Self-harm
This article needs more primary sources. (August 2023) |
Self-harm | |
---|---|
Other names | Deliberate self-harm (DSH), self-injury (SI), self-poisoning, nonsuicidal self-injury (NSSI), cutting |
Healed scars on the forearm from prior self-harm | |
Specialty | Psychiatry, surgery, or emergency medicine if serious injuries occur |
Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin
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
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]
History
This section possibly contains synthesis of material which 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 making 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 asylum's 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
Self-harm is practised in
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]
Classification
Karl Menninger considered self-mutilation as a non-fatal expression of an attenuated death wish and thus coined the term partial suicide. He began a classification system of six types:
- neurotic – nail-biters, pickers, extreme hair removal, and unnecessary cosmetic surgery
- religious – self-flagellants and others
- puberty rites – hymen removal, circumcision, or clitoral alteration
- psychotic – eye or ear removal, genital self-mutilation, and extreme amputation
- organic brain diseases – which allow repetitive head-banging, hand-biting, finger-fracturing, or eye removal
- conventional – nail-clipping, trimming of hair, and shaving beards.[29]
Pao (1969) differentiated between delicate (low lethality) and coarse (high lethality) self-mutilators who cut. The "delicate" cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. The "coarse" cutters were older and generally psychotic.[30] Ross and McKay (1979) categorized self-mutilators into nine groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling, hitting, and constricting.[31]
After the 1970s the focus of self-harm shifted from
Walsh and Rosen (1988) created four categories numbered by Roman numerals I–IV, defining Self-mutilation as rows II, III and IV.[33]
Classification | Examples of behavior | Degree of Physical Damage | Psychological State | Social Acceptability |
---|---|---|---|---|
I | Ear-piercing, nail-biting, small tattoos, cosmetic surgery (not considered self-harm by the majority of the population) | Superficial to mild | Benign | Mostly accepted |
II | Piercings, saber scars, ritualistic clan scarring, gang tattoos, minor wound-excoriation, trichotillomania
|
Mild to moderate | Benign to agitated | Subculture acceptance |
III | Wrist- or body-cutting, self-inflicted cigarette burns and tattoos, major wound-excoriation | Mild to moderate | Psychic crisis | Accepted by some subgroups but not by the general population |
IV | self-enucleation, amputation
|
Severe | Psychotic decompensation | Unacceptable |
Favazza and Rosenthal (1993) reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation.[34] Favazza also created two subcategories of sanctioned self-mutilations; rituals and practices. The rituals are mutilations repeated generationally and "reflect the traditions, symbolism, and beliefs of a society" (p. 226). Practices are historically transient and cosmetic such as piercing of earlobes, nose, eyebrows as well as male circumcision while deviant self-mutilation is equivalent to self-harm.[32][35]
Classification and terminology
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
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]
Signs and symptoms
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.
Causes
Mental disorder
Although some people who self-harm do not have any form of recognized mental disorder,
Psychological factors
Self-harm is frequently described as an experience of
Genetics
The most distinctive characteristic of the rare genetic condition Lesch–Nyhan syndrome is uncontrollable self-harm and self-mutilation, and may include biting (particularly of the skin, nails, and lips)[76] and head-banging.[77] Genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behavior. However, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive.[7]
Drugs and alcohol
Substance misuse, dependence and withdrawal are associated with self-harm.
Pathophysiology
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 burdensome 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.
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
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]
Autonomic nervous system
Emotional pain activates the same regions of the brain as physical pain,[98] so emotional stress can be a significantly intolerable state for some people. Some of this is environmental and some of this is due to physiological differences in responding.[99] The autonomic nervous system is composed of two components: the sympathetic nervous system controls arousal and physical activation (e.g., the fight-or-flight response) and the parasympathetic nervous system controls physical processes that are automatic (e.g., saliva production). The sympathetic nervous system innervates (e.g., is physically connected to and regulates) many parts of the body involved in stress responses. Studies of adolescents have shown that adolescents who self-injure have greater physiological reactivity (e.g., skin conductance) to stress than adolescents who do not self-injure.[100][101]
Treatment
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]
Therapy
Dialectical behavior therapy for adolescents (DBT-A) is a well-established treatment for self-injurious behavior in youth and is probably useful for decreasing the risk of non-suicidal self-injury.
A meta-analysis found that psychological therapy is effective in reducing self-harm. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%). Psychological therapies with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT).[115]
In individuals with developmental disabilities, occurrence of self-harm 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-harm 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-harm thus is to teach an alternative, appropriate response which obtains the same result as the self-harm.[116][117][118]
Avoidance techniques
Generating alternative behaviors that the person can engage in instead of self-harm is one successful behavioral method that is employed to avoid self-harm.[119] Techniques, aimed at keeping busy, may include journaling, taking a walk, participating in sports or exercise or being around friends when the person has the urge to harm themselves.[13] The removal of objects used for self-harm from easy reach is also helpful for resisting self-harming urges.[13] The provision of a card that allows the person to make emergency contact with counselling services should the urge to self-harm arise may also help prevent the act of self-harm.[120] Some providers may recommend harm-reduction techniques such as snapping of a rubber band on the wrist,[121] but there is no consensus as to the efficacy of this approach.[122]
Epidemiology
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]
Gender differences
Aggregated research has found no difference in the prevalence of self-harm between men and women.[129] This is in contrast to past research which indicated that up to four times as many females as males have direct experience of self-harm,[9] which many had argued was rather the result of data collection biases.[134]
The
This gender discrepancy is often distorted in specific populations where rates of self-harm are inordinately high, which may have implications on the significance and interpretation of psychosocial factors other than gender. A study in 2003 found an extremely high prevalence of self-harm among 428 homeless and runaway youths (aged 16–19) with 72% of males and 66% of females reporting a history of self-harm.[137] However, in 2008, a study of young people and self-harm saw the gender gap widen in the opposite direction, with 32% of young females, and 22% of young males admitting to self-harm.[138] Studies also indicate that males who self-harm may also be at a greater risk of completing suicide.[8]
There does not appear to be a difference in motivation for self-harm in adolescent males and females. Triggering factors such as low self-esteem and having friends and family members who self-harm are also common between both males and females.[125] One limited study found that, among those young individuals who do self-harm, both genders are just as equally likely to use the method of skin-cutting.[139] 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. In New Zealand, more females are hospitalized 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 hospitalization.[140]
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 by the absence of factors known to be associated with repetition, such as personality disorder and alcohol abuse.[15] However, NICE Guidance on Self-harm in the UK suggests that older people who self-harm are at a greater risk of completing suicide, with 1 in 5 older people who self-harm going on to end their life.[16] A study completed in Ireland showed that older Irish adults have high rates of deliberate self-harm, but comparatively low rates of suicide.[132]
Developing world
Only recently have attempts to improve health in the developing world concentrated on not only physical illness but also mental health.[141] Deliberate self-harm is common in the developing world. Research into self-harm in the developing world is however still very limited although an important case study is that of Sri Lanka, which is a country exhibiting a high incidence of suicide[142] and self-poisoning with agricultural pesticides or natural poisons.[141] Many people admitted for deliberate self-poisoning during a study by Eddleston et al.[141] 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
Prison inmates
Deliberate self-harm is especially prevalent in prison populations. A proposed explanation for this is that prisons are often violent places, and prisoners who wish to avoid physical confrontations may resort to self-harm as a ruse, either to convince other prisoners that they are dangerously insane and resilient to pain or to obtain protection from the prison authorities.[143] Self-harm also occurs frequently in inmates who are placed in solitary confinement.[144]
Awareness
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
Other animals
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.[147][148]
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.[149]
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.[150]
-
Moluccan cockatoo
-
Lick granuloma from excessive licking
See also
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External links
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