Self-harm
Self-harm is intentional conduct that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a 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 by scratching, 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 societally acceptable body modification such as tattoos and piercings.[5]
Self-harm
Deliberate self-harm (DSH), self-injury (SI), self-poisoning, nonsuicidal self-injury (NSSI), cutting
Psychiatry, surgery, or emergency medicine if serious injuries occur
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, as may people experiencing gender dysphoria. 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]
Classification and terminology[edit]
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]
Signs and symptoms[edit]
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]
Causes[edit]
Mental disorder[edit]
Although some people who self-harm do not have any form of recognized mental disorder,[56] self-harm often co-occurs with psychiatric conditions. Self-harm is for example associated with eating disorders,[57] autism spectrum disorders,[58][59] borderline personality disorder, dissociative disorders, bipolar disorder,[60] depression,[11][61] phobias,[11] and conduct disorders.[62] As many as 70% of individuals with borderline personality disorder engage in self-harm.[63] An estimated 30% of individuals with autism spectrum disorders engage in self-harm at some point, including eye-poking, skin-picking, hand-biting, and head-banging.[58][59] According to a meta-analysis that did not distinguish between suicidal and non-suicidal acts, self-harm is common among those with schizophrenia and is a significant predictor of suicide.[64] There are parallels between self-harm and Münchausen syndrome, a psychiatric disorder in which individuals feign illness or trauma.[65] There may be a common ground of inner distress culminating in self-directed harm in a Münchausen patient. However, a desire to deceive medical personnel in order to gain treatment and attention is more important in Münchausen's than in self-harm.[65]
Psychological factors[edit]
Self-harm is frequently described as an experience of depersonalization or a dissociative state.[66] Abuse during childhood is accepted as a primary social factor increasing the incidence of self-harm,[67] as is bereavement,[68] and troubled parental or partner relationships.[9][12] Factors such as war, poverty, unemployment, and substance abuse may also contribute.[9][11][69][70] Other predictors of self-harm and suicidal behavior include feelings of entrapment, defeat, lack of belonging, and perceiving oneself as a burden along with having an impulsive personality and/or less effective social problem-solving skills.[9][71] Two studies have indicated that self-harm correlates more with pubertal phase, particularly the end of puberty (peaking around 15 for girls), rather than with age. Adolescents may be more vulnerable neurodevelopmentally in this time, and more vulnerable to social pressures, with depression, alcohol abuse, and sexual activity as independent contributing factors.[72] Transgender adolescents are significantly more likely to engage in self-harm than their cisgender peers.[73][74] This can be attributed to distress caused by gender dysphoria as well as increased likelihoods of experiencing bullying, abuse, and mental illness.[74][75]
Genetics[edit]
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[edit]
Substance misuse, dependence and withdrawal are associated with self-harm. Benzodiazepine dependence as well as benzodiazepine withdrawal is associated with self-harming behavior in young people.[78] Alcohol is a major risk factor for self-harm.[79] A study which analyzed self-harm presentations to emergency rooms in Northern Ireland found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations.[80] A 2009 study in the relation between cannabis use and deliberate self-harm (DSH) in Norway and England found that, in general, cannabis use may not be a specific risk factor for DSH in young adolescents.[81] Smoking has also been associated with both non-suicidal self injury and suicide attempts in adolescents, although the nature of the relationship is unclear.[82] A 2021 meta-analysis on literature concerning the association between cannabis use and self-injurious behaviors has defined the extent of this association, which is significant both at the cross-sectional (odds ratio = 1.569, 95% confidence interval [1.167-2.108]) and longitudinal (odds ratio = 2.569, 95% confidence interval [2.207-3.256]) levels, and highlighting the role of the chronic use of the substance, and the presence of depressive symptoms or of mental disorders as factors that might increase the risk of self-injury among cannabis users.[83]
Awareness[edit]
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.[145] 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.[146]
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]
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