or cutting the skin with a sharp object.^[52] For adults ages 60 and over, self-poisoning (including intentional drug overdose) is by far the most common form.^[53] Other self-harm methods include burning, head-banging, biting, scratching, hitting, preventing wounds from healing, self-embedding of objects, and hair-pulling.^[54] The locations of self-harm are often areas of the body that are easily hidden and concealed from the sight of others.^[55] 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,^[9] though many people who self-harm would like this to be addressed.^{[49][non-primary source needed]}

Self-injury may result in serious injury and scarring. While non-suicidal self-injury by definition lacks suicidal intent, it may nonetheless result in accidental death.^[84]

While the motivations for self harm vary, the most commonly endorsed reason for self harm given by adolescents is "to get relief from a terrible state of mind".^[85][86] Young people with a history of repeated episodes of self harm are more likely to self-harm into adulthood, ^[87][88] and are at higher risk of suicide.^[89] In older adults, influenced by a combination of interconnected individual, societal, and healthcare factors, including financial and interpersonal problems and comorbid physical conditions and pain, with increased loneliness, perceived burdensomeness of ageing, and loss of control reported as particular motivations.^[86] There is a positive statistical correlation between self-harm and physical, sexual, and emotional abuse.^{[11]: 63 [12][better source needed]} Self-harm may become a means of managing and controlling pain, in contrast to the pain experienced earlier in the person's life over which they had no control (e.g., through abuse).^{[90][medical citation needed]}

Assessment of motives in a medical setting is usually based on precursors to the incident, circumstances, and information from the patient.^[9] However, limited studies show that professional assessments tend to suggest more manipulative or punitive motives than personal assessments.^[91]

A UK Office for National Statistics study reported only two motives: "to draw attention" and "because of anger".^[11] 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.^{[92][90][medical citation needed]} However, those with chronic, repetitive self-harm often do not want attention and hide their scars carefully.^{[93][medical citation needed]}

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.^{[48][medical citation needed]} To complement this theory, one can consider the need to "stop" feeling emotional pain and mental agitation.^{[94][medical citation needed]}

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.^{[94][medical citation needed]}

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.^{[92][medical citation needed]} Endorphins are endogenous opioids that are released in response to physical injury, acting as natural painkillers and inducing pleasant feelings, and in response to self-harm would act to reduce tension and emotional distress.^[2] Many people do not feel physical pain when self-harming.^[95] Studies of clinical and non-clinical populations suggest that people who engage in self-harm have higher pain thresholds and tolerance in general, although a 2016 review characterized the evidence base as "greatly limited". There is no consensus as to the reason for this apparent phenomenon.^[96]

As a coping mechanism, self-harm can become psychologically addictive because, to the self-harmer, it works; it enables them 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 behavioral pattern that can result in a wanting or craving to fulfill thoughts of self-harm.^[97]

Several forms of psychosocial treatments can be used in self-harm including dialectical behavior therapy.^[102] Psychiatric and personality disorders are common in individuals who self-harm and as a result self-harm may be an indicator of depression and/or other psychological problems.^[103] As of 2021^[update], there is little or no evidence that antidepressants, mood stabilizers, or dietary supplements reduce repetition of self-harm. In limited research into antipsychotics, one small trial of flupentixol found a possible reduction in repetition, while one small trial of fluphenazine found no difference between low and ultra-low doses.^[104] As of 2012^[update], no clinical trials have evaluated the effects of pharmacotherapy on adolescents who self-harm.^[105]

Emergency departments are often the first point of contact with healthcare for people who self-harm. As such they are crucial in supporting them and can play a role in preventing suicide.^[106] At the same time, according to a study conducted in England, people who self-harm often experience that they do not receive meaningful care at the emergency department. Both people who self-harm and staff in the study highlighted the failure of the healthcare system to support, the lack of specialist care. People who self-harm in the study often felt shame or being judged due to their condition, and said that being listened to and validated gave them hope. At the same time staff experienced frustration from being powerless to help and were afraid of being blamed if someone died by suicide.^[107][108]

There are also difficulties in meeting the need of patients that self-harm in mental healthcare. Studies have shown that staff found the care for people who self-harm emotionally challenging and they experienced an overwhelming responsibility in preventing the patients from self-harming^[109] and the care focuses mainly on maintaining the safety for the patients, for example by removing dangerous items or physical restraint, even if it is believed to be ineffective.^[110]

It is difficult to gain an accurate picture of incidence and prevalence of self-harm.^[123] Even with sufficient monitoring resources, self-harm is usually unreported, with instances taking place in private and wounds being treated by the self-harming individual.^[124] Recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys.^[125] A 2015 meta-analysis of reported self-harm among 600,000 adolescents found a lifetime prevalence of 11.4% for suicidal or non-suicidal self-harm (i.e. excluding self-poisoning) and 22.9% for non-suicidal self-injury (i.e. excluding suicidal acts), for an overall prevalence of 16.9%.^[126] The difference in SH and NSSI rates, compared to figures of 16.1% and 18.0% found in a 2012 review, may be attributable to differences in methodology among the studies analyzed.^[127]

The World Health Organization estimates that, as of 2010, 880,000 deaths occur as a result of self-harm (including suicides).^[128] About 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses.^[68] 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,^[9] 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.^[125] In the United States up to 4% of adults self-harm with approximately 1% of the population engaging in chronic or severe self-harm.^[129]

The onset of self-harm tends to occur around puberty, although scholarship is divided as to whether this is usually before puberty or later in adolescence. Meta-analyses have not supported some studies' conclusion that self-harm rates are increasing among adolescents. It is generally thought that self-harm rates increase over the course of adolescence, although this has not been studied thoroughly.^[130] The earliest reported incidents of self-harm are in children between 5 and 7 years old.^[46] In addition there appears to be an increased risk of self-harm in college students than among the general population.^{[79][page needed][129]} 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.^[131] In Ireland, a study found that instances of hospital-treated self-harm were much higher in city and urban districts, than in rural settings.^[132] 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.^[133]

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 Day (SIAD) around the world.^[146] On this day, some people choose to be more open about their own self-harm, and awareness organizations make special efforts to raise awareness about self-harm.^[147]

Self-harm in non-human mammals is a well-established but not widely known phenomenon. Its study under zoo or laboratory conditions could lead to a better understanding of self-harm in human patients.^[17]

Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self-harm in higher mammals, e.g., macaque monkeys.^[17] Non-primate mammals are also known to mutilate themselves under laboratory conditions after administration of drugs.^[17] For example, pemoline, clonidine, amphetamine, and very high (toxic) doses of caffeine or theophylline are known to precipitate self-harm in lab animals.^[148][149]

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.^[150]

Breeders of show mice have noticed similar behaviors. One known as "barbering" involves a mouse obsessively grooming the whiskers and facial fur off themselves and cage-mates.^[151]

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  Feather-plucking in a Moluccan cockatoo
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  Lick granuloma from excessive licking

• Self-destructive behavior
• Self-hatred
• Self-Injurious Behavior Inhibiting System