Self-mutilation

Emily Jane Willingham & Rebecca J Frey. The Gale Encyclopedia of Medicine. Editor: Jacqueline L Longe, 6th Edition, Volume 8, Gale, 2020.

Definition

Self-mutilation, a feature of self-harm or self-injury, is defined as intentional injury to one’s own body tissues without an accompanying conscious intention to commit suicide. Although this behavior can appear similar to a suicide attempt, the phrase “deliberate self harm” is preferred to “suicide attempt” because the reasons and motivation behind self-harm or mutilation are generally quite different from those that underlie attempted suicide. Self-mutilation is considered a coping mechanism, although not a positive one.

Self-mutilation and self-harm are not explicitly listed as disorders in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM, although some clinicians argue that they should be listed under the category of impulse control disorders. The 2000 edition (the fourth edition, text revision, also known as DSM-IV-TR) mentions self-injury as a symptom or criterion for diagnosis of borderline personality disorder (BPD); stereotypic movement disorder, which can be a comorbidity of autism or intellectual disability; and factitious disorder (specifically factitious disorder with predominantly physical signs and symptoms), in which the person fakes a physical illness. For example, the self-mutilation behavior in factitious disorder might involve pulling out one’s hair or purposely exacerbating a healing wound to mimic disease symptoms. Self-harm, including self-mutilation, also can be associated with other disorders listed in the DSM-IV, including posttraumatic stress disorder (PTSD).

Demographics

The incidence of self-harm has received more attention in clinical populations rather than in community or nonclinical groups. Groups at risk of self-harm include depressed adolescents, those experiencing an interpersonal crisis, and those who have done it before. Although reported incidence in the research literature can vary from study to study, there is some overlap. Some studies report a rate of 4% in the general adult population and 21% in the adult clinical population. Adolescents make up the group at greatest risk: In the community, rates have been reported ranging from 14% to 39% of respondents and a range of 14% to 21% among high school students; in adolescent psychiatric inpatient samples, rates are as high as 40% to 61%. Studies have identified self-harm behaviors in 4% of military recruits and 14% to 35% of psychology students at public universities. Research indicates that self-mutilating behavior occurs among nonclinical populations at higher rates than previously thought.

Rates of frequent self-mutilation activity are significantly higher among lesbian and bisexual women, and the behavior was long thought to be more prevalent among females, although recent findings indicate a similar prevalence in both sexes. Although the function of self-mutilation usually differs from the motivations underlying a suicide attempt, one study suggests that 20% to 45% of those who engage in self-harm think about suicide. In addition, someone who experiences one episode of self-harm may be likely to engage in another: As many as 30% of adolescents who report a previous incident of self-harm will do it again.

Description

Self-mutilation can take different forms and have different functions depending on the individual. In some nonpsychiatric subpopulations, self-mutilation is a sanctioned activity; for example, in some adolescents, mutilation of tissues is socially acceptable and done in a group or to gain acceptance from the group. Self-harm or self-mutilation may also accompany cognitive deficits or psychosis, and in the most severe expression of the practice can manifest as auto-castration or even selfimmolation.

The focus here is self-mutilation that occurs in the absence of cognitive deficits or psychosis. What is known is that this behavior can be a manifestation of anguish that the person cannot otherwise express, or it can be a way for the person to cope with and relieve tension. In some cases, it has been construed as a method of selfpunishment. In general, self-mutilation results in so little actual harm to the body that medical professionals and even family members often do not know that the mutilation is taking place. In addition, the person who engages in self-mutilation may go to great lengths to hide the resulting physical signs. The most common forms of self-mutilation are sticking the skin with needles, scratching, or cutting. Other forms of repetitive self-mutilation are punching or slapping the face, burning the skin, and swallowing harmful substances.

People who engage in self-mutilation often claim that it is accompanied by excitement and that it reduces or relieves such negative feelings as tension, anger, anxiety, depression, and loneliness. They also describe it as addictive. Self-mutilating behavior may occur in episodes, with periods of remission, or it may be continuous over a number of years. Characteristics commonly seen in persons with this disorder are perfectionism, dissatisfaction with one’s physical appearance, and difficulty controlling and expressing emotions. Repetitive self-mutilation often worsens over time, resulting in increasingly serious forms of injury that may culminate in suicide.

Risk factors

General risk factors for self-mutilation include:

• History of sexual abuse or the death of a parent during childhood
• Parents who are perfectionistic or critical of the child’s physical appearance
• Diagnosis of concurrent depression, PTSD, borderline personality disorder, or anxiety disorder
• Female sex
• Age between 12 and 25
• Lesbian or bisexual orientation
• Frequent and excessive use of drugs of abuse or alcohol

There is a correlation between self-harm and suicide attempts, feelings of hopelessness and other symptoms of depression, anxiety, external expectations of perfection, and most often, a history of abuse. Risk factors can be classified into two categories: environmental risk factors and individual risk factors. In addition, risk factors from one category can influence those of the other.

Environmental risk factors

Some of the most commonly seen environmental risk factors in self-mutilation are associated with abuse experienced in childhood. Most research into the phenomenon of self-harm has focused on sexual abuse, but there are some indications that self-harm can also be associated with physical abuse and even emotional abuse, and it is strongly associated with low self-esteem. Almost any discussion about factors directly related to self-harm, however, is theoretical because of the paucity of actual experimental or empirical data.

In what may be a blurring of the distinction between socially sanctioned self-mutilation and the kind of selfmutilation discussed here, another risk factor for engaging in this behavior is awareness that others in one’s peer group are doing it. Substance abuse can be a contributing factor, and depression may lead someone to turn to selfmutilation as a coping mechanism. Perfectionism may also be a risk factor. Perfectionism consistently correlates with thoughts and behaviors related to self-injury.

Individual risk factors

The interaction of environmental factors and personal factors arises because of the individual ways in which people respond to environmental risk factors. Researchers have identified alexithymia, which is the inability to express feelings verbally, as an individual risk factor. The importance of this inability to express emotion as a risk factor in self mutilation is underscored by research that suggests that self-harmers who learn to express their feelings verbally decrease their selfharming behavior.

Causes and Symptoms

The major cause of self-mutilation is the underlying motivation. Self-injury is closely linked to dysfunctions of emotional expression. For some who self mutilate, the physical pain of cutting or scratching provides a distraction from emotional pain. Some may use self mutilation as a way to punish themselves or relieve a feeling of evil, while for others the practice offers a relief from tension or a way to “feel real through the physical pain or the visible evidence of physical injury. Causing physical pain to one’s body through self mutilation may also provide an outlet for a person who has difficulty communicating emotions like anger or emotional pain. In addition, people who engage in self mutilation may be trying, either consciously or subconsciously, to alter the behavior of someone near them or seek help, although many people who self harm go to great lengths to conceal the signs of the behavior.

The immediate triggers for self mutilation often center on some kind of interpersonal crisis. A person may have just experienced a separation from a partner, a major confrontation with a parent, or have just run away from home, for example.

The signs that a self-mutilation event has occurred are obvious, but less obvious are the symptoms that one will occur. A recent study found that individuals engaging in self-mutilating behavior usually thought about it for only a few minutes or even less time before completing the act; almost half reported not thinking about it at all before doing it. This association of impulsivity with selfmutilation may be related to the specific characteristics of the population studied, which was a group of adolescents who had previously self-mutilated. High levels of dissociation (a defense mechanism to isolate and protect the psyche from thoughts, emotions, or physical sensations that cause anxiety) may accompany self-mutilating behavior.

There are some signs that may precede an impulsive act of self-mutilation. These signs include trouble with parents, school, partners, or siblings; health problems; trouble with peers, including being bullied; being depressed; or having low self-esteem. Again, knowing that others in the peer group are doing it can be a precipitating factor.

Diagnosis

Many cases of self-mutilation never come to the attention of a clinician, parent, or caregiver. Often, identified self-mutilation has occurred in the context of a personality disorder, such as BPD. It may also appear as a manifestation of other psychiatric disorders, including substance abuse, intermittent explosive disorder, and eating disorders.

Self-mutilation and borderline personality disorder

For a person with BPD, self-mutilating behavior offers relief during a dissociative episode by functioning as an affirmation of the ability to feel or by relieving the person’s personal feeling of being bad. Clinical populations with BPD have been the target of most studies focusing on self-harm, and in these populations, emotional vulnerability appears to play an important role in whether an individual will self-harm and in the development of BPD itself. Emotional vulnerability involves two aspects: emotional reactivity (high sensitivity to stimuli) and emotional intensity (extreme reactions to those stimuli). These factors are among the individual characteristics that might interact with environmental factors to elicit self-mutilating behaviors. Persons with BPD may feel empty or detached to the point of anhedonia, an inability to experience pleasure from things that most people find pleasurable, such as eating good food. In addition, they may exhibit a narrow range of affect, the mood that a person displays to others. These signs of emotional inexpressivity may, according to some research, increase the possibility that a person with BPD will engage in self mutilating behavior.

Self-mutilation and suicide

Because self-mutilation can be interpreted as a cry for help, suicide can be a concern for those who become aware that an individual is self mutilating. Research suggests that there is a distinction between the risk of suicide and impulsive self-mutilation compared to self-mutilation that is deliberate and well thought out. Statistically, 20% to 25% of self harmers think about suicide, and the risk of suicide after self-harm ranges from 0.24% to 4.3%. Among the self-harming population, suicide risk factors include being an adolescent male, using a violent method of self-harm, and a history of inpatient treatment at a psychiatric facility. Some other features also are associated with conscious suicidal intent in a person who self-mutilates: self-mutilation performed alone; attempts to hide the behavior; preparations made for death, such as a plan for disposition of effects; or an act of self-harm that was planned considerably in advance (i.e., it was not impulsive).

Proposed diagnostic criteria for DSM-5

The fifth edition of DSM, known as DSM-5, contains a new category for self-mutilation, called non-suicidal self-injury disorder (NSSID). The criteria for NSSI are as follows:

• The person has on five or more days within the past year engaged in self-injury for purposes of inflicting pain (not tattooing or body piercing). The person does not intend to commit suicide, and the injury is more severe than minor wound-picking or nail biting.
• The self-injury is associated with at least two of the following four characteristics: negative thoughts preceding the act; a period of preoccupation with self-injury before the act that is difficult to resist; frequent urges to selfinjure (which may or may not be acted out); and the self-injury has a purpose (relief from painful feelings or induction of positive feelings).
• The self-injury leads to significant distress or impairment in interpersonal, academic, or other important areas of functioning.
• The behavior is not associated with intoxication, psychosis, or delirium, and cannot be better accounted for by another physical or mental disorder.

These criteria include two subtypes of NSSID, one in which individuals injure themselves fewer than five times per year but think about it often, and one in which the person may have suicidal intent as well as self-injury.

Examination

In some cases, an office examination will disclose physical evidence of self-mutilation, such as needle or burn marks, scars, or bruises. Another clue for the doctor is that the patient is wearing a long-sleeved shirt or long pants in hot weather. The patient may also acknowledge that he or she self-mutilates.

Tests

There are a number of questionnaires and inventories that can be administered in the examiner’s office to determine whether the patient meets the criteria for BPD. In addition, a group of therapists in the United Kingdom has evaluated a possible new instrument for selfharming behaviors. There are, however, no laboratory tests (blood or urine samples) that can be used to either diagnose or rule out self-mutilation.

Treatment

Treatment for self-harming behavior tends to be psychological rather than physiological.

Traditional

Psychotherapy treatments for self mutilation include dialectical behavioral therapy, problem-solving therapy, and cognitive-behavioral therapy.

Dialectical Behavioral Therapy. Dialectical behavioral therapy is a relatively new approach developed by Marsha Linehan at the University of Washington. It focuses on teaching alternative ways to manage emotion and handle distress. The relationship between emotional inexpressivity and self-harm suggests that those who engage in self-mutilating behaviors to express emotions might benefit from a clinical approach involving tutoring in other methods of emotional expression. Dialectical behavioral therapy (DBT), which involves individual therapy and group skills training, was originally developed for individuals with BPD who engage in self-harm, but it is now used for self-harming individuals with a wide variety of other psychological issues, including eating disorders and substance dependence. Research indicates that the approach is helpful in reducing selfharm.

Problem-Solving Therapy. Problem-solving therapy involves developing and rehearsing coping strategies for the situations that may precipitate self harm. The approach can involve the entire family, using structured family interventions over five or six sessions. Focus is on improved cognitive and social skills to facilitate sharing feelings, controlling emotion, and family negotiation. Group treatment can also be a facet of problem-solving therapy. Briefly, this therapeutic approach identifies problems, prioritizes them, defines goals, and establishes and executes a strategy to achieve the goals, addressing any psychological issues that become obstacles along the way.

Cognitive-Behavioral Therapy. In cases of self-mutilation accompanied by depression, a suggested approach is cognitive-behavioral therapy (CBT), which involves identifying patterns of destructive or negative behaviors or thinking and modifying them to be more realistic and pragmatic.

Other potential treatments for self mutilation in the context of other disorders include treatment for any substance abuse, anger management therapy, or environmental changes.

Drugs

There are no medications specifically indicated for self-injury. The doctor may, however, prescribe antidepressants to help the patient cope with strong feelings. The medications most often given to treat self-mutilation are the selective serotonin reuptake inhibitors (SSRIs), which work by increasing the level of serotonin in the spaces (synapses) between nerve cells in the central nervous system. The SSRIs include fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), fluvoxamine (Luvox), and sertraline (Zoloft).

In extreme cases (such as when the patient’s self-inflicted injuries are life-threatening), the doctor may recommend inpatient psychiatric treatment. Another option is a day hospital program.

Prognosis

Some studies indicate that following self-harm, some adolescents see improvement in their relationship with their parents. In addition, research suggests that selfharm may result in more support from social networks. In terms of decreasing the incidence of self-harm, selfharmers who learn to express their feelings verbally see a decrease in self-mutilating behaviors.

Prevention

Due to the lack of research on the disorder, self mutilation remains a poorly understood phenomenon, and prevention measures have not been thoroughly explored. In addition, the mixed and varied development pathways that lead to self-harm may complicate efforts at prevention. The risk factors for self-harm are often associated with other pathologies, and an awareness of this association might be a potential aid in targeting prevention.

Specific preventive strategies include helping young people with a history of self-injury to expand their social networks; forming peer counseling groups; and educating adolescents about the effects of the mass media in encouraging self-injury.