Self Injury – Causes, Signs and Symptoms

Self Injury

Also called: Self Injurious Behavior, Self Harm, Self Abuse

Summary

Self-injury is any intentional act that causes harm to one’s own body for the purpose of emotional relief. Self-injury can involve a variety of behaviors, including cutting, burning, scratching, biting, pinching, hitting, head-banging and hair-pulling. Tattoos and body piercings are not typically considered self-injury.

The majority of self-injurers are young women. Significant factors that increase a person’s risk of self-injury are a history of physical or sexual abuse and an inability to express negative emotions such as anger or sadness. Self-injury can also be a symptom of a number of different mental disorders including major depression, bipolar disorder, borderline personality disorder(BPD), bulimia nervosa and substance abuse.

It is often difficult to determine that self-injury is occurring. Self-injurers often hurt themselves in private and conceal or make excuses for any resulting scars, burns or bruises. Intense feelings of shame often prevent them from discussing their behavior with others. However, there are signs to look for, including wounds that do not heal, bald spots and frequent injuries at various stages of healing.

Self-injury requires immediate professional attention. Suspected self-injurers should receive a mental health evaluation in which they will be asked to discuss their history of previous self-injury, as well as the function of and thoughts behind the self-injury. A physical examination may also be necessary, with emphasis on any areas of the body where self-injury has occurred. 

Treatment for self-injury may include medication for any underlying mental disorders, cognitive behavior therapy(CBT), interpersonal therapy(IPT) or other types of psychotherapy. Support from family and friends is especially beneficial in helping a person overcome self-injurious behaviors. In addition, self-injurers can employ various coping skills to help prevent them from hurting themselves once they are receiving treatment.

About self injury

Self-injury involves behavior intended to cause harm to one’s own body. Methods of self-injury include cutting or burning the skin, head-banging, hair-pulling(trichotillomania), ingesting poison and even breaking bones.

Although self-injurers can cause serious physical harm to their bodies, they often are not trying to kill themselves. Self-injury differs from suicide or suicidal ideation because the self-injurer does not wish to die. Instead, self-injury is performed in order to relieve emotional distress. For self-injurers, hurting themselves may become a method of coping with stress – an effort to turn internal emotional pain into an external sensation.

About 2 million people deliberately injure themselves each year in the United States, according to the National Mental Health Association (NMHA). However, this number may be even greater because many self-injurers do not seek help for their condition. Most are teenagers and young adults, and women self-injure more often than men. Although self-injury affects people of all races and backgrounds, it appears to be more common in individuals in the middle to upper class who are of average to high intelligence and who have low self-esteem. Most have difficulty expressing negative emotions, such as anger or sadness. Self-injury can easily turn into a self-destructive pattern, since those who have injured themselves in the past are more likely to do so again.

Self-injury can occur anywhere on the body, depending on the method used. For example, cutting and burning are usually done on the front of the torso, arms and legs. Punching usually involves injury to the head and thighs, and head-banging involves the skull. Biting can occur on the lips, nails or elsewhere. Drinking harmful fluids such as detergent or bleach can affect a number of internal organs.

Although not intended to cause death, self-injury can sometimes result in fatality. An inability to stop the behavior can lead self-injurers to make actual suicide attempts. Also, self-injurers may accidentally kill themselves due to medical complications as a result of the behavior or if they are unable to control the extent of the injury.

Types and differences of self injury

Self-injury can include a variety of self-harming behaviors – all of which are performed intentionally and without suicidal intent. Those who self-injure often use multiple methods to injure themselves.

Some self-harming behaviors, such as cutting and burning, can involve ritual-like activity that may have a calming effect on the self-injurer. This can include a preoccupation with an instrument, a designated environment (e.g., a bathroom or bedroom) or the procedure itself. Other types of self-injury, such as lip-biting, hair-pulling, scratching or picking scabs can be performed almost anywhere and at any time.

Methods such as cutting and burning are described as a subset of self-injury called self-mutilation since they cause actual disfigurement of the skin.

Types of self-injury include:

  • Cutting. Use of any sharp instrument to cut the skin, causing tissue damage. Cutting is among the most common methods of self-injury. Knives, razors and shards of glass are commonly used instruments. Parts of the body affected by cutting include the arms, legs, wrists and/or chest.
  • Burning. Use of cigarettes, lighters, matches or any item hot enough to burn the skin (e.g., hot iron). Flammable fluids (e.g., alcohol, lighter fluid) are sometimes used. Most people who burn themselves do so on their arms, legs, wrists or chest.
  • Hair-pulling. Also known as trichotillomania, hair-pulling involves compulsive pulling or twisting of the hair, resulting in noticeable patches of missing hair. Areas commonly affected include the scalp, eyebrows or beard, but hair can be pulled from any part of the body. Bald spots are usually disguised with a hat, bandage or sunglasses.
  • Scratching. Involves scratching one’s own skin until raw or bloody. Scratching is usually done with the fingernails, but sometimes other sharp objects are used.
  • Pinching. Involves repeatedly pinching oneself to induce pain and/or injury.
     
  • Biting. Use of one’s own teeth to cause injury. This type of self-injury involves severe and frequent biting of the lips, nails or skin, usually until blood is drawn.
  • Punching. When self-harm is done with one’s own fists in an effort to cause physical harm. Areas of the body commonly affected are the head and thighs.
  • Interfering with wound healing. The deliberate interruption of the healing process. This type of self-injury includes picking at scabs, poking wounds with sharp objects and the premature removal of stitches.
  • Ingestion of poisons. Drinking dangerous liquids, such as bleach or detergent, in an attempt to cause illness or damage to one’s own body.
  • Breaking bones. Causing one’s own bones to break. Instruments used to break bones include hammers, bricks or other heavy objects. Breaking one’s own bones is a rare form of self-injury.

Tattoos and body piercings are not generally considered self-injury because emotional relief is not the intended goal of these acts. They are usually an effort to decorate or alter the appearance of a person’s body. Also, another person is usually involved.

Risk factors and potential causes of self injury

Many different factors may increase a person’s risk of self-injury. People who have self-injured in the past have a greater likelihood of repeating the pattern. Females who self-injure outnumber males. Teenagers and young adults make up the majority of self-injurers. Usually first occurring at puberty, self-injury may continue for up to 10 years or longer if left untreated.

A history of physical or sexual abuse may increase a person’s risk of self-injury. Nearly 50 percent of self-injurers were physically or sexually abused as children, according to the National Mental Health Association (NMHA).

Self-injury may be associated with many different mental disorders, including:

  • Mood disorders. Disorders that affect a person’s mood and impair functioning, such as major depression and bipolar disorder.
  • Personality disorders. Conditions involving chronic patterns of behavior that can worsen stress and interpersonal difficulties. An example is borderline personality disorder (BPD), which involves significant personal instability and impulsive behavior. Self-mutilating behavior (e.g., cutting) can be a symptom of BPD and is among the diagnostic criteria for BPD identified by the American Psychiatric Association (APA).
  • Anxiety disorders. Disorders associated with debilitating levels of worry and fear, such as post-traumatic stress disorder(PTSD).
  • Eating disorders. Disorders characterized by altered eating habits (e.g., eating too little or binging-and-purging) due to obsessive and distorted thoughts regarding body image. This behavior may lead to feelings of shame and physical harm to the body. Examples include anorexia nervosa and bulimia nervosa.
  • Substance abuse. The chronic use of alcohol or drugs that alter mood or behavior, causing significant disruption in a person’s life.

Almost all self-injurers have difficulty talking about their feelings. Ninety percent report being discouraged from expressing emotions (especially anger and sadness) by caregivers, according to the NMHA. An inability to cry, scream or yell may lead to self-injury as a way to express emotional pain.  Additional reasons for self-injury may include loneliness, alienation and self-loathing. Self-injury is often used as a distraction, to alleviate feelings of numbness, validate strong negative emotions, and as a means of self-control or self-punishment.

Signs and symptoms of self injury

Self-injurers frequently harm themselves in private and hide their injuries (e.g., scars, burns) from others or make excuses for them. This makes it difficult to determine whether self-injury is actually occurring. However, sometimes it is possible to witness the act itself.

Additional signs of self-injury include:

  • Frequent injuries (cuts, burns, bruises, broken bones) with suspicious excuses
  • Cuts or scars that are usually short and appear precise or controlled
     
  • Similar scars in various stages of healing
  • Wounds that do not appear to heal
  • Noticeable hair loss on the scalp, eyebrows or beard
  • Inappropriate clothing worn to conceal the skin (e.g., long sleeves in warm weather)
  • Blood stains on clothing
  • Long periods of personal isolation, after which new injuries are evident
  • Knife or razor in purse or book bag
  • Difficulty talking about feelings
  • Relationship problems
  • Poor functioning at home, work or school
  • Low self-esteem, extreme self-criticism

Diagnosis and treatment of self injury

When self-injury is suspected, it is likely a symptom of another mental disorder. Therefore, people suspected of self-injury will be given a complete psychological evaluation. This evaluation is performed by a licensed mental health professional and should include a mental status examination and medical history.

A physical examination will also be performed, with emphasis on any areas of the body where self-injury has occurred.

Once the diagnosis is confirmed, a treatment plan will be designed. During treatment, the  mental health professional will attempt to identify and assess the following:

  • What function self-injury serves for the person doing it
  • The intent behind past self-injury
  • Thoughts that contribute to self-injury
  • Intended or unintended consequences that reinforce self-injury

Treatment will vary depending on which, if any, other disorders are present, but may include:

  • Medication. A number of different medications have been utilized for the disorders associated with self-injurious behavior.  These include antidepressants, antipsychotics and mood stabilizers.
  • Psychotherapy. Communication with a therapist about thoughts, feelings, emotions and behaviors either in a one-on-one, family or group setting. The goal is to help people identify any possible underlying cause of their self-injury.
  • Cognitive behavior therapy (CBT). Therapy that addresses a person’s thoughts in relation to their actions. The goal is to help self-injurers to understand and manage their self-destructive thoughts and behaviors. Dialectical behavior therapy(DBT)is a form of CBT that focuses on coping skills, managing emotional trauma and tolerating distress.
  • Interpersonal therapy(IPT). Therapy that focuses on human relationships. The goal is to help self-injurers develop better social skills to decrease the likelihood of emotional and physical isolation from others.
  • Contracts, journals, behavior logs. These tools track thought and behavior patterns and can help the self-injurer regain self-control.

Self-injurers may also find comfort and support from various Internet sites dedicated to the issue. However, it is important to note that although many of these sites provide outlets for support and address ways to treat and prevent self-injurious behaviors, some sites actually reinforce the practice.  

Whether or not to hospitalize an individual who engages in self-injury should be carefully evaluated. Friends, family, teachers and physicians are sometimes shocked when they discover self-injury and seek to immediately hospitalize the person to prevent further self-harm. However, hospitalizing a person immediately after an episode of self-injury may come at a time when the patient is actually feeling well and is less likely to engage in additional self-harm.

Before making the decision to hospitalize, it is important to identify whether the behavior was an act of nonsuicidal self-injury or an actual suicide attempt. A comprehensive mental health evaluation is needed to help make this determination.Specialized self-injury hospital programs with experienced staff are recommended when the behavior interferes with daily life or becomes life-threatening. These programs can include inpatient hospitalization or partial hospitalization (day treatment), which consists of remaining in a hospital part-time, for 6 to 12 hours per day.

Prevention and lifestyle issues with self injury

There are several things people may do to help reduce the likelihood of self-injury. Perhaps the most valuable is to learn to express emotions – especially those of anger or sadness. Most people who self-injure have difficulty expressing these emotions. Seeking counseling for any type of abuse that may have previously occurred can also help prevent a person from becoming a self-injurer. Nearly half of those who self-injure were physically or sexually abused as children, according to the National Mental Health Association (NMHA).

Once people have become self-injurers, there are steps they can take to reduce their risk of future episodes. The first step is to recognize the behavior as something they no longer wish to do. In order to help them accomplish this, it is recommended they seek help from a mental health professional who has experience dealing with self-injury. Other steps self-injurers can take include:

  • Learn to respect and value their own bodies.
  • Express emotions. Identify and express negative feelings – especially anger and sadness.
  • Think rather than act. Stop and evaluate the pros and cons of self-injury instead of impulsively acting on feelings or thoughts.
  • Self-soothe. Engage in positive, non-injurious distractions when feelings of self-harm arise. These may include breathing exercises, positive imagery, counting to 10, waiting 15 minutes or journaling.
  • Develop better social skills. Learn to enjoy the company of others and spend less time alone.

After self-injurers have identified and taken steps to address their problem, they will need to make certain lifestyle adjustments. These may include:

  • Avoiding physical and emotional isolation
  • Making time for therapy sessions
  • Keeping a list of people to contact handy (for times of intense emotional distress)
  • Being aware of the side-effects of certain substances that may affect mood or energy level (e.g., medications, alcohol)
  • Identifying how to treat or explain physical scars

Friends and family members can lessen the likelihood of self-injury by helping their loved one talk about the problem. Ignoring self-injury does not make it go away. Open, honest and direct conversation helps the self-injurer air feelings, reduces the shame and secrecy surrounding self-injury and helps prevent social isolation. Because self-injurers often have difficulty expressing emotions, it is important to be empathetic and nonjudgmental when discussing self-injury with them. Offering options but not telling the self-injurer what to do will keep the lines of communication open. Demanding the self-injurer stop, for example, often just succeeds in ensuring that the self-injury remains hidden.

Questions for your doctor regarding self injury

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to self-injury:

  1. Do you have experience treating self-injury?
  2. What type of therapy would be most effective for me?
  3. Can you recommend a therapist, mental health professional, group or other setting that may benefit me?
  4. Are there other treatment methods I might benefit from?
  5. What do you think is causing my self-injury?
  6. Do I have an underlying disorder that is related to self-injury?

Friends and family of a self-injurer may wish to ask their doctor the following questions about self-injury:

  1. I suspect a loved one may be injuring him/herself. How can I know for sure?
  2. How should I approach someone about self-injury?
  3. How do I encourage a loved one to get help? Is there anything I can do to help a person refrain from self-injury?
  4. How can I be sure a loved one is not trying to commit suicide?
  5. Should I call 911 when I’ve discovered a loved one who self-injures?
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