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SELF HARM

Acts of self harm come under various headings: Self Mutilation, Self Injurious Behaviour, Deliberate Self Harm Syndrome, and Self Harm.

It can be best defined as doing deliberate self harm to one’s own body, resulting in tissue damage, without a conscious intent to die, without the help of others.

Acts that are committed with intent to end life, or are associated with sexual arousal or pleasure, should be disregarded. Thus suicide, sadomasochism, drug abuse, etc, are excluded.

Ways of Self Harming

There are many ways in which a person can harm themselves:-

Cutting/laceration

Burning - including friction burns

Ingestion - drugs / injecting, alcohol, poisons, laxatives and objet d’art

Fasting - anorexia/bulimia

Motives

1. The wish to die (does not mean the wish to commit suicide)

2. A cry for help - aimed at changing a seemingly intolerable situation

3. An attempt to influence other(s), e.g. seeking to make a relative feel guilty for failing the patient in some way - “If I miss East Enders....”

4. Escape from emotional distress - the patient seeking immediate relief from their state of mind, through temporary oblivion (i.e. unconsciousness)

5. Anger directed at a loved one - and sometimes redirected against the self

6. Testing the benevolence of fate

10% of patients admitted to hospital following deliberate self harm commit suicide within 10 years.

There are four major categories of the type of patient and environment which can be looked at:-

1. Mentally retarded individuals (learning disability)

2. Psychotic patients (mental illness)

3. Prison populations

4. Individuals with character disorders (primarily borderline personality disorder)

Mentally Retarded

There is a serious problem in areas which care for the mentally retarded. Outwardly directed aggression, which is common here, often co-exists alongside self injurious behaviour.

The most dramatic and relentless form of self-injury occurs in children with Lesch-Nyham Syndrome. This is an x-linked enzyme-deficiency disorder, characterised by mental retardation, spasticity and often almost unremitting self-injurious behaviour. Often excessive finger chewing necessitates physical restraint, but the patients frequently manage to find other ways to injure themselves, concentrating on the lips or tongue.

Another rare form of congenital disorder of retarded development is Cornelia de Lange Syndrome, where behaviour is similar to Lesch-Nyham Syndrome but is less severe.

A notable relationship has been found between the frequency of self-harm and the number of disabilities, both mental and physical, a person has, which supports the idea that a combination of handicaps may lead to a high frequency of self injury - almost as if self harm were used as a perverse form of stimulus? (1)

It is interesting to note that self-injurious behaviour in those NOT suffering from Lesch-Nyham or similar syndromes, usually appears only after admission to a chronic care facility. Types of self-injurious behaviour found in this area include head-banging, face-slapping, scratching, skin-picking and biting - possibly explained by an inability to communicate, and from boredom.

Psychotic Patients

Unlike the mentally retarded's repetitive self injurious behaviour, the psychotic tends to be more dramatic.

Not all, but most of those involved in self harm, do so in response to their commands emanating from hallucinations, or their psychotic delusions, which are usually of a religious nature. The actions range from the bizarre to the ridiculous, and I myself have witnessed attempts in hospital by psychotics towards self harm, often ending in tragedy.

1. Male schizophrenic who drowned himself in the bath, convinced that he could breathe underwater. (At the time he was not thought to be acting on his delusions).

2. Female manic-depressive who had to have her arm amputated after setting fire to herself during a depressive state.

Attempts to self amputate or self castrate are not unusual, especially in the USA. There is one report of a 22-year-old male who attempted to remove his adrenal glands because he wanted to stop the production of his hormones which he felt were responsible for his unwanted aggression and sexual impulses (2).

Types of self injury are best left to the psychotic imagination, usually bizarre and of high risk.

Prison Populations

Within the prison service, many self injurious events among inmates are suspected as being manipulative. In an attempt to get transferred to a less restricted area, or to another prison, the felon may go to any lengths to gain a sympathetic ear to enable a more lenient existence. It is unfortunately difficult to assess self injury within the prison service, due to:-

1. Poor documentation on prisoners, which inhibits the ability to look for causative factors and focuses attention on the herd rather than the individual

2. Drug abuse, increasing in most prison institutions, which inhibits the emotions and keeps the population quiet - unless the supply dries up, whereupon riots, violence and other forms of aggression, including self-harm, emerge. It is, however, a form of self-harm in its own right, which can create a strong urge for more powerful drugs with even greater consequences in the prisoner’s future freedom.

3. Undiagnosed psychiatric problems. Although the lack of understanding and treatment of this problem has begun to be addressed, it is still an area which causes the prison service great difficulty, and they should not have to cater for this problem. There is significantly a higher rate of fighting, rage, drug abuse and anxiety amongst prisoners who self-mutilate. Epidemics among young offenders in institutions are common. Men are more likely to self-injure than women.

Types of self-injury: Ingestion (tablets, fluids, batteries, etc), laceration, friction burns.

Personality Disorders

Most individuals are treated in an Accident & Emergency department or in the general hospital setting. It is within either of these places that the first-time contact may be made with the psychiatric services.

A complete and thorough assessment of the individual is essential for the correct care to be planned. Impulsive self injurious behaviour among non-psychotic, intellectually normal individuals may be diagnosed as impulsive control disorder.

This type of behaviour is quite common among young females with a poor tolerance towards anxiety and anger. They tend to lacerate themselves and it is very common for them to have absolute or relative analgesia during the procedure.

Eating disorders such as anorexia and bulimia are also typical displays of poor anxiety tolerance, usually with family relationship problems. There appears to be a high rate of self injury amongst people with eating disorders, particularly bulimics. (3)

Gardner & Cowdry (4) describe the range and type of self injurious behaviours by borderline personality disordered clients. They include: cuts to the wrist and body; cigarette burns; scratching oneself with fingernails; carving words on the skin; arm and head banging; sandpapering the face; dripping acid on the hands; and trying to break an arm with a hammer. (All the sort of thing you would expect from watching 5 minutes of East Enders!)

During the act of self-injury, i.e. cutting, many describe experiences in changes of self awareness, both of de-realisation (the environment feels unreal), of de-personalisation (the person feels unreal). This can be looked upon as an emotional disturbance rather than one of intellect. It would probably explain the apparent lack of pain these patients have during acts of self harm; but we have to understand the actual need to self harm.

Graff & Malin (5) noted frequent histories of maternal deprivation and speculated that the patient had protected herself against maternal rejection by introjecting (or symbolising) her mother, allowing her to deal with it, by destroying that part of it within herself. The pleasurable feeling derived from slashing is therefore both the joy of punishing the deprivor and an act of self manipulation to make up for the lack of outside stimulation (substitution by symbolism).

Describing the reaction of a self injuring patient, Kafka (6) noted the relief experienced by the patient as she felt her own warm blood flowing over her skin. Kafka suggested that the blood was linked to the patient’s internalised representation of her mother which the patient sought to externalise into a soothing transitional object in times of crisis.

This motivation to injure oneself springs from a need to reduce intolerable feelings of tension. It would appear that it is a maladaptive way of evoking comfort and calm when in a highly anxious state.

At the sight of blood, the patient often feels relief and may then take the appropriate action, such as clearing away broken glass, stopping the bleeding or attending Casualty. As dissociation at the time of cutting is short-lived, and the same mental process does not occur during suturing, the surprising practice of some doctors or casualty departments to suture wounds without anaesthetic is therefore punitive and unjustified.

Sexual connotations may occur; it was noted that self mutilating patients with borderline personality disorders have experienced sadistic sexual abuse from an older person earlier in life. Subsequent sexual desire by the patient is then associated with extreme guilt.

Types of abuse: As stated by Gardener et al

Plus: Overdose, razor blades, swallowing, drug abuse, overdose, etc.

Chemical Imbalance

A study on Impulsivity found that the degree of impulse behaviour, rather than violence, was associated with a low CSF and 5H1AA concentration (5H1AA is the major metabolite of seretonin). The authors suggested that mild hypoglycaemia may be the final common pathway leading to impulsive behaviour. (9)

Opiate anatagonists have been administered to patients with self injurious behaviour, some with Nalaxone, other with Naltrexone. Although the treatments and experiments varied, an improvement was reported in 17 out of the 25 treated.

Great importance is put on the Serotonergic system by both American and Canadian research teams. In pilot trials, mild forms of self harm were reported to respond to Fluoxetine and Clomipramine.

Patel et al described successful treatment of self injurious behaviour with Trazadone in a patient with major recurrent depression (hair pulling). (12)

Notes
5H1AA (5 Hydroxyindoleacetic acid) is the major metabolite of seretonin (5 Hydroxytryptamine) and its concentration in the CSF (cerebrospinal fluid) has been a reliable index of seretonin concentration in the brain. Aggressive behaviour therefore stems from low seretonin levels.

Treatment

Mild forms of self harm are relatively easy to treat, usually with the aid of anti-depressants, supervised behaviour therapy and lots of counselling (dependant on client type).

However, for the more severe forms, treatment is extremely difficult due to ingrained guilt, low self esteem and poor motivation, or for those having a severe retardation.

Prescribed Medication

MAOI anti-depressants are supposedly superior treatments to Tricyclics

Viz:- Tranylcypromine or Carbamazepine. See Medication

Behavioural

Behavioural therapy is labour intensive and difficult to implement.

1. Patients commit themselves to a programme and pledge to have a ‘No Harm’ contract

2. Identifiable behaviour is pointed out to them (viz: attempts to manipulate, i.e. splitting staff)

3. Stable emotional support, non-rejecting and non-isolating

4. Relaxation methods taught and regularly used

5. Learning to control frustrations and express emotions

Self Help Support Groups

Modelled on the AA’s 12-Step Programme

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All of the people I have met that self harm, have done so from being the victim of abuse.

The following sites may be of benefit to those who are angry and injure themselves.

Links
http://www.selfharm.org.uk also http://www.thesite.org
and
http://www.nice.org.uk

Abuse
http://www.siawso.org
http://www.mind.org.uk
http://www.patient.co.uk

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A Bill of Rights for Those Who Self-Harm

1. The right to caring, humane medical treatment.

Self-injurers should receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures should be done as gently as they would be for others. If stitches are required, local anaesthesia should be used. Treatment of accidental injury and self-inflicted injury should be identical.

2. The right to decide what, if any psychological treatment is warranted, so long as no one's life is in immediate danger.

When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment should be considered. If the person is not in obvious distress and is not suicidal, he or she should not be subjected to an arduous psychiatric evaluation. Doctors should be trained to assess suicidal/homicidal and should make decisions about further psych treatment in the emergency room based on those factors alone; the fact that the injury was self-inflicted should not be a deciding factor.

3. The right to body privacy.

No one should subject a self-injurer to a body search looking for evidence of self-injury. Many of us have been abused; the humiliation of a strip-search is likely to increase the amount and intensity of self-injury while making the person subject to the searches look for better ways to hide the marks.

4. The right to have the feelings behind the self injury validated.

Self-injury doesn't occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings should be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it "is" distressing and respect the self-injurer's right to be upset about it.

5. The right to disclose to whom they choose only what they choose.

No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care.

6. The right to choose what coping mechanisms they will use.

No person should be forced to choose between self-injury and treatment. No care provider should demand that a no-harm contact be signed; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. The client should always be free to use whatever coping mechanism he or she feels is best at the moment. No client should be afraid to tell a care provider about an incident of self injury.

7. The right to have care providers who are not afraid of Self Injury.

Those who work with clients who self-injure should keep their own fear, revulsion, anger, anxiety, etc out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.

8. The right to have the role Self Injury has played as a coping mechanism validated.

No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use self Injury as a last-ditch effort to avoid suicide. The self-injurer should be taught to honour the positive things that self-injury has done for him/her while recognizing that the negatives of self Injury far outweigh those positives and that it is possible to learn methods of coping that aren't as destructive and life-interfering.

9. The right not to be treated like a dangerous person.

No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of self injury.

10. The right to have self-injury regarded as an attempt to communicate, not manipulate.

Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers should respect the communicative function of self injury.

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Self Harm References...

(1) Self Injurious Behaviour in People with a Mental Handicap

Emberson & Walker, Nursing Times, June 1990

(2) Genital and Abdominal Self Surgery

Kalin, Jama 1979

(3) Fallon & Witchell - Unpublished

(4) Suicidal and Parasuicidal Behaviour in Borderline Personality Disorder

Gardner & Cowdry, Psy.Clin.N.A. 1985

(5) Syndrome of the Wrist Cutter

Graff & Mallin, Am.J.Psy. 1967

(6) The Body as a Transitional Object

A Psycho-Analytical Study of a Self Mutilating Patient

Kafka, Brit.M.J. 1969

(7) UCH. Textbook of Psychiatry

Wolf et al

(8) J. Personality Disorders

Stone, 1987

(9) Life Science 1983, Linnoila, Virkkunen et al

and Arch Gen Psy.1987, Virkkunen et al.

(10) Effects of Nalaxone + Naltrexone on Self Injury

Double Blind. Am.J. Mental Retard

Barret, Feinstein & Hole, 1989

(11) N. England J Med 1989

and ACN Abstract 1989

Winchel et al

(12) Can.J. Psy

Patel et al, 1988

(13) Basic Notes in Psychiatry

Levi, 1989

(14) An Outcome Study of Psychotherapy for Patients with Borderline Personality Disorder

Stevenson, Mearles. Am.J. Psych, 1992

(15) Personality Disorder and Self Wounding

Tantam & Whittaker, B.J. Psych, 1992

(16) The Deliberate Self Harming Behaviour of Patients within a British Special Hospital

Burrow, J.A.N. 1992

(17) What Happens to Patients who Frequently Self Harm Themselves?

Stocks & Scott, B.J.Psych, 1991

(18) The Deliberate Self Harm Syndrome

Pattison, Kahan. Am.J.Psych, 1983

(19) Self Mutilation in Personality Disorders

Simeon et al. Am.J.Psych, 1992.

Researched and Written by D. Alcock.

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