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." 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. 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. 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. 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. There is also an increased risk of suicide in individuals who self-harm to the extent that self-harm is found in 40–60% of suicides. However, generalising self-harmers to be suicidal is, in the majority of cases, inaccurate.
Self-harm in childhood is relatively rare but the rate has been increasing since the 1980s. 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. Self-harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. The motivations for self-harm vary and it may be used to fulfill a number of different functions. 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. 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. 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.
Self-harm is most common in adolescence and young adulthood, usually first appearing between the ages of 12 and 24. However, self-harm can occur at any age, including in the elderly population. The risk of serious injury and suicide is higher in older people who self-harm. 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.
Signs and symptomsEighty percent of self-harm involves stabbing or cutting the skin with a sharp object. 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. The locations of self-harm are often areas of the body that are easily hidden and concealed from the detection of others. 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. 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, though many people who self-harm would like this to be addressed. 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).
Mental illnessAlthough some people who self-harm do not suffer from any forms of recognised mental illness, 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, depression, phobias, and conduct disorders. 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. Substance abuse is also considered a risk factor as are some personal characteristics such as poor problem-solving skills and impulsivity. There are parallels between self-harm and Münchausen syndrome, a psychiatric disorder where those affected feign illness or trauma. 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.
Psychological factorsEmotionally invalidating environments where parents punish children for expressing sadness or hurt can contribute to a difficulty experiencing emotions and increased rates of self-harm. Abuse during childhood is accepted as a primary social factor, as is bereavement, and troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. Self-harm is frequently described as an experience of depersonalisation or a dissociative state. 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. 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.
GeneticsThe most distinctive characteristic of the rare genetic condition Lesch-Nyhan syndrome is self-harm and may include biting and head-banging. 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.
Drugs and alcoholSubstance 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. Alcohol is a major risk factor for self-harm. 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. 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.
Prison inmatesDeliberate 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.