Virginia Commission on Youth

Self Injury

Self injury (SI), also called self mutilation or cutting, is a highly stigmatized emotional disorder. According to Focus Adolescent Services (FAS) (2001), approximately one percent of Americans suffer from SI. While SI can occur in people regardless of age, gender, ethnicity, or socioeconomic status (FAS), much of the discourse is centered on adolescents, as this behavior tends to begin during adolescence (Boesky, 2002). However, groups at risk for SI have been defined as those with borderline personality disorder (particularly females age 16 to 25), those who are in a psychotic state (mainly young adult males), children who are emotionally disturbed and/or battered, children who are mentally retarded and autistic, those with a history of self injury, and those with a history of physical, emotional or sexual abuse (Mosby, 1994, as quoted in Martinson).

SI is the repetitive, deliberate infliction of harm to one’s own body. Injuries are severe enough to cause tissue damage and include cutting, carving, scratching, burning, bruising, biting, hitting, bone-breaking, skin picking, hair pulling, branding, and marking (Martinson, 1998; Boesky, 2002). SI is thought to be a maladaptive coping mechanism that is utilized when the self injuring youth experiences highly stressful or emotionally overwhelming circumstances. Many youth who engage in SI describe an immediate relief from psychological and physiological tension as the act is completed (Martinson, Boesky). For some, the production of pain is a component of the tension relief, while for others the blood-letting is what becomes necessary to gain a sense of relief.

Table 1
Risk Factors for Self Injury
Mosby, 1994, as quoted in Martinson

° Being a member of an at-risk group

° Inability to cope with increased psychological/physiological tension in a healthy manner

° Feelings of depression, rejection, isolation, self-hatred, separation anxiety, guilt and depersonalization

° Command hallucinations

° Need for sensory stimuli

° Dysfunctional family

Research has shown that SI is seldom an attempt at suicide. While some believe it to be in the spectrum of suicidal behavior, there is growing recognition that SI represents a different pattern of interpersonal dynamics that is distinct from clear suicidal intent. Favazza, as quoted in Martinson in 1998, states, “…a person who truly attempts suicide seeks to end all feelings, whereas a person who self-mutilates seeks to feel better.” Additionally, SI is generally not associated with sexual gratification, body decoration (piercing and tattooing), cultural rituals that induce spiritual enlightenment, or trying to be cool or fit in (FAS). There are, however, clusters of peer group acceptance of this behavior.

Studies have shown that physical or sexual abuse and trauma are commonly associated with SI. A 1991 study found that exposure to sexual or physical abuse, emotional or physical neglect, and chaotic family conditions during childhood, latency, and adolescence strongly predicts the number and severity of cutting incidents (Van der Kolk et al., 1991, as cited in Martinson). However, some self injurers never suffered childhood abuse. A 1994 study by Zweig-Frank et al. found no association among abuse, dissociation, and SI among patients diagnosed with borderline personality disorder (Martinson, 1998).

Abuse aside, it has been suggested that growing up in a chronically invalidating home environment may be a chief factor for SI. Linehan (1993, as cited by Martinson) defines an invalidating environment as one in which the communication of private feelings is met by erratic, inappropriate, or extreme responses. That is, expressing one’s private emotions (painful or otherwise) is not validated, but is instead constantly punished or trivialized, thus dismissing the child’s interpretation of his own actions or behaviors, as well as his behaviors’ intentions and motivations. Such persistent invalidation, Linehan concluded, can lead to subconscious self-invalidation and self-distrust and feelings of “I never mattered.”

Studies have shown that low serotonin levels in the brain are associated with SI in some cases. Researchers have found that self injurers have fewer platelet imipramine binding sites, which is a marker of serotonin activity. Studies done by Stoff et al. (1987), Birmaher et al. (1990) and others link low numbers of platelet imipramine binding sites to impulsive behavior and aggression (Martinson, 1998). Thus, it appears that SI may have similarities to other impulse control disorders such as kleptomania or compulsive gambling.

Children with autism or mental retardation often exhibit self injuring behavior. Other conditions with which SI is seen include Borderline Personality Disorder, Mood Disorders, Eating Disorders, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Dissociative Disorders, Anxiety and/or Panic Disorder, and Impulse Control Disorder Not Otherwise Specified. However, it is important to note that, while many self injurers may be labeled as or diagnosed with one or more of these conditions, not all self injurers meet the criteria for these conditions. Clinical studies examining the link between SI and some of these conditions have yet to be done (Martinson, 1998).

In treating SI, understanding the dynamics of the disorder and providing structure, safety, and consistency are crucial. The key to helping an adolescent stop engaging in SI as a coping mechanism or stress reliever is to understand why the youth self injures. Self injuring youth should have access to non-judgmental, compassionate medical care for their self inflicted wounds that does not take away their dignity or autonomy (Dallam, 1997 as cited in Martinson). Current approaches to the successful treatment of SI relies heavily on teaching children and adolescents new ways of coping with stressors so that underlying painful feelings can be dealt with (Martinson). Also, it is helpful for the mental health provider to assess whether there are any comorbid disorders and ascertain any implications this would have on treatment.

There are neither proven treatments for SI nor certainty about which forms of psychosocial and physical treatments are most effective. To date, studies have been inconclusive due to the insufficient number of patients in trials (Hawton, 2002). There is a need for further study in order to ascertain evidence-based treatments that have proven effectiveness. Efficacy of treatment interventions for SI has been measured by the rate of repeated suicidal behavior, but other measures, such as compliance with treatment, depression, hopelessness, and reduced rates of repetition of deliberate self-harm, need to be examined (Hawton).

Treatment for SI may depend on the combination of dangerous behaviors which the child displays. Treatments shown to have promising results include the following:

Cognitive behavioral therapy - Cognitive behavioral therapy can be used to help combat the cognitive distortions and the belief that SI is an acceptable way to manage feelings (Beck, 1995, as cited in Jones, 2001).

Behavior Modification - Behavior modification may be used to eliminate some behaviors while establishing others (Jones). Psychodynamic therapy may be used to identify the lack of attachment (Hughes, 1998, as cited in Jones).

Addictions Model - An addictions model may be useful in very chronic cases. The addictions model is used to help the child or adolescent develop a sense of control over their life in other, more realistic ways. This model emphasizes techniques that help in building time between having the urges and acting on those urges (Alderman, 1997, as cited in Jones).

· learn alternative, healthy means for discharging these feelings, such as problem-solving, conflict resolution, anger management, and assertiveness training (Rosen, Suyemoto & MacDonald, 1995, as cited by the Suicide Information & Education Centre, 2001).

Medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) and opiate antagonists have been studied to control SI, but evidence of the effectiveness of pharmacological treatment of this behavior is inconclusive (Martinson, 1998). However, it appears that so far the most promising treatments are high-dose SSRIs and, in some cases, atypical neuroleptics (Martinson). For many individuals, a trial of medication may be a part of the treatment. There is virtually no situation in which medication alone would be appropriate treatment.

Hospitalization is usually used as a last resort in the treatment of SI. Self injuring youth are hospitalized in order to prevent them from hurting themselves, and intensive individual and group therapy, as well as medications, are readily available (Clarke, 1999, as cited in SIEC). However, hospitals are “artificially safe” environments, and it is more important to understand the feelings behind the self injuring behavior and to teach better coping mechanisms that can be practiced in the real world (Martinson, 1998).

Boesky, L. Juvenile Offenders with Mental Health Disorders: Who Are They and What Do We Do With Them? “Self-Injurious Behavior among Juvenile Offenders.” Lanham , MD : American Correctional Association, 2002.

Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. (2002). Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Review. In: The Cochrane Library, Issue 2, 2002. Oxford : Update Software.

Jones, A.B. (2001). Self-injurious behavior in children and adolescents, Part II: Now what? The treatment of SIB, KidsPeace Healing Magazine.

Alderman, T. The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland : New Harbinger Publications, 1997.

Favazza, A.R. Bodies under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry. Baltimore: Johns Hopkins University Press, 1996.

Holmes, A. Cutting the Pain Away: Understanding Self-Mutilation. C. E. Reinburg and C.C. Nadleson, Eds. Broomall, PA: Chelsea House Publishers, 1999.