What self-injury is

Classifying self-harm

An easy line to draw is that of deliberate, immediate physical harm being done. For example, cutting your arm or hitting yourself with a hammer are clearly self-injurious acts. Things like overeating, smoking, not exercising, etc., are harmful to a person in the long run but immediate physical damage is not the desired effect of the behaviors. What, then, about things like tattooing and piercing, where physical modification of the body is deliberate and is the desired effect?

The first step in classifying self-harm, as demonstrated by Favazza (1996), is to sort out what makes a type of self-injury pathological, as opposed to culturally-sanctioned. Socially sanctioned self-harm, he found, falls into two groups: rituals and practices. Body modification (piercings, tattoos, etc) can fall into either class.

Rituals are distinguished from practices in that they reflect community tradition, usually have deep underlying symbolism, and represent a way for an individual to connect to the community. Rituals are done for purposes of healing (mostly in primitive cultures), expressions of spirituality and spiritual enlightenment, and to mark place in the social order. Practices, on the other hand, have little underlying meaning to the practitioners and are sometimes fads. Practices are done for purposes of ornamentation, showing identification with a particular cultural group, and in some cases, for perceived medical/hygienic reasons.

Non-socially sanctioned (pathological) self-harm can be classified as either suicidality, self-mutilation (which is further broken down into major, stereotypic, and superficial/moderate), or unhealthful behavior.

Kahan and Pattison (1984; Pattison and Kahan, 1983) tackled these taxonomic problems. They began by identifying three components of self-harming acts: directness, lethality, and repetition.

Directness

Lethality

Repetition

The following table gives examples of each combination of these factors: Repetitive In Nature? Direct Behaviors Indirect Behaviors High lethality Low lethality High lethality Low lethality yes taking small doses of arsenic over time self-injury: cutting, burning, hitting, etc. type 1 diabetic not injecting insulin smoking, alcoholism no gunshot wound to head major self-mutilation terminal cancer patient refusing chemo walking around downtown alone at 3 a.m.

Definitions of moderate/superficial self-injury Perhaps the best definition of self-injury is found in Winchel and Stanley (1991), who define it as

...the commission of deliberate harm to one's own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.

Self-mutilation, high risk for
A nursing diagnosis . . . defined as a state in which an individual is at high risk to injure but not kill himself or herself, and that produces tissue damage and tension relief. Risk factors include being a member of an at-risk group, inability to cope with increased psychological/physiological tension in a healthy manner, feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization, command hallucinations, need for sensory stimuli, parental emotional deprivation, and a dysfunctional family. Groups at risk include clients with borderlines personality disorder (especially females 16 to 25 years of age), clients in a psychotic state (frequently males in young adulthood), emotionally disturbed and/or battered children, mentally retarded and autistic children, clients with a history of self-injury, and clients with a history of physical, emotional, or sexual abuse.

Investigators have discovered a common pattern in the cutting behavior. The stimulus...appears to be a threat of separation, rejection, or disappointment. A feeling of overwhelming tension and isolation deriving from fear of abandonment, self-hatred, and apprehension about being unable to control one's own aggression seems to take hold. The anxiety increases and culminates in a sense of unreality and emptiness that produces an emotional numbness or depersonalization. The cutting is a primitive means for combating the frightening depersonalization.

This site is concerned mainly with moderate/superficial self-harm, which is direct, repetitive, and of low lethality. Stereotypic self-mutilation tends also to be direct, repetitive, and of low lethality, whereas major self-mutilation (discussed below) is direct, not repetitive, and of low lethality. Moderate self-harm can be further divided into impulsive and compulsive.

Compulsive self-harm

Impulsive self-harm

What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners (Favazza and Rosenthal, 1993; Kahan and Pattison, 1984; Miller, 1994; among others) believe should be classified as a separate Axis I impulse-control disorder. Favazza (1997) suggests that until repetitive self-harm is recognized as a separate category in the DSM, practitioners should diagnose it on Axis I as 312.3, Impulse-Control Disorder Not Otherwise Specified.

Repetitive self-harm is marked by a shift toward ruminating on self-injury even when not actually doing it and self-identification as a self-injurer (Favazza, 1996). Episodic self-harm becomes repetitive when what was formerly a symptom becomes a disease in itself (as seen in the way many people who self-injure describe self-harm as being "addictive"). It is impulsive in nature, and often becomes a reflex response to any sort of stress, positive or negative. Just like smokers who reach for a cigarette when they're overwhelmed, repetitive self-injurers reach for a lighter or a blade or a belt when things get to be too much.

In a study of bulimics who self-harm, Favaro and Santonastaso (1998), used a statistical technique known as factor analysis to try to distinguish between which kinds of acts were compulsive in nature and which were impulsive. They report that vomiting, severe nail biting, and hair pulling loaded on the compulsive factor, whereas suicide attempts, substance abuse, laxative abuse, and skin cutting and burning loaded on the impulsive factor.

Should self-injurious acts be considered botched or manipulative suicide attempts?

. . . self-mutilation is distinct from suicide. Major reviews have upheld this distinction. . . A basic understanding is that a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better. p. 262.

Thus, although self-injurious behavior is not suicidal in intent, it can easily lead to suicidal ideation or even, when a self-harmer goes too far, suicide itself. Herpertz (1995) notes that self-injurers distinguish between self-injurious acts and suicidal ones, and Solomon and Farrand (1996) say "Although the [self-injurious and suicidal] acts themselves may blur, their meaning does not. What does emerge, though, is a link between the two acts in that one (self-injury) is an alternative to the other (suicide), and is preferable." In a review of the literature on self-injury, Favazza (1998) notes that only recently has it become generally recognized that self-harm is a morbid form of coping, one which is often turned to when suicide seems inescapable. He writes that "traditionally it has been trivialized ([delicate] wrist cutting), misidentified (suicide attempt) and regarding solely as a symptom [of borderline personality disorder.

Further support for the distinct nature of self-injury comes from a study of psychiatric diagnoses among self-injurers as opposed to attempted suicides (Ferreira de Castro et al., 1998). On Axis I, 14% of self-injurers (SI) were diagnosed with major depression, as opposed to 56% of the suicide-attempters (SA). Alcohol dependence was diagnosed in 16% of the SI group, but in 26% of the SA group. Only 2% of the SI group were considered schizophrenic; 9% of the SA group were. The SI group was more likely to be dysthymic (12% vs 7%) or to be diagnosed with adjustment disorder with depressed mood (24% vs 6%). Of course, the fact of a suicide attempt may have influenced the depression-related diagnoses.

This study also revealed similar disparities in Axis II diagnoses of those whose self-harm was directed toward suicide and those whose was not, although 9% of both groups were considered borderline and 0% of each were considered to have avoidant personality disorder. There were sharp differences among rates in the other personality disorders -- dependent: 13% SI, 7% of SA; schizoid: 2% SI, 5% SA; and histrionic: 22% SI, 4% SA. It seems clear, then, that those who self-injure in order to die and those who do it in order to cope present very different psychiatric profiles.

Informal surveys collected via the net reveal that many of those who injure themselves are strongly aware of the fine line they walk, but are also resentful of doctors and mental health professionals who mistake their incidents of self-harm as suicide attempts instead of seeing them as the desperate attempts to stave off suicide that they often are.

Is self-injury the same thing as Munchausen's or some other factitious disorder?

Next section: Self-injury: a quick guide to the basics