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Self-Injury (SI) 
What self-injury isNOTE: This section contains potentially distressing material. If you self-injure now or have in the past, please make yourself safe before reading this section; it may intensify your urge to harm. SMHAI Discussion Forum
The SMHAI Discussion Forum purpose is suicide awareness, support, education, and prevention for those whose lives have been affected by the suicide, those who may be attempters or self-injurers and for those who want to learn more about suicide and related issues. We also promote good mental health practices and information. Hope For SA ~ Online Support Group
(For Self-Injurers & Suicide Attempters) Self-Coaching out of Suicide Treatments For SI
Classifying self-harmWe all do things that aren't good for us and that may harm us. We also do things that inflict injury but that are primarily intended for other purposes. Some self-harm is culturally sanctioned, while other types are seen as pathological. Where does one draw lines? The 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? Classifying self-harm, Favazza, 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 identified three components of self-harming acts: directness, lethality, and repetition. Back To The Top Directness refers to how intentional the behavior is; if an act is completed in a brief period of time and done with full awareness of its harmful effects and there was conscious intent to produce those effects, it is considered direct. Otherwise, it is an indirect method of harm. Lethality refers to the likelihood of death resulting from the act in the immediate or near future. A lethal act is one that is highly likely to result in death, and death is usually the intent of the person doing it. Repetition refers to whether of not the act is done only once or is repeated frequently over a period of time It is defined simply by whether or not the act is done repeatedly. 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.
Mosby's Medical, Nursing, and Allied Health Dictionary (1994) contains the following definition: 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.
Malon and Berardi summarize the process they believe underlies self-injury:
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 seems to coincide with the definition given in Mosby's of someone susceptible to self-harm. Back To The Top Varieties of Self-Harm Self-injury is separated into three types. Major self-mutilation (including such things as castration, amputation of limbs, enucleation of eyes, etc) is fairly rare and usually associated with psychotic states. Stereotypic self-injury comprises the sort of rhythmic head-banging, etc, seen in autistic, mentally retarded, and psychotic people. The most common form of self-mutilation, and the topic of this site, is called superficial or moderate. This can include cutting, burning, scratching, skin-picking, hair-pulling, bone-breaking, hitting, deliberate overuse injuries, interference with wound healing, and virtually any other method of inflicting damage on oneself. Both in clinical studies and in an informal Usenet survey, the most popular act was cutting, and the most popular sites were wrists, upper arms, and inner thighs. Many people have used more than one method, but even they tend to favor one or two preferred methods and sites of abuse. Compulsive self-harm Further break downs: superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury differs in character from the other two types and is more closely associated with obsessive-compulsive disorder (OCD). Compulsive self-harm comprises hair-pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. These acts may be part of an OCD ritual involving obsessional thoughts; the person tries to relieve tension and prevent some bad thing from happening by engaging in these self-harm behaviors. Compulsive self-harm has a somewhat different nature and different roots from the impulsive (episodic and repetitive types). Impulsive self-harm Both episodic and repetitive self-harm are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-harm is self-injurious behavior engaged in every so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder. What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners believe should be classified as a separate Axis I impulse-control disorder. Favazza 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. 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, 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? Favazza states, quite definitively, that:
self-mutilation is distinct from suicide. 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. Although these behaviors are sometimes referred to "parasuicide," most researchers recognize that the self-injurer generally does not intend to die as a result of his/her acts. "[S]uicide attempts are reported not to provide relief, to be repeated less frequently, and to have less communicative value". "Patients with the [proposed Deliberate Self-Harm Syndrome] often suffer social ostracism and, in desperation, may attempt suicide[emphasis added]. 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 notes that self-injurers distinguish between self-injurious acts and suicidal ones, and Solomon and Farrand 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. 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 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. Back To The Top Is self-injury the same thing as Munchausen's or some other factitious disorder? NO. Little research has been done on whether there is a connection between SI and Munchausen's or similar syndromes, but uneducated medical professionals sometimes conflate the two. In SI, the person is injuring to escape unbearable emotional and physiological tension; in Munchausen's the injuries inflicted are deliberate and calculated to produce specific symptoms that will lead to a medical hospital admission. Although some people who self-injure desire hospitalization, it is almost always to a psychiatric ward and not to a general medical floor. Clients with Munchausen's, on the other hand, shy away from psychiatric care and seek to be admitted on the medical service. Those who do not do it ask - Why would anyone choose to inflict physical damage on him or herself? Because they cannot imagine themselves doing such a thing under any circumstances, many people dismiss self-injury as "senseless" or "irrational" behavior. And certainly it does seem that way at first glance. But people generally do things for reasons that make sense to them. The reasons may not be apparent or may not fit into our frame of reference, but they exist and recognizing their existence is crucial to understanding self-harm. With understanding of the reasons behind a particular act of self-harm comes knowledge of the coping skills that are lacking. When you know what skills are missing, you can start trying to introduce them. The assumption is that the alternative to self-injury is "acting normally," but on the contrary . . . the alternative to self-injury is total loss of control and possibly suicide. It becomes a forced choice from among limited options. Psychological motivations: What self-injurers say SI does for them Many papers on self-harm, have uncovered possible motivations for self-injurious behavior: Escape from emptiness, depression, and feelings of unreality.
Easing tension.
Providing relief: when intense feelings build, self-injurers are overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.
Relieving anger: many self-injurers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings. Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive.
Grounding in reality, as a way of dealing with feelings of depersonalization and dissociation
Maintaining a sense of security or feeling of uniqueness
Obtaining a feeling of euphoria
Preventing suicide
Expressing emotional pain they feel they cannot bear
Obtaining or maintaining influence over the behavior of others
Communicating to others the extent of their inner turmoil
Communicating a need for support
Expressing or repressing sexuality
Expressing or coping with feelings of alienation
Validating their emotional pain -- the wounds can serve as evidence that those feelings are real
Continuing abusive patterns: self-injurers tend to have been abused as children.
Punishing oneself for being "bad" Obtaining biochemical relief: there is some thought that adults who were repeatedly traumatized as children have a hard time returning to a "normal" baseline level of arousal and are, in some sense, addicted to crisis behavior. Self-harm can perpetuate this kind of crisis state. Diverting attention (inner or outer) from issues that are too painful to examine
Exerting a sense of control over one's body
Preventing something worse from happening
These reasons can be broadly grouped into three categories: Back To The Top Affect regulation -- Trying to bring the body back to equilibrium in the face of turbulent or unsettling feelings. This includes reconnection with the body after a dissociative episode, calming of the body in times of high emotional and physiological arousal, validating the inner pain with an outer expression, and avoiding suicide because of unbearable feelings. In many ways, as Sutton says, self-harm is a "gift of survival." It can be the most integrative and self-preserving choice from a very limited field of options. Communication -- Some people use self-harm as a way to express things they cannot speak. When the communication is directed at others, the SIB is often seen as manipulative. However, manipulation is usually an indirect attempt to get a need met; if a person learns that direct requests will be listened to and addressed the need for indirect attempts to influence behavior decreases. Thus, understanding what an act of self-harm is trying to communicate can be crucial to dealing with it in an effective and constructive way. Control/punishment -- This includes trauma reenactment, bargaining and magical thinking (if I hurt myself, then the bad thing I am fearing will be prevented), protecting other people, and self-control. Self-control overlaps somewhat with affect regulation; in fact, most of the reasons for self-harm listed above have an element of affect control in them. In an interesting theory that combines all three categories, Miller posits an explanation for why such a large majority of peep who self-harm are female. Women are not socialized to express violence externally and when confronted with the vast rage many self-injurers feel, women tend to vent on themselves. She quotes the feminist poet Adrienne Rich: "Most women have not even been able to touch this anger except to drive it inward like a rusted nail." Miller says, "Men act out. Women act out by acting in." Another reason fewer men self-injure may be that men are socialized in a way that makes repressing feelings the norm. Linehan's theory that self-harm results in part from chronic invalidation, from always being told that your feelings are bad or wrong or inappropriate, could explain the gender disparity in self-injury; men are generally brought up to hold emotion in. Alexithymia Alexithymia is a fairly recent psychological construct describing the state of not being able to describe the emotions one is feeling. Alexithymia was positively linked to self-injurious behavior in a 1996 study and is congruent with how people who self-injure often describe the emotional state before an injury; they frequently cannot pinpoint any particular feeling that was present. This is especially important in understanding the communicative function of self-injury: "Rather than use words to express feelings, an alexithymic's communication is an act aimed at making others feel [those same feelings]" Self-capacities and Invalidation A constructivist theory of self-injurious behavior holds that people who self-injure usually have not developed three important self-capacities: the ability to tolerate strong affect, the ability to maintain a sense of self-worth, and the ability to maintain a sense of connection to others. The first of these speaks directly to the affect-regulation role of self-harm; the others are perhaps related to its communicative functions. Pearlman et al. note that "when children experience shaming and punitive rhetoric or physical blows rather than responsive words" they cannot internalize others are loving and cannot develop the capacity to maintain a sense of connection to others. They further state, "The ability to experience, tolerate, and integrate strong affect cannot develop fully when strong feelings are met with punishment or derision." Having a sense that some feelings are unacceptable and not allowed also impairs this ability. And the ability to maintain a sense of oneself as a person of worth cannot be developed when a child never feels she is good enough, when her "existence and accomplishments are met with silence or abusive words or actions." All of these conditions are found in invalidating environments, which Linehan and others have tied to future self-injury. Haines and Williams found that self-mutilators reported more use of problem avoidance as a coping strategy and perceived themselves to have less control over problem-solving options. This feeling of disempowerment may in turn be related to the chronic invalidation many self-injurers have experienced. Back To The Top Physiological concerns: What the researchers have found People who self-injure tend to be dysphoric -- experiencing a depressed mood with a high degree of irritability and sensitivity to rejection and some underlying tension -- even when not actively hurting themselves. The pattern found by Herpertz indicates that something, usually some sort of interpersonal stressor, increases the level of dysphoria and tension to an unbearable degree. The painful feelings become overwhelming: it's as if the usual underlying uncomfortable affect is escalated to a critical maximum point. "SIB has the function of bringing about a transient relief from these [high levels of irritability and sensitivity to rejection]," Herpertz said. This conclusion is supported by Haines and her colleagues.
Haines et al. led groups of self-injuring and non-self-injuring subjects through guided imagery sessions. Each subject experienced the same four scenarios in random order: a scene in which aggression was imagined, a neutral scene, a scene of accidental injury, and one in which self-injury was imagined. The scripts had four stages: scene-setting, approach, incident, and consequence. During the guided imagery sessions, physiological arousal and subjective arousal were measured. The results were striking. Subject reactions across groups didn't differ on the aggression, accident, and neutral scripts. In the self-injury script, though, the control groups went to a high level of arousal and stayed there throughout the script, in spite of relaxation instructions contained in the "consequences" stage. In contrast, self-injurers experienced increased arousal through the scene-setting and approach stages, until the the decision to self-injure was made. Their tension then dropped, dropping even more at the incident stage and remaining low. These results provide strong evidence that self-injury provides a quick, effective release of physiological tension, which would include the physiological arousal brought on by negative or overwhelming psychological states. As Haines et al. say. Self-mutilators often are unable to provide explanations for their own self-mutilative behavior. . . . Participants reported continued negative feelings despite reduced psychophysiological arousal. This result suggests that it is the alteration of psychophysiological arousal that may operate to reinforce and maintain the behavior, not the psychological response. Self-injury may be a preferred coping mechanism because it quickly and dramatically calms the body, even though people who self-injure may have very negative feelings after an episode. They feel bad, but the overwhelming psychophysiological pressure and tension is gone. Herpertz et al. explain this:
We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. A recent case study supports the idea that self-injury acts to reduce physiological and thus emotional stress. They tracked the nightly cortisol levels in a woman who self-harmed, then compared the results for days on which she did not engage in self-harm acts to those for days during which she did hurt herself. Cortisol excretion is increased under stress, which makes it an excellent marker for stress levels. An analysis of the results showed that on the days during which the woman had harmed herself, her cortisol levels were significantly lower than on other days. Another stress-reduction theory, Herman, says that most children who are abused discover that a serious jolt to the body, like that produced by self-injury, can make intolerable feelings go away temporarily. This may help explain how self-injury gets entrenched as a coping mechanism. Brain chemistry and serotonin Brain chemistry may play a role in determining who self-injures and who doesn't. Simeon et al. found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system. Favazza refers to this study and work by Coccaro on irritability to posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts. ©Martinson, D. Source
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