Self-harm

Self-harm is intentional behavior that causes harm to oneself. This is most commonly regarded as direct injury of one's own tissues, usually without suicidal intention. Other terms such as cutting, self-abuse, self-injury, and self-mutilation have been used for any self-harming behavior regardless of suicidal intent. Common forms of self-harm include damaging the skin with a sharp object or scratching with the fingernails, hitting, or burning. The exact bounds of self-harm are imprecise, but generally exclude tissue damage that occurs as an unintended side-effect of eating disorders or substance abuse, as well as more societally acceptable body modification, such as tattoos and piercings. Although self-harm is by definition non-suicidal, it may still be life-threatening. People who do self-harm are more likely to die by suicide, and 40–60% of people who die by suicide have previously self-harmed. Still, only a minority of those who self-harm are suicidal. The desire to self-harm is a common symptom of some personality disorders. People with other mental disorders may also self-harm. Studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions. Self-harm can also occur in high-functioning individuals who have no underlying mental health diagnosis. The motivations for self-harm vary; some use it as a coping mechanism to provide temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness, or a sense of failure. Self-harm is often associated with a history of trauma, including emotional and sexual abuse. There are a number of different methods that can be used to treat self-harm, which concentrate on either treating the underlying causes, or on treating the behavior itself. 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 tends to begin in adolescence. Self-harm in childhood is relatively rare, but the rate has been increasing since the 1980s. Self-harm can also occur in the elderly population. The risk of serious injury and suicide is higher in older people who self-harm. Captive animals, such as birds and monkeys, are also known to harm themselves.

Classification

Although the 20th-century psychiatrist Karl Menninger is often credited with the initial clinical characterization of self-harm, self-harm is not a new phenomenon. There is frequent reference in 19th-century clinical literature and asylum records which make a clear clinical distinction between self-harm with and without suicidal intent. This differentiation may have been important to both safeguard the reputations of asylums against accusations of medical neglect and to protect patients and their families from the legal or religious consequences of a suicide attempt. In 1896, the American ophthalmologists George Gould and Walter Pyle categorized self-mutilation cases into three groups: those resulting from "temporary insanity from hallucinations or melancholia; with suicidal intent; and in a religious frenzy or emotion". Menninger considered self-mutilation as a non-fatal expression of an attenuated death wish and thus coined the term partial suicide. He began a classification system of six types:

neurotic – nail-biters, pickers, extreme hair removal, and unnecessary cosmetic surgery religious – self-flagellants and others puberty rites – hymen removal, circumcision, or clitoral alteration psychotic – eye or ear removal, genital self-mutilation, and extreme amputation organic brain diseases – which allow repetitive head-banging, hand-biting, finger-fracturing, or eye removal conventional – nail-clipping, trimming of hair, and shaving beards. Pao differentiated between delicate (low lethality) and coarse (high lethality) self-mutilators who cut. The "delicate" cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. The "coarse" cutters were older and generally psychotic. Ross and McKay (1979) categorized self-mutilators into nine groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling, hitting, and constricting. After the 1970s the focus of self-harm shifted from Freudian psycho-sexual drives of the patients. Walsh and Rosen created four categories numbered by Roman numerals I–IV, defining Self-mutilation as rows II, III and IV.

Favazza and Rosenthal reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation. Favazza also created two subcategories of sanctioned self-mutilations; rituals and practices. The rituals are mutilations repeated generationally and "reflect the traditions, symbolism, and beliefs of a society" (p. 226). Practices "imply activities that may be faddish and that often hold little underlying significance" such as piercing of earlobes, nose, eyebrows as well as male circumcision while deviant self-mutilation is equivalent to self-harm.

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