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.: "[B]ehaviors associated with substance and eating disorders—such as alcohol abuse, binging, and purging—are usually not considered self-injury because the resulting tissue damage is ordinarily an unintentional side effect. In addition, body piercings and tattoos are typically not considered self-injury because they are socially sanctioned forms of cultural or artistic expression. However, the boundaries are not always clear-cut. In some cases behaviors that usually fall outside the boundaries of self-injury may indeed represent self-injury if performed with explicit intent to cause tissue damage."
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.
Classification Examples of behavior Degree of physical damage Psychological state Social acceptability I Ear-piercing, nail-biting, small tattoos, cosmetic surgery (not considered self-harm by the majority of the population) Superficial to mild Benign Mostly accepted II Piercings, saber scars, ritualistic clan scarring, sailor tattoos, gang tattoos, minor wound-excoriation, trichotillomania Mild to moderate Benign to agitated Subculture acceptance III Wrist- or body-cutting, self-inflicted cigarette burns and tattoos, major wound-excoriation Mild to moderate Psychic crisis Possibly accepted by a handful of similar-minded friends but not by the general population IV Auto-castration, self-enucleation, amputation Severe Psychotic decompensation Unacceptable
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 a society's traditions, symbolism and beliefs. 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.
Terminology Self-harm (SH), self-injury (SI), nonsuicidal self-injury (NSSI) and self-injurious behavior (SIB) are different terms to describe tissue damage that is performed intentionally and usually without suicidal intent. The adjective "deliberate" is sometimes used, although this has become less common, as some view it as presumptuous or judgmental. Less common or more dated terms include parasuicidal behavior, self-mutilation, self-destructive behavior, self-inflicted violence, self-injurious behavior, and self-abuse. Others use the phrase self-soothing as intentionally positive terminology to counter more negative associations. Self-inflicted wound or self-inflicted injury refers to a broader range of circumstances, including wounds that result from organic brain syndromes, substance abuse, and autoeroticism.
Different sources draw various distinctions between some of these terms. Some sources define self-harm more broadly than self-injury, such as to include drug overdose, eating disorders, and other acts that do not directly lead to visible injuries.: "Some authors differentiate self harm from self injury .... Self harm may be defined as any act that causes psychological or physical harm to the self without a suicide intention, and which is either intentional, accidental, committed through ignorance, apathy or poor judgement. By far the most common form of self harm is drug overdose which requires standard medical management in the first instance. Self injury, on the other hand, is a kind of self harm which leads to visible, direct, bodily injury. Self injury includes cutting, burning, scalding and injurious insertion of objects into the body[.]" Others explicitly exclude these. Some sources, particularly in the United Kingdom, define deliberate self-harm or self-harm in general to include suicidal acts. (This article principally discusses non-suicidal acts of self-inflicted skin damage or self-poisoning.) The inconsistent definitions used for self-harm have made research more difficult.
Nonsuicidal self-injury (NSSI) is listed in Section II (Diagnostic criteria and codes) of the latest, , edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) under the category "other conditions that may be a focus of clinical attention". While NSSI is not a separate mental disorder, the DSM-5-TR adds a diagnostic code for the condition in-line with the ICD. The disorder is defined as intentional self-inflicted injury without the intent of dying by suicide. Section III (Emerging measures and models) of the previous edition of the DSM (DSM-5) contains the proposed diagnosis along with criteria and description of Nonsuicidal Self-injury. Criteria for NSSI include five or more days of self-inflicted harm over the course of one year without suicidal intent, and the individual must have been motivated by seeking relief from a negative state, resolving an interpersonal difficulty, or achieving a positive state.
People who self-harm are not usually seeking to end their own life; it has been suggested instead that they are using self-harm as a coping mechanism to relieve emotional pain or discomfort or as an attempt to communicate distress.
Concealment A common practice in those who self-harm is that of concealment. Concealment is the process of hiding one's self-harm scars or wounds via methods such as wearing concealing attire, harming in less perceived places such as the thighs, applying makeup, or receiving plastic surgery or tattoos. There are many reasons a person may choose to conceal, the most common of which is caused by the stigma around self-harm. Individuals who choose to conceal often believe their scars to be socially detrimental or that people may perceive them to be seeking attention. Some individuals may also wish to conceal their scars from themselves, due to a sense of shame or belief it makes them weak.
Not all people who engage in self-harm wish to conceal their wounds and may be indifferent to or in some cases have a desire for them to be seen. Some people who self-harm do so to exert interpersonal influence, validation, belonging, protection or punishment; in cases like these, people may not wish to conceal their scars or wounds either from themselves or others, believing they will gain approval, cause disgust or instill fear in others.
Signs and symptoms The most common form of self-harm for adolescents, according to studies conducted in six countries, is stabbing or cutting the skin with a sharp object. For adults ages 60 and over, self-poisoning (including intentional drug overdose) is by far the most common form. Other self-harm methods include burning, head-banging, biting, scratching, hitting, preventing wounds from healing, self-embedding of objects, and hair-pulling. The locations of self-harm are often areas of the body that are easily hidden and concealed from the sight of others, most commonly being the forearms, thighs or torso.
Causes
Mental disorder