Laura E. Gibson, PhD, and Tina Crenshaw, PhD, MLS

What is self-harm?

Self-harm refers to the deliberate, direct destruction of body tissue. Other terms for self-harm include “parasuicide,” “self-mutilation,” “self-injury,” “self-abuse,” “cutting,” or “self-inflicted violence.” When someone engages in self-harm, they may have a variety of intentions; these are discussed below. However, the person’s intention is not to kill himself or herself.

Self-harm tends to begin in adolescence or early adulthood. While some people may engage in self-harm a few times and then stop, others engage in it frequently and have great difficulty stopping the behavior (1). Self-harm is related to trauma in that those who engage in self-harm are likely to have experienced abuse in childhood (2-6).

How common is self-harm?

The rates of self-harm revealed through research vary tremendously, depending on how researchers pose their questions about this behavior. Estimates of lifetime self-harm prevalence in the general population range from 2.2% to 6% (2). In samples of students, the rates are higher, ranging from 13% to 35% (2).

In studies that have compared general population samples to clinical samples, the rates of self-harm were higher in the clinical samples (2-3). Within clinical samples, those with a diagnosis of PTSD report higher rates of self-harm than do those without PTSD (7). In one sample of psychiatric outpatients, as many as 60% of those with a diagnosis of PTSD reported harming themselves in the previous three months (7).

Characteristics of self-harmers

A systematic review of the literature on correlates of self-harm found that self-harmers, as compared to others, have more frequent and more negative emotions such as anxiety, depression, and aggressiveness. Links between self-harm and dissociation, low emotional expressivity, and low self-esteem have also been found (2). The evidence on whether self-harm is more common in females or males is mixed (2-3, 7).

Individuals who self-harm appear to have higher rates of PTSD and other psychological problems (1, 4-6). Self-harm may be most often related to trauma exposure in childhood rather than adulthood (2-3). A number of studies (2-6) have found that individuals who engage in self-harm report unusually high rates of histories of:

• Childhood sexual abuse
• Childhood physical abuse
• Emotional neglect
• Insecure attachment
• Prolonged separation from caregivers

Childhood sexual abuse appears especially frequently in the histories of those who self-harm (2). In one sample of individuals who self-harmed, 93% reported a history of childhood sexual abuse (3). Some research has looked at whether particular characteristics of childhood sexual abuse place individuals at greater risk for engaging in self-harm as adults. More severe, more frequent, or a longer duration of sexual abuse was associated with an increased risk of engaging in self-harm in one’s adult years (8-9).

Why do people engage in self-harm?

While there are many theories about why individuals harm themselves, the answer to this question may vary from individual to individual (10-11). One study specifically examined the reasons given for the behavior in a sample of self-harmers (3). The top two reasons were “To distract yourself from painful feelings” and “To punish yourself.” When factor analysis was applied the responses, nine factors were found:

• Decrease dissociative symptoms, especially depersonalization and numbing.
• Reduce stress and tension.
• Block upsetting memories and flashbacks.
• Demonstrate a need for help.
• Ensure safety and self-protection.
• Express and release distress.
• Reduce anger.
• Disfigure self as punishment.
• Hurt self in lieu of others.

How is self-harm treated?

Self-harm is a problem that many people are embarrassed or ashamed to discuss. Often, individuals try to hide their self-harm behaviors and are very reluctant to seek needed psychological or even medical treatment.

Psychological treatments

Because self-harm is often associated with other psychological problems, it tends to be treated under the umbrella of a co-occurring disorder like PTSD, substance abuse, or borderline personality disorder. There is evidence, however, suggesting more improvement when the self-harming behavior is the primary focus of treatment. A randomized controlled trial looked at the effects of adding a short cognitive behavioral therapy (CBT) intervention focused on self-harm to treatment as usual in a sample of self-harmers. Treatment as usual included medications or psychotherapy not specific to self-harm. The group that received the self-harm CBT showed a significant reduction in self-harming behaviors, as compared to the group receiving only treatment as usual (12).

Pharmacological treatments

It is possible that psychopharmacological treatments would be helpful in reducing self-harm behaviors, but this has not yet been rigorously studied. As yet, there is no consensus regarding whether or not psychiatric medications should be used in relation to self-harm behaviors. This is a complicated issue to study because self-harm can occur in many different populations and co-occur with many different kinds of psychological problems.

References

1. Simeon, D., & Hollander, E. (Eds.). (2001). Self injurious behaviors: Assessment and treatment. Washington, DC: American Psychiatric Press.
2. Fliege, H., Lee, J., Grimm, A., & Klapp, B. F. (2009). Risk factors and correlates of deliberate self-harm behavior: A systematic review. Journal of Psychosomatic Research, 66(6), 477-493.
3. Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68(4), 609-620.
4. Gratz, K.L., Conrad, S.D., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128 – 140.
5. Van der Kolk, B.A., Perry, J.C., & Herman, J.L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665 – 1671.
6. Zlotnick, C., Shea, M.T., Pearlstein, T., Simpson, E., Costello, E., & Begin, A. (1996). The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive Psychiatry, 37, 12 – 16.
7. Zlotnick, C., Mattia, J.I., & Zimmerman, M. (1999). Clinical correlates of self-mutilation in a sample of general psychiatric patients. The Journal of Nervous and Mental Disease, 187, 296 – 301.
8. Boudewyn, A.C., & Liem, J.H. (1995). Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood. Journal of Traumatic Stress, 8, 445 – 459.
9. Turell, S.C., & Armsworth, M.W. (2000). Differentiating incest survivors who self-mutilate. Child Abuse & Neglect, 24,237 – 249.
10. Conterio, K., & Lader, W. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York: Hyperion.
11. Favazza, A. (1998). The coming of age of self-mutilation. Journal of Nervous and Mental Disease, 186, 259 – 268.
12. Slee,N., Garnefski, N., van der Leeden, R., Arensman, E., & Spinhoven, P. (2008). Cognitive-behavioural intervention for self-harm: Randomised controlled trial. British Journal of Psychiatry. 192(3), 202-211.