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Self-Harm

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self harm

Self-Harm is a common behavior of self harm stemming from multiple mental disorders in children, adolescents, and the elderly population. It is conducted without any suicidal intention. According to the World Health Organization, 880,000 people died as a result of self harm in 2010.

What Is Self-Harm?

The term “self-harm” (SH) or “self-injury” covers a spectrum of intentional behavior, with the behaviors at the milder end of the spectrum merging with emotional distress and the most severe behaviors relating closely to suicidal tendencies. The World Health Organization explains that it is “an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or intentionally ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, with the goal of achieving the desired changes through the actual use of the substance or expected physical consequences”.

The more common forms of self-harm include cutting and self-mutilation by a sharp object; tissue damage by excessive scratching, hitting, pulling, or burning; undertaking non-lethal overdoses and wilful ingestion of toxins; and inflicting harm on the body by disordered eating. Current psychiatric usage make distinctions in these behaviors; however, these are thought to be directed at deliberate tissue damage to cause injury and pain without suicidal intent.

Common taxonomy for SH encompasses the following synonymous terms:

  • Self-harm (SH)
  • Self-injury (SI)
  • Deliberate self-harm (DSH)
  • Self-inflicted violence (SIV)
  • Nonsuicidal self-injury (NSSI)
  • Nonsuicidal self-harm (NSSH)
  • Self-injurious behavior (SIB)

Prevalence Of Self-Harm

Studies 1 show that self harm (SH) is most common among adolescents and young adults. The lifetime rates in these populations are about 15% to 20%, with onset typically occurring around age 13 or 14 and extending to age 24. In contrast, about 6% of adults report a history of NSSI. According to the World Health Organization, 880,000 people died as a result of self-harm in 2010.

Given that self-harming tendencies cannot be charted properly, the epidemiology of self harm (SH) remains unclear. However, based on data from hospital admissions and psychiatric morbidity surveys, it is inferred that SH remains high in psychiatric populations–living in city and urban districts than in rural settings–who are prone to self-directed negative emotions, self-criticism, emotional distress, and substance abuse. The rates for SH more or less remain the same across different countries and are more common 2 in groups like children in foster care, adolescents, students, prison inmates, and the elderly population.

Studies 3 also show women and men equally affected by SH. However, women are more prone to cutting and men to hitting and burning. A 2008 study 4 suggests that the life-time risk of self-injury is ~1:7 for women and ~1:25 for men. Research 5 also shows that NSSI appears to be more common among LGBTQ+ people who report non-heterosexual orientations.

Misconceptions About Self-Harm

Misconceptions About Self Harm
Self-Harm

Self-harm comprises complex behavior existing in a spectrum and therefore various misconceptions exist around it:

1. SH Is Not Suicidal Behavior

Self-Harm (SH), though associated with suicide in its highest form, is by definition non-suicidal. When clinically considered, SH is a coping strategy 6 for difficult situations involving emotional distress, infliction of mental disorders, self-punishment, surviving grief, etc. It is not associated with suicidal or para-suicidal behavior.

2. SH Is Differentiated Behavior

SH is differentiated from other similar ‘practices’ by a number of psychosocial and clinical dimensions:

  • Religious (ascetic self-flagellation)
  • Puberty rites (hymen removal, clitoral alteration, etc.)
  • Psychotic (eye enucleation, ear removal, amputation, etc.)
  • Neurotic (nail biting, skin picking, etc.)
  • Tissue damage occurring due to organic and inorganic diseases
  • Customary practices (nail clipping, shaving beards, trimming hair, tattooing, piercing, cosmetic surgeries, etc.)

Read More About Religion Here

3. SH Is Not Attention-seeking Behavior

SH, contrary to popular belief, is not attention-seeking behavior. Self-harmers are self-conscious of their self-mutilating tendencies. They experience shame and guilt for the injury caused and go to great lengths to conceal their behavior by offering alternative explanations or wearing clothing that conceal the injury.

4. SH Is Not Enjoyable Behavior

SH, contrary to popular belief, is not enjoyable behavior. Self-harming people see self-harm as a coping mechanism for emotional distress and not pleasure. They perceive the pain endured in the process of injury as something that provides relief from mental agitation, helps them express suppressed feelings, or regain control over oneself.

5. SH Is Not Behavior With Stereotypical Reinforcements

It is sometimes deemed to have ritualistic association and identification with youth-subcultural groups such as Alternative, Goth, Emo, Punk, Metal, etc. These are simply stereotypical reinforcements 7.

6. SH Is Not Gendered Behavior

Women are thought to be more prone to SH, and this arises from sexist notions surrounding SH. Studies show that both men and women are afflicted with SH in the same equivalence. However, LGBTQ+ youth, especially the adolescent subpopulations 8, are approximately 2–4 times more likely to self-harm than non-GBLT youth.

Read More About Gender Here

7. SH Is Different From SIW

SH is not to be confused with self-inflicted wounds (SIW), a specific term reserved for non-lethal injuries inflicted by soldiers to obtain early dismissal from combat.

8. SH Is Different From Münchausen Syndrome

Parallels exist between behaviors displayed in SH and Münchausen syndrome 9 (a psychiatric disorder in which individuals feign illness or trauma)–common grounds being the experience of mental distress and deliberate self-harm. However, both disorders are different and Münchausen patients are provided separate therapies, different from those in SH, for recovery.

Symptoms Of Self-Harm

Symptoms Of Self Harm
Self-Harm

For clinical convenience and raising laymen-awareness about SH, people engaging in SH are usually taken to follow the endless “SH Cycle” comprising shame/grief, emotional suffering, emotional overload, panic, self-harm, temporary relief, and guilt. Research 10 shows that SH patients experience depersonalization or dissociation (like emotional numbness and anhedonia) from their immediate environment, question their worth and identity, and display negative emotions (anger, hopelessness, helplessness, aggression, depressed behavior, self-loathing) before and during engaging in SH.

The symptoms of self-harm can be classified as but not restricted to the following:

  • Cutting and self-mutilation by a sharp object
  • Self-mutilation by self-embedding of objects
  • Tissue damage by excessive scratching, hitting, pulling, or burning
  • Undertaking substance abuse or/and non-lethal overdoses (of alcohol, entertainment drugs, cannabis, over-the-counter prescription drugs)
  • Undertaking willful ingestion of toxins (i.e., self-poisoning)
  • Inflicting bodily harm by disordered eating (like bulimia and anorexia)
  • Ideating suicide or showing signs of repeating suicidal attempts (in most severe cases)

Read More About Drug Abuse Here

Causes Of Self-Harm

The personal and demographic profiles of an individual taking to SH are determined by multiple factors 11, namely, age, sex, marital status, employment status, socio-economic status, social and family factors, religion, sexual orientation, physical and mental health, situational factors (personal and interpersonal influence), methods of self-harm, attainment of suicide, and service contact (medical and/or psychological practices).

Usually enlisted under models of self-harm (such as the Psychodynamic Model, Psychosocial Model, Cognitive Model, Emotional Dysregulation, and Behavioral Model), the causes of SH typically include:

1. Mental Disorders

Studies show that people experiencing mental illnesses practice or are at greater risk of SH. The recognized disorders associated with SH include but are not restricted to spectrum disorders, dissociative disorders, personality disorders, anxiety disorders, conduct disorders, phobias, mania and bipolar disorders, depression 12, and schizophrenia.

Read More About Schizophrenia Here

2. Neurodevelopmental Disorders

People with neurodevelopmental disorders are prone to SH–because of emotional distress arising from social problems and personal reflection associated with their disabilities. These neurodevelopmental disorders include autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), communication and language disorders, intellectual disabilities (IDs), motor disorders, neurogenetic disorders (like Fragile X syndrome, Down syndrome), learning disorders, and traumatic brain injury

3. Psychological Factors

SH is perceived as coping mechanism to combat trauma arising from physical, emotional, and sexual abuse. Especially in adolescents, self-harm accompanies neurodevelopmental changes like puberty. Individuals with poor or less effective social problem-solving skills, impulsivity, and tendencies of self-criticism and self-punishment are more prone to SH.

People suffering from developmental and intellectual disabilities also take to SH, because of emotional distress arising from social problems experienced by people with such disabilities.

4. Social Factors

SH is triggered by psychological abuse attributed to abuse during childhood, bereavement, troubled domestic relationships, abuse in foster care, the experience of mental illness and trauma, experiences of bullying, peer pressure and social contagion, depersonalization disassociation from immediate environment and peer group (especially during pubertal periods), as well as experiences of war, poverty, debt, and unemployment.

Studies show that non-heterosexual ‘unconventional’ gender orientation and gender dysphoria also contribute to SH, with LGBLQ+ youth (especially the adolescent subpopulations) approximately 2–4 times more likely to self-harm than non-LGBLTQ+ youth.

Peer-pressure and peer-expectation-induced substance abuse (misuse, dependency, and withdrawal) of alcohol, tobacco, cannabis, entertainment drugs, and over-the-counter prescription medicines can also result in self-harm. For instance, studies 13 show that benzodiazepine dependence, as well as benzodiazepine withdrawal, is associated with self-harming behavior in young people.

5. Genetic Factors

Genetic disorders like Lesch–Nyhan syndrome cause self-harm in the form of head-banging and biting. Genetics, in the context of people suffering from neurogenetic disorders or having a history of mental illness, can lead to the development of psychological conditions that facilitate SH.

Read More About Genetics Here

Treatment Of Self-Harm

Given that SH involves an entire spectrum of behavior and not one or more mental disorders, it should not be misunderstood and sensationalized. It should be effectively managed 14 by therapy, medication, or a combination of both in inpatient and outpatient mental health treatment programs. This should be backed by active involvement of family, friends, community, social service, governmental/non-governmental regulatory bodies, and health organizations. In the most severe cases, however, hospitalization and psychiatric admission should be sought to prevent acts of SH culminating into suicide or injury to others.

1. Therapy

SH can be effectively managed by disciplined adherence to therapy (sometimes backed by medication) through inpatient and outpatient mental health treatment programs, safety planning, justice programs, youth access programs, support groups, etc. The most common forms of counseling and intervention in SH include–

  • Dialectical behavior therapy (DBT)
  • Integrated CBT (I-CBT)
  • Mentalization-based treatment (MBT)
  • Attachment-based family therapy (ABFT)
  • Integrated family therapy
  • Resourceful adolescent parent program (RAP-P)
  • Intensive interpersonal psychotherapy for adolescents (IPT-A-IN)
  • Multisystemic therapy and psychiatric intervention

Read More About Therapy Here

2. Medication

SH is effectively managed by medication 15, 2(10), 28–37. )), backed by a disciplined adherence to therapy. As it is often associated with other mental disorders (like depression, spectrum disorders, dissociative disorders, personality disorders, etc.), medication in SH involves antidepressants and medicinal drugs like flupentixol, clomipramine, duloxetine, escitalopram, fluoxetine, fluvoxamine, olanzapine, and sertraline.

3. Awareness

Psychoeducation and mental health awareness programs and campaigns should help destigmatize mental health concerns in the long-run and normalize seeking help for any mental disorder, not just SH.

Scholarly researchers and psychiatric professionals should produce effective crisis intervention programs and heavily researched evidence-based resource guides to aid psychoeducation. These resources should be made readily available to the greater public by community organizations, healthcare systems, welfare services, social service, and justice programs. Campaigns should be effectively run in schools, universities, and other organizations to raise awareness about SH. Hotline services, parenting skills training, mental health workshops, group support programmers, safety planning, and so on should all be included in such campaigns.

March 1 is designated as Self-injury Awareness Day (SIAD) around the world.

4. Distraction And Avoidance Techniques

People with self-harm tendencies should develop healthy and safe self-help strategies known as distraction or avoidance techniques/substitution coping strategies to cope with emotional distress. For instance, generating mindful ‘alternative behaviors’ like journaling, taking strolls, exercising or meditating, developing a new hobby, etc. can lead to recession of SH tendencies in sufferers.

Recovery In Self-Harm

Like diagnosis in any other mental health disorder, self-harm can be effectively managed by punctual and long-term adherence to therapy or medication or both. It should be kept in mind that SH is indicative of graver mental disorders and suicide. To combat and prevent SH is to reduce greater risks involved.

Self-Harm is rare in children, most common in adolescents and young adults, and not so much in adults. However, SH tends to show relapses in the elderly population. Because numbers can not be ascertained in research concerning SH (as most SH cases are concealed), it has been difficult to gauge the rate of functioning recovery and relapses in SH.

Seeking And Providing Help In Self-Harm

Seeking And Providing Help In Self Harm
Self-Harm

Self-Harm comprises complex behavior existing in a spectrum and therefore prone to misunderstanding. A haphazard idea of SH will make its combat difficult, both for people seeking and providing help. So, it is important to understand the fundamental ways in which help can be sought and provided in SH.

1. Suggestions For People Seeking Help

  • Assess your thoughts and feelings about yourself
  • Develop substitution strategies to distract yourself from self-harm
  • Talk to someone–face-to-face or online. It can be your family, a friend, a social worker, or a helpline
  • Ask for psychiatric help
  • Adhere to therapy and medication
  • With safety planning, devise an emergency care plan
  • Involve your loved ones in the therapy process
  • Be patient and understand that healing from SH takes time

2. Suggestions For People Providing Help

  • Do not make panic, make assumptions, and judge people with SH. Instead, be empathetic and devise ways for effective communication to help them
  • Listening, caring, understanding, and acceptance are the most helpful responses
  • Show concern for the injury and offer medical help
  • Encourage seeking psychological help
  • Acknowledge that living with SH and healing from it are difficult and try to help during the therapy process

Takeaway

Self-Harm is a common behavior of self-injury stemming from multiple mental disorders in children, adolescents, and the elderly population. It is conducted without any suicidal intention, but comprises undenible symptoms of more complex underlying psychiatric disorders. It causes death if untreated. People prone to SH should avail therapy, medication, and self-help mechanisms to combat SH. People providing help for SH should help in its combat by active participation and empathy.

Self-Harm At A Glance

  1. Self-Harm is a common behavior of self-injury stemming from multiple mental disorders in children, adolescents, and the elderly population. It is conducted without any suicidal intention but comprises undeniable symptoms of more complex underlying psychiatric disorders.
  2. SH is neither enjoyable nor attention-seeking behavior.
  3. The more common forms of self-harm include cutting and self-mutilation by a sharp object; tissue damage by excessive scratching, hitting, pulling, or burning; undertaking non-lethal overdoses and wilful ingestion of toxins; and inflicting harm on the body by disordered eating.
  4. SH stems mainly from mental disorders and a variety of social, psychological, and neurological factors.
  5. People prone to SH should avail therapy, medication, and self-help mechanisms to combat SH.
  6. People providing help for SH should help in its combat by active participation and empathy.
👇 References:
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  2. Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal Self-injury: A Systematic Review. Frontiers in psychology, 8, 1946. https://doi.org/10.3389/fpsyg.2017.01946 []
  3. National Collaborating Centre for Mental Health (UK). Self-Harm: Longer-Term Management. Leicester (UK): British Psychological Society (UK); 2012. (NICE Clinical Guidelines, No. 133.) 2, INTRODUCTION TO SELF-HARM. Available from: https://www.ncbi.nlm.nih.gov/books/NBK126787/ []
  4. Madge, N., Hewitt, A., Hawton, K., de Wilde, E. J., Corcoran, P., Fekete, S., van Heeringen, K., De Leo, D., & Ystgaard, M. (2008). Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. Journal of child psychology and psychiatry, and allied disciplines, 49(6), 667–677. https://doi.org/10.1111/j.1469-7610.2008.01879.x []
  5. Williams, A. J., Jones, C., Arcelus, J., Townsend, E., Lazaridou, A., & Michail, M. (2021). A systematic review and meta-analysis of victimisation and mental health prevalence among LGBTQ+ young people with experiences of self-harm and suicide. PloS one, 16(1), e0245268. https://doi.org/10.1371/journal.pone.0245268 []
  6. Clarke, S., Allerhand, L. A., & Berk, M. S. (2019). Recent advances in understanding and managing self-harm in adolescents. F1000Research, 8, F1000 Faculty Rev-1794. https://doi.org/10.12688/f1000research.19868.1 []
  7. Phillipov M. (2006). Self harm in Goth youth subculture: study merely reinforces popular stereotypes. BMJ (Clinical research ed.), 332(7551), 1215–1216. https://doi.org/10.1136/bmj.332.7551.1215-b []
  8. Young, R., Sproeber, N., Groschwitz, R.C. et al. Why alternative teenagers self-harm: exploring the link between non-suicidal self-injury, attempted suicide and adolescent identity. BMC Psychiatry 14, 137 (2014). https://doi.org/10.1186/1471-244X-14-137 []
  9. Weber B, Gokarakonda SB, Doyle MQ. Munchausen Syndrome. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518999/ []
  10. National Collaborating Centre for Mental Health (UK). Self-Harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care. Leicester (UK): British Psychological Society (UK); 2004. (NICE Clinical Guidelines, No. 16.) 2, Introduction to self-harm. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56398/ []
  11. Kohli, Adarsh & Kumar, Krishan & Dogra, Rajeev & Sharma, Samita. (2019). Deliberate Self-harm: Bench to Bedside. Journal of Postgraduate Medicine, Education, and Research. 53. 79-84. 10.5005/jp-journals-10028-1318. []
  12. Ennis, Jon & Barnes, Rosemary & Kennedy, Sidney & Trachtenberg, Dvora. (1989). Depression in Self-Harm Patients. The British journal of psychiatry : the journal of mental science. 154. 41-7. 10.1192/bjp.154.1.41. []
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  15. Smith B. D. (2005). Self-mutilation and pharmacotherapy. Psychiatry (Edgmont (Pa. : Township[]

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