Cutting and Self-Harm

Adolescents who cut themselves or engage in various other types of self-harming behavior often feel that their actions are very strange and unusual. Sometimes they are told that they are motivated by the desire to get attention. But in fact hurting themselves is their way of coping with difficult feelings. Self-harm occurs more often than one might think, and is usually done in private, with the hope that no one will ever find out about it. To explain self-harm, this entry defines the behavior and then discusses who engages in it and when, possible causes for this behavior, and how it can be treated.

What is Self-Harm?

Self-harm can take several forms, including cutting various parts of the body, most often the forearms or legs; head banging; skin picking; taking pills; and burning. (Self-harm is sometimes called self-injury or self-mutilation. However, because "mutilation" implies a frightening degree of severity, the term does not accurately represent the behavior.) It often occurs along with thoughts of wanting to be dead and/or killing oneself. Yet self-harm is very different from making a suicide attempt. While suicide attempts involve a wish to die, a young adult who acts on the urge to self-harm does not intend to cause death. Even so, self-harm behavior can at times be extremely dangerous, even if not intended. For example, a study led by Barbara Stanley in 2001 found that while suicide attempters with a history of self-injury perceived their suicide attempts as less serious than did suicide attempters without such a history, they were just as much at risk for dying and in fact suffered from greater depression . Therefore the behavior should always be taken very seriously.

Who Self-Harms?

Both adults and adolescents engage in self-harm. Adults who self-harm generally started doing so in adolescence. Recently, the number of acts of intentional self-harm not ending in death among adolescents has increased greatly. Armando R. Favazza and Karen Conterio in 1998 found that as many as 1,800 out of every 100,000 15- to-35-year-olds were deliberately hurting themselves. While some researchers say that there are no differences between males and females, others state that the behavior is more frequent in girls.

Adolescents who self-harm are in many ways similar to other kids. They sometimes have special strengths or skills, such as sensitivity and perceptiveness. However, they also often suffer from a variety of psychological or psychiatric difficulties, including depression and hopelessness, anxiety and anger, and personality disorders (having problems with difficult relationships and poor self-image). They may also have trouble in areas related to the body, such as with an eating disorder, having a clear sense of sexual identity, and/or substance abuse. Richard H. Schwartz and others in 1989 noted that many young self-harmers use alcohol, drugs, or both excessively. While certainly not true for everyone, self-harming adolescents can sometimes be aggressive toward others. Adolescents who suffer from major mental illnesses such as schizophrenia and who also self-harm tend to do so in a very different way than other self-harming adolescents. These young people often see their actions as a kind of religious act.

What Causes Self-Harm?

Many people believe that adolescents who harm themselves are trying to get attention or manipulate others, or that they are very disturbed. This may be true in some cases. But most often, the behavior is kept extremely private and secret. For most of the young people who self-harm, the behavior is a way to get relief from distressing feelings. Unfortunately, the relief obtained from self-injury is often only temporary. Usually a sense of shame and self-hatred quickly sets in after the act.

One researcher, Marsha M. Linehan, in 1993 wrote about self-harm as being an attempt to regulate emotions, meaning to feel more balanced and relaxed. Linehan suggested that self-harmers may have grown up in an environment that was not supportive, or that they may have a biological predisposition to the behavior.

Scientists are studying some unusual differences in the brain chemistry of people who self-harm. Work by Maria Oquendo and J. John Mann in 2001 and Ronald Winchell and Michael Stanley in 1991 (among others) shows that adults, and perhaps adolescents as well, who engage in self-harm tend to have lower levels of a brain chemical called serotonin . Some studies have also shown that, in these people, other brain chemicals (norepinephrine, dopamine, prolactin, cortisal) function in an unusual way, or that their brains respond to these chemicals in an unusual way.

Research into the causes of self-harm has considered the issue of whether self-harmers feel pain. Some people who practice self-harm say that they do not feel physical pain during the act. Ingrid Kemperman and others in 1997 found that this may be due to malfunctioning brain chemistry, such as the lower levels of serotonin. Self-harmers may have high levels of brain chemicals called opioids , which block the pain of their self-injury and instead cause a surging feeling of well-being.

Some people who self-harm have a higher threshold for pain in general, according to Martin Bohus in 2001, meaning they may experience less discomfort than the average person during any injury, even when they are not emotionally upset. On the other hand, at times self-harmers may experience and even welcome the feeling of pain as a way to help prove that their psychological pain (such as extremely distressing feelings of confusion, guilt, or self-doubt) is real. They may also be trying to reverse a sense of deadness, to feel alive by feeling pain.

Certain factors in the life of an adolescent can contribute to a tendency to self-harm. These include life events that cause stress or trauma ; problems with school, relationships, or family; the loss of parents; a history of physical or sexual abuse; serious illness and/or surgery; and violence and alcohol abuse in childhood. A crisis situation involving a relationship and the emotions of loss or anger can bring on self-harming behavior. Adolescents who self-harm while hospitalized for psychiatric reasons may do so out of a reaction to the imposition of an unwanted routine, or because they feel abandoned or ignored by their family and/or hospital personnel and employees. Adolescents who have had several different caretakers in their lives are also more likely to engage in self-harm. This suggests that self-harming adolescents may have trouble forming secure and trusting attachments to others, according to J. M. Vivona and others in 1995. Self-harm may also be triggered by too much or too little emotional involvement in a family, as well as the absence of someone the young person can confide in.

Some experts believe there are psychoanalytical explanations for self-harm. Psychoanalysis seeks to uncover a person's early experiences that may have affected their patterns of behavior without their being aware of it. For example, if in the person's childhood a caretaker, whether a parent or someone else, tended to criticize the child frequently, this criticism may contribute in later life to a desire to self-harm. Other psychoanalytic explanations of self-harm, such as that of S. Doctors in 1981, include having a poorly defined sense of self, anxiety about sex, a desire to separate from one's parents, or a conflicted relationship with one's body.

Self-harm among adolescents has sometimes been referred to as contagious. Adolescents who self-harm may occasionally let friends in on their secretive behavior as a way of communicating with their peers and forming close, if only temporary, bonds. Unfortunately, sharing the secret often leads to the confidant's beginning to self-harm. Teenagers who live together or spend a lot of time together can put pressure on each other to follow the example of self-harm, according to Barent W. Walsh and Paul M. Rosen in 1988.

Treating Those Who Self-Harm

There are a number of forms of treatment for self-harm, many of which are considered quite effective. Some treatments directly target self-harm behavior. Other treatments focus on improving factors in a person's life that often occur along with self-harm, such as poor self-image, trouble sustaining close relationships, and overeating.

Psychiatrists sometimes prescribe medications to treat self-harm. Antidepressants , such as tricyclics, MAO inhibitors, and SSRIs, can address any accompanying feelings of sadness. Neuroleptics or mood stabilizers may be used to treat patients' occasional feelings of being out of touch with reality, anxiety, extreme sensitivity in relating to others, anger, and depression. Benzodiazepines , a type of anti-anxiety medication, are used occasionally. As mentioned earlier, research suggests that people who self-harm produce high levels of brain opioids that prevent them from feeling the pain of their self-injury. To counter this, some researchers (including A. Roth, R. Ostroff, and R. Hoffman in 1990) have studied the use of the drug naltrexone, which can block the rewards delivered by brain opioids and as a result increase the feeling of pain.

Another form of treatment for self-harm takes a psychological approach. A concern of this treatment is to keep patients who self-harm safe yet also to ensure that they do not become overly reliant on hospitalization. Patients need to set realistic and flexible goals, and therapists must be careful not to act out on their own feelings of frustration by blaming patients for not reaching these goals. Patients should not be made to feel that they have been rejected by their therapists.

Behavioral treatments have proven particularly effective with various forms of self-harm. An increasingly well-known form is dialectical behavior therapy (DBT), developed by Linehan specifically for self-harming patients with a diagnosis of borderline personality disorder . In this type of therapy, there is an emphasis on achieving a balance between acceptance and change, learning how to adapt to various life situations, and teamwork by therapists. Patients receive both individual and group treatment, generally on an outpatient basis.

Conclusion

The mental health community must pay more attention to the problem of self-harm. In addition, education by teachers and parents using sources in the media and the Internet can help to dispel myths about self-harm. All resources should be used to inspire hope and encourage recovery. If you or anyone you know suffers from this behavior, please make sure to get help as soon as possible. Organizations such as the American Psychological Association (http://www.apa.org) and the American Psychiatric Association (http://www.psych.org) can offer help. A web site, Mental-Health-Matters.com, and a telephone referral service, 1-800-lifenet, may also help.