Self-Injury

What is self-injury ?

• self-injury typically refers to a variety of behaviors in which an individual intentionally inflicts harm to his or her body for purposes not socially recognized or sanctioned and without suicidal intent (Favazza, 1996).

Types of self-injury

• intentional carving or cutting of the skin• subdermal tissue scratching• burning • ripping or pulling skin or hair• swallowing toxic substances• self bruising• breaking bones

• Tattoos and body piercing are not typically considered self-injurious unless undertaken with the intention to harm the body.

• Although cutting is one of the most common and well documented forms, over 16 forms have been documented in a college population (Whitlock, Eckenrode, & Silverman, 2006).

• several studies have shown that the number of forms used by an individual varies significantly; from 1 to over 10 (Laye-Gindhu & Schonert-Reichl, 2005; Whitlock et al., 2006).

• Self-injury can be and is performed on any part of the body, but most often occurs on the hands, wrists, stomach and thighs.

• The severity of the act can vary from superficial wounds to those resulting in lasting disfigurement.

• Among respondents in a two college study, 1 in 5 self-injurious students indicated that they had hurt themselves more than intended at least once.

• 1 in 10 indicated that they had hurt themselves so badly that they should have been seen by a medical professional.

Who self-injures?

• It is commonly assumed that females are significantly more likely to self-injure than males.

• Although multiple studies support this assumption, there are other studies which suggest that males are equally likely to self-injure as females, particularly among non-clinical samples.

• Some of our recent works suggests that there may be different self-injury groups or "classes“…

• The first one consists largely of men who use self-injury forms which can be described as "self-battery.“

• The second consists of more females. • Members in this (2nd) group face heightened risk

for other adverse conditions, such as suicidality and psychological distress, while members in the 1st group are likely to engage in these behavioral patterns for shorter periods of time.

How common is self-injury among adolescents and young adults?

• Because it so often occurs in private, it is very difficult to identify one or more discrete self-injurer "profiles.“

• Unless being treated for related conditions, such as depression or anxiety, detecting self-injurious individuals can be very difficult.

• Thus, most studies of self-injury have relied on samples in clinical settings being treated for other disorders (Brodsky et al., 1995).

• estimates of self-injury prevalence from 4% to 38% percent

When does self-injury start and how long does it last?

• Early onset self-injury is common around the age of 7, although it can begin earlier.

• Most often, however, self-injury behaviors begin in middle adolescence between the ages of 12 and 15.

• Self injury can last for weeks, months, or years.• For many self-injury is cyclical rather than linear

meaning that it is used for periods of time, stopped, and then resumed.

• Although the majority of college students surveyed report stopping within five years of starting, it is also clear that the behavior can last well into adulthood.

Why do people self-injure?

• Reasons given for self-injuring are diverse. Many individuals who practice it report overwhelming sadness, anxiety, or emotional numbness as common emotional triggers.

• Self-injury, they report, provides a way to manage intolerable feelings or a way to experience some sense of feeling.

• It is also used as means of coping with anxiety or other negative feelings and to relieve stress or pressure.

• Those who self-injure also report doing so…– to feel in control of their bodies and minds…– to express feelings…– to distract themselves from other problems… – to communicate needs…– to create visible and treatable wounds…– to purify themselves…– to reenact a trauma in an attempt to resolve it…– or to protect others from their emotional pain– Some report doing it simply because it feels good or

provides an energy rush .

• Regardless of the specific reason provided, self-injury may best be understood as a maladaptive coping mechanism, but one that works – at least for a while.

Is self-injury a suicidal act?

• There are important distinctions between those attempting suicide and those who practice self-injurious behaviors in order to cope with overwhelming negative feelings.

• Most studies find that self-injury is often undertaken as a means of avoiding suicide.

• Perhaps one of the most paradoxical features of self-injury is that most of those who practice self-injury report doing so as a means of relieving pain or of feeling something in the presence of nothing.

• The particular relationship between self-injury undertaken without suicidal intent and self-injury undertaken with suicidal intent are not clear since individuals who report the former are also more likely to report having considered or attempted suicide

• although it is common to assume that non-suicidal self-injury may be linked solely to suicidal ideation, recent studies show that individuals with a history of non-suicidal self-injury were over nine times more likely to report suicide attempts, and seven times more likely to report a suicide gesture and nearly six times more likely to report a suicide plan than individuals without a history of non-suicidal self-injury.

• Nevertheless, since the majority of individuals with self-injury history report not considering suicide, non-suicidal self-injury may be best understood as a symptom of distress that, if unsuccessfully mitigated, may lead to suicide behavior.

What factors contribute to self-injurious behavior?

• In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse.

• Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders.

Is self-injury addictive?

• Most self-injury researchers agree that self-injury does show some addictive qualities and may serve as a form of self-medication for some individuals.

• A significant number of individuals who practice self-injury report having a difficult time controlling their urge to self-injure.

• Interviews conducted for several studies show that many self-injurers describe both the immediate effect and overall practice as something with addictive properties.

• For example, many interviewees talk about moments of feeling the strong need to injure even when there is no obvious trigger…

• and about having "self-injury free" hours or days. • They also liken it to other drugs and talk about needing

increasingly more or deeper injuries to feel the same effect.

• Recognition of the addictive properties of self-injury for some individuals is the basis for the "addiction hypothesis" noted by Grossman and Siever (2001) and summarized by Walsh (2005).

“The addiction hypothesis”

• The addiction theory suggest that self-injurious acts may solicit involvement of the endogenous opioid system (EOS) which regulates both pain perception and levels of endogenous endorphins which occur as a result of injury.

• Overestimation of the EOS can then lead to actual withdrawal symptoms which in turn lead to more self-injurious behavior.

Is self-injury contagious?

• self-injurious behavior has been shown repeatedly to follow epidemic-like patterns in institutional settings such as hospitals and detention facilities.

• For many, self-injury is a very private, hidden act.• Some surveys suggest that there may be multiple

forms of self-injury in middle and high school settings –groups of youth injuring together or separately as part of a group membership.

Clinical signs

• Unexplained burns, cuts, scars, or other clusters of similar markings on the skin can be signs of self-injurious behavior.

• Fists, and forearms opposite the dominant hand are common areas for injury.

• Inappropriate dress for season (consistently wearing long sleeves or pants in summer).

• Constant use of wrist bands / coverings.• Unwillingness to participate in events / activities which

require less body coverage (such as swimming or gym class).

• Frequent bandages, odd / unexplainable paraphernalia (e.g. razor blades or other implements which could be used to cut or pound).

• Heightened signs of depression or anxiety.

Inquiring

• It is important that questions about the marks be non-It is important that questions about the marks be non-threatening and emotionally neutral. threatening and emotionally neutral.

• Evasive responses are common. Evasive responses are common. • Not knowing how to broach the subject is often what Not knowing how to broach the subject is often what

restrains concerned individuals form probing. restrains concerned individuals form probing. • However, concern for their well-being is often what However, concern for their well-being is often what

many who self-injure most need. many who self-injure most need. • Persistent but neutral probing may eventually elicit Persistent but neutral probing may eventually elicit

honest responses.honest responses.

Intervention Strategy• Kress, Gibon & Reynods (2004) maintain that structure, consistency, and

predictability are important elements in forming relationships with self-injurious youth.

• Developing plans which emphasize: – a) taking responsibility for the behavior,– b) reducing the harm inflicted by the behavior– c) identifying and more positively reacting to self-injury triggers and

physical cues– d) identifying safe people and places for assistance when needing to

reduce the urge to self-injure– e) avoiding objects which could be used to self-injure (e.g., paper clips,

staples, erasers, sharp objects)

Avoid displaying shock, engaging in shaming responses, or showing great pity

• The intensely private and shameful feelings associated The intensely private and shameful feelings associated with self-injury prevent many from seeking treatment.with self-injury prevent many from seeking treatment.

• Because so little is known about self-injury, it is often Because so little is known about self-injury, it is often misunderstood by medical staff members. misunderstood by medical staff members.

• Staff reactions, if expressed in shocked or punitive ways, Staff reactions, if expressed in shocked or punitive ways, may reinforce the self-injurious behavior and its may reinforce the self-injurious behavior and its underlying causes, and encourage the self-injurer not to underlying causes, and encourage the self-injurer not to seek care in the future.seek care in the future.

• Being willing to listen to the self-injurer while reserving Being willing to listen to the self-injurer while reserving shock or judgment encourages them to use their voice, shock or judgment encourages them to use their voice, rather than their body, as a means of self-expression.rather than their body, as a means of self-expression.

• Explicitly teaching more appropriate coping strategies may be one way to provide self-injurers with adaptive alternatives.

• Self-injury is most common in youth having trouble coping with anxiety, depression, or other conditions that overwhelm their capacity to regulate their emotion (Chapman, Gratz, Brown, 2006).

• It is thus important to focus on enhancing awareness of the environmental stressors that trigger self-injury and on helping individuals identify, practice, and use more productive and positive means of coping with their emotional states.

• Focusing on elimination of the self-injury behavior Focusing on elimination of the self-injury behavior without enhancing positive means of regulating emotion without enhancing positive means of regulating emotion may simply lead to adoption of other self-destructive may simply lead to adoption of other self-destructive behavior, such as drug abusebehavior, such as drug abuse.

• Drug therapy may help in some cases as well. Some Drug therapy may help in some cases as well. Some patients using prescribed drugs for depression have patients using prescribed drugs for depression have found a reduction in the urge to self-injure while taking found a reduction in the urge to self-injure while taking these medications (Walsh, 2005)these medications (Walsh, 2005).

• Therapy may be useful in exploring the underlying causes Therapy may be useful in exploring the underlying causes of self-injuryof self-injury.

Assess the safety of self-injurious practices

• DiClemente et al. (1991) found that over one quarter of hospitalized adolescents who self-injured reported that they had shared cutting implements with others.

Assess level of group involvement

• Evidence of self-injurious practices among groups of Evidence of self-injurious practices among groups of youth is increasingly common.youth is increasingly common.

• Group self-injury is often a means of group bonding and Group self-injury is often a means of group bonding and membership and, as such, is undertaken with aims other membership and, as such, is undertaken with aims other than reducing anxiety or coping with overwhelming than reducing anxiety or coping with overwhelming negative feeling.negative feeling.

• Since self-injurious behavior can be contagious in Since self-injurious behavior can be contagious in institutional and school settings, identifying and institutional and school settings, identifying and intervening in group self-injurious activities is important.intervening in group self-injurious activities is important.

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About Self-InjuryCornell Research Program on Self-Injurious

Behavior in Adolescents and Young Adults

Cornell University Family Life Development Center