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Saturday, 19 February 2011


Self-harm (SH) or deliberate self-harm (DSH) includes self-injury (SI) and self-poisoning and is defined as the intentional, direct injuring of body tissue without suicidal intent. These terms are used in the more recent literature in an attempt to reach a more neutral terminology. The older literature, especially that which predates the DSM-IV-TR, almost exclusively refers to self-mutilation. The term is synonymous with "self-injury."[1][2][3] The most common form of self-harm is skin-cutting but self-harm also covers a wide range of behaviours including, but not limited to, burning, scratching, banging or hitting body parts, interfering with wound healing, hair-pulling (trichotillomania) and the ingestion of toxic substances or objects.[2][4][5] Behaviours associated with substance abuse and eating disorders are usually not considered self-harm because the resulting tissue damage is ordinarily an unintentional side effect.[6] However, the boundaries are not always clear-cut and in some cases behaviours that usually fall outside the boundaries of self-harm may indeed represent self-harm if performed with explicit intent to cause tissue damage.[6] Although suicide is not the intention of self-harm, the relationship between self-harm and suicide is complex, as self-harming behaviour may be potentially life-threatening.[7] There is also an increased risk of suicide in individuals who self-harm[4][8] to the extent that self-harm is found in 40–60% of suicides.[9] However, generalising self-harmers to be suicidal is, in the majority of cases, inaccurate.[10][11]
Self-harm in childhood is relatively rare but the rate has been increasing since the 1980s.[12] Self-harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a symptom of borderline personality disorder. However patients with other diagnoses may also self-harm, including those with depression, anxiety disorders, substance abuse, eating disorders, post-traumatic stress disorder, schizophrenia, and several personality disorders.[2] Self-harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis.[6] The motivations for self-harm vary and it may be used to fulfill a number of different functions.[13] These functions include self-harm being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness and a sense of failure or self-loathing. Self-harm is often associated with a history of trauma and abuse, including emotional abuse, sexual abuse, drug dependence, eating disorders, or mental traits such as low self-esteem or perfectionism. There is also a positive statistical correlation between self-harm and emotional abuse.[14][15] There are a number of different methods that can be used to treat self-harm and which concentrate on either treating the underlying causes or on treating the behaviour itself. When self-harm is associated with depression, antidepressant drugs and treatments may be effective.[8] Other approaches involve avoidance techniques, which focus on keeping the individual occupied with other activities, or replacing the act of self-harm with safer methods that do not lead to permanent damage.[16]
Self-harm is most common in adolescence and young adulthood, usually first appearing between the ages of 12 and 24.[1][5][6][17][18] However, self-harm can occur at any age,[13] including in the elderly population.[19] The risk of serious injury and suicide is higher in older people who self-harm.[18] Self-harm is not limited to humans. Captive non-human animals are also known to participate in self-mutilation, such as captive birds and monkeys.[20][21]

Signs and symptoms

Eighty percent of self-harm involves stabbing or cutting the skin with a sharp object.[5][30][31] However, the number of self-harm methods are only limited by an individual's inventiveness and their determination to harm themselves; this includes, but is not limited to burning, self-poisoning, alcohol abuse, self-embedding of objects and forms of self-harm related to anorexia and bulimia.[5][31] The locations of self-harm are often areas of the body that are easily hidden and concealed from the detection of others.[32] As well as defining self-harm in terms of the act of damaging one's own body, it may be more accurate to define self-harm in terms of the intent, and the emotional distress that the person is attempting to deal with.[31] Neither the DSM-IV-TR nor the ICD-10 provide diagnostic criteria for self-harm. It is often seen as only a symptom of an underlying disorder,[10] though many people who self-harm would like this to be addressed.[27] A formal proposal is currently under review (2010) to include Non-Suicidal Self-Injury as a distinct diagnosis in the forthcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[33]

Mental illness

Although some people who self-harm do not suffer from any forms of recognised mental illness,[26] many people experiencing various forms of mental ill-health do have a higher risk of self-harm. The key areas of illness which exhibit an increased risk include borderline personality disorder, bipolar disorder,[34] depression,[14][35] phobias,[14] and conduct disorders.[36] Schizophrenia may also be a contributing factor for self-harm. Schizophrenics have a high risk of suicide, which is particularly greater in younger patients as they may have an insight into the serious effects that the illness can have on their lives.[37] Substance abuse is also considered a risk factor[10] as are some personal characteristics such as poor problem-solving skills and impulsivity.[10] There are parallels between self-harm and Münchausen syndrome, a psychiatric disorder where those affected feign illness or trauma.[38] There may be a common ground of inner distress culminating in self-directed harm in a Münchausen patient. However, a desire to deceive medical personnel in order to gain treatment and attention is more important in Münchausen's than in self-harm.[38]

Psychological factors

Emotionally invalidating environments where parents punish children for expressing sadness or hurt can contribute to a difficulty experiencing emotions and increased rates of self-harm.[30][39] Abuse during childhood is accepted as a primary social factor,[40] as is bereavement,[41] and troubled parental or partner relationships.[10][15] Factors such as war, poverty, and unemployment may also contribute.[14][42][43] Self-harm is frequently described as an experience of depersonalisation or a dissociative state.[44] An estimated 30% of individuals with autism spectrum disorders engage in self-harm at some point, including eye-poking, skin-picking, hand-biting, and head-banging.[45][46] Recent authors discuss the possible psychological purposes behind self-harm: it can act as a way for people to re-enact traumas experienced in the past which were possibly out of the person's control. Self-harm may therefore serve as a chance for these people to regain control and autonomy over their life if it is in any way disorderly.[47]


The most distinctive characteristic of the rare genetic condition Lesch-Nyhan syndrome is self-harm and may include biting and head-banging.[48] Genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behaviour. However, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive.[4]

Drugs and alcohol

Substance misuse, dependence and withdrawal are associated with self-harm. Benzodiazepine dependence as well as benzodiazepine withdrawal is associated with self-harming behaviour in young people.[49] Alcohol is a major risk factor for self-harm.[30] A study which analysed self-harm presentations to emergency rooms in Northern Ireland found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations.[50] A recent study in the relation between cannabis use and deliberate self-harm (DSH) in Norway and England, found that, in general, cannabis use may not be a specific risk factor for DSH in young adolescents.[51]

Prison inmates

Deliberate self-harm is especially prevalent in prison populations. A proposed explanation for this is that prisons are often violent places, and prisoners who wish to avoid physical confrontations may resort to self-harm as a ruse, either to convince other prisoners that they are dangerously insane and resilient to pain or to obtain protection from the prison authorities.[83]

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