
                              What self-injury is
                                       
   NOTE: This section contains potentially distressing material. If you
   self-injure now or have in the past, please make yourself safe before
   reading this section; it may intensify your urge to harm.
   
Classifying self-harm

   We all do things that aren't good for us and that may harm us. We also
   do things that inflict injury but that are primarily intended for
   other purposes. Some self-harm is culturally sanctioned, while other
   types are seen as pathological. Where does one draw lines?
   
   An easy line to draw is that of deliberate, immediate physical harm
   being done. For example, cutting your arm or hitting yourself with a
   hammer are clearly self-injurious acts. Things like overeating,
   smoking, not exercising, etc., are harmful to a person in the long run
   but immediate physical damage is not the desired effect of the
   behaviors. What, then, about things like tattooing and piercing, where
   physical modification of the body is deliberate and is the desired
   effect?
   
   The first step in classifying self-harm, as demonstrated by Favazza
   (1996), is to sort out what makes a type of self-injury pathological,
   as opposed to culturally-sanctioned. Socially sanctioned self-harm, he
   found, falls into two groups: rituals and practices. Body modification
   (piercings, tattoos, etc) can fall into either class.
   
   Rituals are distinguished from practices in that they reflect
   community tradition, usually have deep underlying symbolism, and
   represent a way for an individual to connect to the community. Rituals
   are done for purposes of healing (mostly in primitive cultures),
   expressions of spirituality and spiritual enlightenment, and to mark
   place in the social order. Practices, on the other hand, have little
   underlying meaning to the practitioners and are sometimes fads.
   Practices are done for purposes of ornamentation, showing
   identification with a particular cultural group, and in some cases,
   for perceived medical/hygienic reasons.
   
   Non-socially sanctioned (pathological) self-harm can be classified as
   either suicidality, self-mutilation (which is further broken down into
   major, stereotypic, and superficial/moderate), or unhealthful
   behavior.
   
   Kahan and Pattison (1984; Pattison and Kahan, 1983) tackled these
   taxonomic problems. They began by identifying three components of
   self-harming acts: directness, lethality, and repetition.
   
   Directness
          refers to how intentional the behavior is; if an act is
          completed in a brief period of time and done with full
          awareness of its harmful effects and there was conscious intent
          to produce those effects, it is considered direct. Otherwise,
          it is an indirect method of harm.
          
   Lethality
          refers to the likelihood of death resulting from the act in the
          immediate or near future. A lethal act is one that is highly
          likely to result in death, and death is usually the intent of
          the person doing it.
          
   Repetition
          
   refers to whether of not the act is done only once or is repeated
          frequently over a period of time It is defined simply by
          whether or not the act is done repeatedly.
          
   The following table gives examples of each combination of these
   factors:
   
   Repetitive In Nature? Direct Behaviors Indirect Behaviors
   High lethality Low lethality High lethality Low lethality
   yes taking small doses of arsenic over time self-injury: cutting,
   burning, hitting, etc. type 1 diabetic not injecting insulin smoking,
   alcoholism
   no gunshot wound to head major self-mutilation terminal cancer patient
   refusing chemo walking around downtown alone at 3 a.m.
   
  Definitions of moderate/superficial self-injury Perhaps the best definition
  of self-injury is found in Winchel and Stanley (1991), who define it as
  
     ...the commission of deliberate harm to one's own body. The injury
     is done to oneself, without the aid of another person, and the
     injury is severe enough for tissue damage (such as scarring) to
     result. Acts that are committed with conscious suicidal intent or
     are associated with sexual arousal are excluded.
     
   Mosby's Medical, Nursing, and Allied Health Dictionary (1994) contains
   the following definition:
   
   Self-mutilation, high risk for
          A nursing diagnosis . . . defined as a state in which an
          individual is at high risk to injure but not kill himself or
          herself, and that produces tissue damage and tension relief.
          Risk factors include being a member of an at-risk group,
          inability to cope with increased psychological/physiological
          tension in a healthy manner, feelings of depression, rejection,
          self-hatred, separation anxiety, guilt, and depersonalization,
          command hallucinations, need for sensory stimuli, parental
          emotional deprivation, and a dysfunctional family.
          Groups at risk include clients with borderlines personality
          disorder (especially females 16 to 25 years of age), clients in
          a psychotic state (frequently males in young adulthood),
          emotionally disturbed and/or battered children, mentally
          retarded and autistic children, clients with a history of
          self-injury, and clients with a history of physical, emotional,
          or sexual abuse.
          
   Malon and Berardi (1987) summarize the process they believe underlies
   self-injury:
   
     Investigators have discovered a common pattern in the cutting
     behavior. The stimulus...appears to be a threat of separation,
     rejection, or disappointment. A feeling of overwhelming tension and
     isolation deriving from fear of abandonment, self-hatred, and
     apprehension about being unable to control one's own aggression
     seems to take hold. The anxiety increases and culminates in a sense
     of unreality and emptiness that produces an emotional numbness or
     depersonalization. The cutting is a primitive means for combating
     the frightening depersonalization.
     
   This seems to coincide with the definition given in Mosby's of someone
   susceptible to self-harm.
   
   This site is concerned mainly with moderate/superficial self-harm,
   which is direct, repetitive, and of low lethality. Stereotypic
   self-mutilation tends also to be direct, repetitive, and of low
   lethality, whereas major self-mutilation (discussed below) is direct,
   not repetitive, and of low lethality. Moderate self-harm can be
   further divided into impulsive and compulsive.
   
Varieties of Self-Harm

   Self-injury is separated by Favazza (1986) into three types. Major
   self-mutilation (including such things as castration, amputation of
   limbs, enucleation of eyes, etc) is fairly rare and usually associated
   with psychotic states. Stereotypic self-injury comprises the sort of
   rhythmic head-banging, etc, seen in autistic, mentally retarded, and
   psychotic people. The most common form of self-mutilation, and the
   topic of this site, is called superficial or moderate. This can
   include cutting, burning, scratching, skin-picking, hair-pulling,
   bone-breaking, hitting, deliberate overuse injuries, interference with
   wound healing, and virtually any other method of inflicting damage on
   oneself. Both in clinical studies and in an informal Usenet survey,
   the most popular act was cutting, and the most popular sites were
   wrists, upper arms, and inner thighs. Many people have used more than
   one method, but even they tend to favor one or two preferred methods
   and sites of abuse.
   
  Compulsive self-harm
  
   Favazza (1996) further breaks down superficial/moderate self-injury
   into three types: compulsive, episodic, and repetitive. Compulsive
   self-injury differs in character from the other two types and is more
   closely associated with obsessive-compulsive disorder (OCD).
   Compulsive self-harm comprises hair-pulling (trichotillomania), skin
   picking, and excoriation when it is done to remove perceived faults or
   blemishes in the skin. These acts may be part of an OCD ritual
   involving obsessional thoughts; the person tries to relieve tension
   and prevent some bad thing from happening by engaging in these
   self-harm behaviors. Compulsive self-harm has a somewhat different
   nature and different roots from the impulsive (episodic and repetitive
   types).
   
  Impulsive self-harm
  
   Both episodic and repetitive self-harm are impulsive acts, and the
   difference between them seems to be a matter of degree. Episodic
   self-harm is self-injurious behavior engaged in every so often by
   people who don't think about it otherwise and don't see themselves as
   "self-injurers." It generally is a symptom of some other psychological
   disorder.
   
   What begins as episodic self-harm can escalate into repetitive
   self-harm, which many practitioners (Favazza and Rosenthal, 1993;
   Kahan and Pattison, 1984; Miller, 1994; among others) believe should
   be classified as a separate Axis I impulse-control disorder. Favazza
   (1997) suggests that until repetitive self-harm is recognized as a
   separate category in the DSM, practitioners should diagnose it on Axis
   I as 312.3, Impulse-Control Disorder Not Otherwise Specified.
   
   Repetitive self-harm is marked by a shift toward ruminating on
   self-injury even when not actually doing it and self-identification as
   a self-injurer (Favazza, 1996). Episodic self-harm becomes repetitive
   when what was formerly a symptom becomes a disease in itself (as seen
   in the way many people who self-injure describe self-harm as being
   "addictive"). It is impulsive in nature, and often becomes a reflex
   response to any sort of stress, positive or negative. Just like
   smokers who reach for a cigarette when they're overwhelmed, repetitive
   self-injurers reach for a lighter or a blade or a belt when things get
   to be too much.
   
   In a study of bulimics who self-harm, Favaro and Santonastaso (1998),
   used a statistical technique known as factor analysis to try to
   distinguish between which kinds of acts were compulsive in nature and
   which were impulsive. They report that vomiting, severe nail biting,
   and hair pulling loaded on the compulsive factor, whereas suicide
   attempts, substance abuse, laxative abuse, and skin cutting and
   burning loaded on the impulsive factor.
   
Should self-injurious acts be considered botched or manipulative suicide
attempts?

   Favazza (1998) states, quite definitively, that
   
     . . . self-mutilation is distinct from suicide. Major reviews have
     upheld this distinction. . . A basic understanding is that a person
     who truly attempts suicide seeks to end all feelings whereas a
     person who self-mutilates seeks to feel better. p. 262.
     
   Although these behaviors are sometimes referred to "parasuicide," most
   researchers recognize that the self-injurer generally does not intend
   to die as a result of his/her acts. "[S]uicide attempts are reported
   not to provide relief, to be repeated less frequently, and to have
   less communicative value" (van der Kolk et al., 1991). "Patients with
   the [proposed Deliberate Self-Harm Syndrome] often suffer social
   ostracism and, in desperation, may attempt suicide (Favazza et al,
   1989) [emphasis added]. Thus, although self-injurious behavior is not
   suicidal in intent, it can easily lead to suicidal ideation or even,
   when a self-harmer goes too far, suicide itself. Herpertz (1995) notes
   that self-injurers distinguish between self-injurious acts and
   suicidal ones, and Solomon and Farrand (1996) say "Although the
   [self-injurious and suicidal] acts themselves may blur, their meaning
   does not. What does emerge, though, is a link between the two acts in
   that one (self-injury) is an alternative to the other (suicide), and
   is preferable." In a review of the literature on self-injury, Favazza
   (1998) notes that only recently has it become generally recognized
   that self-harm is a morbid form of coping, one which is often turned
   to when suicide seems inescapable. He writes that "traditionally it
   has been trivialized ([delicate] wrist cutting), misidentified
   (suicide attempt) and regarding solely as a symptom [of borderline
   personality disorder.
   
   Further support for the distinct nature of self-injury comes from a
   study of psychiatric diagnoses among self-injurers as opposed to
   attempted suicides (Ferreira de Castro et al., 1998). On Axis I, 14%
   of self-injurers (SI) were diagnosed with major depression, as opposed
   to 56% of the suicide-attempters (SA). Alcohol dependence was
   diagnosed in 16% of the SI group, but in 26% of the SA group. Only 2%
   of the SI group were considered schizophrenic; 9% of the SA group
   were. The SI group was more likely to be dysthymic (12% vs 7%) or to
   be diagnosed with adjustment disorder with depressed mood (24% vs 6%).
   Of course, the fact of a suicide attempt may have influenced the
   depression-related diagnoses.
   
   This study also revealed similar disparities in Axis II diagnoses of
   those whose self-harm was directed toward suicide and those whose was
   not, although 9% of both groups were considered borderline and 0% of
   each were considered to have avoidant personality disorder. There were
   sharp differences among rates in the other personality disorders --
   dependent: 13% SI, 7% of SA; schizoid: 2% SI, 5% SA; and histrionic:
   22% SI, 4% SA. It seems clear, then, that those who self-injure in
   order to die and those who do it in order to cope present very
   different psychiatric profiles.
   
   Informal surveys collected via the net reveal that many of those who
   injure themselves are strongly aware of the fine line they walk, but
   are also resentful of doctors and mental health professionals who
   mistake their incidents of self-harm as suicide attempts instead of
   seeing them as the desperate attempts to stave off suicide that they
   often are.
   
Is self-injury the same thing as Munchausen's or some other factitious
disorder?

   Again, NO. Little research has been done on whether there is a
   connection between SI and Munchausen's or similar syndromes, but
   uneducated medical professionals sometimes conflate the two. In SI,
   the person is injuring to escape unbearable emotional and
   physiological tension; in Munchausen's the injuries inflicted are
   deliberate and calculated to produce specific symptoms that will lead
   to a medical hospital admission. Although some people who self-injure
   desire hospitalization, it is almost always to a psychiatric ward and
   not to a general medical floor. Clients with Munchausen's, on the
   other hand, shy away from psychiatric care and seek to be admitted on
   the medical service.
   
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References

   1. file://localhost/usr/home/llama/Web/psych/why.html
   2. file://localhost/usr/home/llama/Web/psych/injury.html
