- Trigger Warning: Contains information about self-harm/injury to oneself.
Self-Harm
OVERVIEW
Self-harm is a form of distress caused by an individual purposefully injuring their own body without the intention of committing suicide.[1] Although self-harm is differentiated from suicide attempts, it still has the potential to cause fatal injuries and carries a significant risk of future suicide.[2] Other terms used to refer to this condition include self-mutilation, self-wounding and self-injury.[3] The Diagnostic and Statistical Manual, fifth version (DSM-5) also added non-suicidal self-injury disorder (NSSID) as a medical diagnosis in 2015.[4]
Examples of self-harm include, but are not limited to:[5,6]
Scratching or fully cutting skin with a razor blade, knife or other sharp object
Burning or branding skin with hot objects
Overdosing on drugs or poisonous substances
Pulling out hair on the head or body (i.e., trichotillomania)
Breaking bones or causing bruises
Each of the physical forms also vary among individuals regarding their severity and frequency. 70% of people who self-harm cut as their method of self-injury, between 21-44% bang or hit themselves and between 15-35% burn their skin.[7] Most individuals who demonstrate self-injuring behavior also do so repeatedly and utilize more than one method.[8]
While all forms of self-harm need professional treatment, there are also instances when self-harm leads to emergency medical care. The Center for Disease Control (CDC) notes that in 2020 there were 187,000 emergency department visits over self-injurious behavior.[9] Another CDC study conducted between 1999 and 2018 found that 43 of 50 states had an increase in mortality rates of non-suicidal self-injuries, highlighting a growing mental health crisis around this condition.[10]
CAUSES
Self-harm is commonly linked to mental health and personality disorders such as anxiety, depression, dissociative disorders, autism, posttraumatic stress disorder (PTSD), and borderline personality disorder.[11] Still, it is important to note that many individuals with mental illness who do not injure themselves. Generally, self-harm signals a need for better emotional regulation and is an unhealthy coping mechanism for perceived challenges or difficult emotions.
Most commonly, self-harm is used as an outlet for any of the following:
Strong emotions like anger or sadness
Self-punishing after making a mistake
Making internal distress visible to alert others
To diminish emotional numbness
A distraction or relief from feelings[12]
An attempt to no longer feel angry, lonely or isolated[13]
Temporary relief or distraction from a stressful environment
A false sense of peace or euphoria from the endorphins the body releases in response to pain[14]
Physical pain can be a distraction for emotional pain, and there is a link between adolescents having the highest rate of self-harm amongst all age demographics and the compounding pressures they face in their transition to adulthood.[15] Young people are simultaneously facing hormonal changes, added responsibilities (e.g., studying, applying for college, finding a job) and a new level of independence.[16] Sometimes, during these transitions young adults also acquire unhealthy coping mechanisms. According to Nock & Prinstein (2006), the onset age for self-harm is typically 13-14 years old.[17] The categories that impact a person’s likelihood of self-harming can be broken down into environmental and personal stressors.
Environmental stressors that increase a person’s risk of self-harm:[18]
Family breakdown or conflict such as divorce, domestic violence or separation
Platonic or romantic relationship difficulties
Family history of self-harm, alcohol or drug abuse
School or work problems such as bullying, financial stress or difficulty building relationships with peers
Witnessing violence or unrest within one’s community
Personal stressors that increase a person’s risk of self harm:[19,20]
Belonging to the LGBTQIA+ community
Childhood trauma, neglect or abuse
Behavioral health disorder diagnosis
Previous history of self-harm
Having a history of aggression or violence
Alcohol or drug abuse
Poor self-esteem, poor body-image and self-hatred
Having a physical illness or disability
Impulsivity, or acting without thinking
Having poor coping skills or difficulties with problem solving
PREVALENCE
An average of 18% of adolescents aged 12-18 and 4% of adults report that they have intentionally injured themselves.[21] Research conducted by the Cleveland State University Counseling Center (2023) found there is an increasing prevalence of self-injury among adolescents and young adults.[22] Within socioeconomic trends, self-injurious behavior appears to be most common among people who report nonheterosexual orientations (e.g., homosexual, bisexual and questioning) and among Caucasians than non-Caucasians.[23] Women have also been found to self-harm more frequently than men, accounting for 65% of the cases.[24] This gender disparity is uncertain in part because men present differently than women when they self-harm, often causing their cases to be underreported. Women are more likely to engage in self-cutting, while males are more prone to deliberately bruising themselves, hurting themselves while taking a substance or having others hurt them.[25,26]
Regardless of their gender, according to a 2013 study by Muehlenkamp and colleagues, individuals that self-harm tend to have larger issues with body devaluation, with eating disorders occurring in 55% of those who self-injure.[27] Another demographic with a higher likelihood of self-harming behavior are college students. A 2019 study conducted by Liu and colleagues indicates that as many as 15-17% engage in self-injury.[28] Shortly after, research conducted in 2020 found that while college students experienced similar personal and environmental factors to other people who self-harm, another factor attributed to this demographic’s self-harm and related mental health issues is emotional exhaustion.[29]
SIGNS & SYMPTOMS
Signs someone may be injuring themselves include:
Unexplained frequent injuries, including cuts and burns
Scars, particularly in one location
Having sharp or dangerous objects on hand
Low self-esteem
Difficulty handling feelings
Making statements about helplessness, hopelessness or worthlessness
Relationship problems or relationship avoidance
Poor functioning at work, school, or home
People who self-injure may attempt to hide their marks with clothing, and may wear long sleeves and pants even in hot weather.[30] If discovered, a person who self-injures may often make up reasons for how an injury happened (e.g., “It was an accident,” “I was cooking” or “my pet scratched me”).[31]
TREATMENT
There are several treatment modalities for self-harming individuals to get support:
Psychodynamic Therapy uses methods such as self-reflection and self-examination to get to the roots of emotional suffering. This approach primarily uses talk-therapy, or discussion-based reflection on journal entries to bring up the aspects buried in one’s unconscious. For self-harming patients these practices can provide insight, resolve inner conflicts and change unhelpful behavior patterns.[32,33]
Peer Support Groups are led by individuals who have recovered successfully and seek to help others in their recovery process.[34] Peer support services build a relationship built on a shared understanding, respect and mutual empowerment in order to help their recovering counterpart heal without shame.[35] Peer support workers help people become and stay engaged in the recovery process and reduce the likelihood of relapse, effectively moving outside of the clinical setting into the everyday environment of those seeking a successful, sustained recovery process.[36] In recent years, peer support groups have also extended to online options, offering an additional format for patients who are not ready to seek in-person treatment or do not have the access to a treatment area.[37]
Dialectical Behavioral Therapy (DBT) is a psychotherapy aimed at helping people with severe emotional dysregulation (e.g., extreme fluctuations in mood, impulsive behavior or difficulty returning to a calm state) learn to build new skills into their life while at the same time reducing the behaviors and patterns that cause personal issues.[38]
Cognitive Behavioral Therapy (CBT) is a psychotherapy intervention that targets both maladaptive thoughts and behaviors to enhance mood and daily functioning, and is utilized for a wide range of psychiatric disorders in youth.[39] CBT has been adapted specifically for suicide prevention and self-harm in adults.[40] CBT helps identify unhealthy, negative beliefs and behaviors and replace them with more effective ones. Individuals who struggle with self-harm can also gain skills that help individuals cope in different situations when needed.[41]
Inpatient Care provides additional treatment when a person’s self-harming habits are severe (e.g., they inadvertently bring themselves close to dying, injure themselves repeatedly or they are not seeing progress). A health care provider may recommend a hospital for psychiatric care.[42] Being cared for in a hospital, often short term, can provide a safe environment and more-intensive treatment until an individual sees progress through a crisis. Mental health day-treatment programs that focus on learning behavioral coping skills to manage distress also may be an option.[43]
If you are experiencing self-harm, or if you know or suspect someone is self-harming, reach out to a licensed mental health provider for assistance. For more resources on how to support someone who is self-harming, click here.
Contributed by: Kate Campbell
Editor: Jennifer (Ghahari) Smith, Ph.D.
REFERENCES
1 Klonsky, D.E. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226-239. https://doi.org/10.1016/j.cpr.2006.08.002
2 Mind. (2020) Self-harm. Mind Website. https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/treatment-and-support/
3 Ibid.
4 Ibid.
5 U.S. Department of Health and Human Services. (2022). Self-Harm. Mentalhealth.gov. Retrieved 25 March 2023, from, https://www.mentalhealth.gov/what-to-look-for/self-harm
6 Rethink Mental Illness. (2022) Self-Harm. Rethink Mental Illness Website. https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-symptoms/self-harm/
7 Herpertz S. (1995). Self-injurious behaviour. Psychopathological and nosological characteristics in subtypes of self-injurers. Acta psychiatrica Scandinavica, 91(1), 57–68. https://doi.org/10.1111/j.1600-0447.1995.tb09743.x
8 Ibid.
9 Centers for Disease Control and Prevention (CDC). (2023) Suicide and Self-Harm Injury. CDC. https://www.cdc.gov/nchs/fastats/suicide.htm. Updated 2023. Accessed March 25, 2023.
10 Rockett, I.R.H, Caine, E.D., Connery, H.S. (2021). Fatal self-injury in the United States, 1999- 2018: Unmasking a national mental health crisis. eClinical Medicine, 34(1). https://doi.org/10.1016/j.eclinm.2021.100823
11 Rethink Mental Illness (2022)
12 National Alliance on Mental Illness (2023)
13 Rethink Mental Illness (2022)
14 Ibid.
15 Mind. (2020)
16 Ibid.
17 Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral functions of self mutilation among adolescents. Journal of Abnormal Psychology, 114, 140–146. https://www.jabfm.org/content/23/2/240.full
18 Ibid.
19 Rethink Mental Illness (2022)
20 Ibid.
21 Cleveland State University Counseling Center. Responding to self-harm. CSU Counseling Center Website. https://www.csuohio.edu/counselingcenter/responding-self-harm. Updated 2023. Accessed March 24, 2023.
22 Ibid.
23 Klonsky (2022)
24 American Psychological Association (APA). (2010).Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge. https://www.apa.org/news/press/releases/2010/01/psychodynamic-therapy
25 Ibid.
26 Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Abrams, J.B., Barreira, P., & Kress, V. (2012). Non-suicidal self-injury as a gateway to suicide in young adults. Journal of Adolescent Health, 52(2), 486-492. https://doi.org/10.1016/j.jadohealth.2012.09.010
27 Ibid.
28 Bettis, A. H., Liu, R. T., Walsh, B. W., & Klonsky, E. D. (2020). Treatments for Self-Injurious Thoughts and Behaviors in Youth: Progress and Challenges. Evidence-based practice in child and adolescent mental health, 5(3), 354–364. https://doi.org/10.1080/23794925.2020.1806759
29 Ibid.
30 Victor, S. E., Muehlenkamp, J. J., Hayes, N. A., Lengel, G. J., Styer, D. M., & Washburn, J. J. (2018). Characterizing gender differences in nonsuicidal self-injury: Evidence from a large clinical sample of adolescents and adults. Comprehensive psychiatry, 82, 53–60. https://doi.org/10.1016/j.comppsych.2018.01.009
31 Rethink Mental Illness (2022)
32 American Psychological Association (2010)
33 Mind (2020)
34 Substance Abuse and Mental Health Services Administration. (2022). Peer support workers for those in recovery. SAMHSA Website. https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers
35 Ibid.
36 Mind (2020)
37 Ibid.
38 Gottlieb, A. (2020). How dialectical behavior treats self harm. Sheppard Pratt Organization. https://www.sheppardpratt.org/news-views/story/how-dialectical-behavior-therapy-treats-self-harm/
39 Substance Abuse and Mental Health Services Administration (2022)
40 Ibid.
41 Bettis, A. H., Liu, R. T., Walsh, B. W., & Klonsky, E. D. (2020). Treatments for Self-Injurious Thoughts and Behaviors in Youth: Progress and Challenges. Evidence-based practice in child and adolescent mental health, 5(3), 354–364. https://doi.org/10.1080/23794925.2020.1806759
42 Ibid.
43 Ibid.