Nonsuicidal self-injury, often simply called self-injury, is the act of deliberately harming the surface of your own body, such as cutting or burning yourself. It’s typically not meant as a suicide attempt. Rather, this type of self-injury is an unhealthy way to cope with emotional pain, intense anger and frustration.
While self-injury may bring a momentary sense of calm and a release of tension, it’s usually followed by guilt and shame and the return of painful emotions. Although life-threatening injuries are usually not intended, with self-injury comes the possibility of more serious and even fatal self-aggressive actions.
Getting appropriate treatment can help you learn healthier ways to cope.
Symptoms and Causes
Symptoms
Signs and symptoms of self-injury may include:
- Scars
- Fresh cuts, scratches, bruises or other wounds
- Excessive rubbing of an area to create a burn
- Keeping sharp objects on hand
- Wearing long sleeves or long pants, even in hot weather
- Difficulties in interpersonal relationships
- Persistent questions about personal identity, such as “Who am I?” “What am I doing here?”
- Behavioral and emotional instability, impulsivity and unpredictability
- Statements of helplessness, hopelessness or worthlessness
Forms of self-injury
Self-injury usually occurs in private and is done in a controlled or ritualistic manner that often leaves a pattern on the skin. Examples of self-harm include:
- Cutting (cuts or severe scratches with a sharp object)
- Scratching
- Burning (with lit matches, cigarettes or hot, sharp objects like knives)
- Carving words or symbols on the skin
- Hitting or punching
- Piercing the skin with sharp objects
- Pulling out hair
- Persistently picking at or interfering with wound healing
Most frequently, the arms, legs and front of the torso are the targets of self-injury, but any area of the body may be used for self-injury. People who self-injure may use more than one method to harm themselves.
Becoming upset can trigger an urge to self-injure. Many people self-injure only a few times and then stop. But for others, self-injury can become a long-term, repetitive behavior.
Although rare, some young people may self-injure in public or in groups to bond or to show others that they have experienced pain.
When to see a doctor
If you’re injuring yourself, even in a minor way, or if you have thoughts of harming yourself, reach out for help. Any form of self-injury is a sign of bigger issues that need to be addressed.
Talk to someone you trust — such as a friend, loved one, health care provider, spiritual leader or a school official — who can help you take the first steps to successful treatment. While you may feel ashamed and embarrassed about your behavior, you can find supportive, caring and nonjudgmental help.
When a friend or loved one self-injures
If you have a friend or loved one who is self-injuring, you may be shocked and scared. Take all talk of self-injury seriously. Although you might feel that you’d be betraying a confidence, self-injury is too big a problem to ignore or to deal with alone. Here are some ways to help.
- Your child. You can start by consulting your pediatrician or other health care professional who can provide an initial evaluation or a referral to a mental health specialist. Don’t yell at your child or make threats or accusations, but do express concern.
- Teenage friend. Suggest that your friend talk to parents, a teacher, a school counselor or another trusted adult.
- Adult. Gently encourage the person to seek medical and mental health treatment.
When to get emergency help
If you’ve injured yourself severely or believe your injury may be life-threatening, or if you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.
Also consider these options if you’re having suicidal thoughts:
- Call your mental health specialist.
- Call a suicide hotline number — in the U.S., call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255).
- Seek help from your primary doctor or other health care provider.
- Reach out to a close friend or loved one.
- Contact a spiritual leader or someone else in your faith community.
Causes
There’s no one single or simple cause that leads someone to self-injure. In general:
- Nonsuicidal self-injury is usually the result of an inability to cope in healthy ways with psychological pain.
- The person has a hard time regulating, expressing or understanding emotions. The mix of emotions that triggers self-injury is complex. For instance, there may be feelings of worthlessness, loneliness, panic, anger, guilt, rejection, self-hatred or confused sexuality.
Through self-injury, the person may be trying to:
- Manage or reduce severe distress or anxiety and provide a sense of relief
- Provide a distraction from painful emotions through physical pain
- Feel a sense of control over his or her body, feelings or life situations
- Feel something — anything — even if it’s physical pain, when feeling emotionally empty
- Express internal feelings in an external way
- Communicate depression or distressful feelings to the outside world
- Be punished for perceived faults
Risk factors
Certain factors may increase the risk of self-injury, including:
- Age. Most people who self-injure are teenagers and young adults, although those in other age groups also self-injure. Self-injury often starts in the early teen years, when emotions are more volatile and teens face increasing peer pressure, loneliness, and conflicts with parents or other authority figures.
- Having friends who self-injure. People who have friends who intentionally harm themselves are more likely to begin self-injuring.
- Life issues. Some people who injure themselves were neglected or abused (sexually, physically or emotionally) or experienced other traumatic events. They may have grown up and still remain in an unstable family environment, or they may be young people questioning their personal identity or sexuality. Some people who self-injure are socially isolated.
- Mental health issues. People who self-injure are more likely to be highly self-critical and be poor problem-solvers. In addition, self-injury is commonly associated with certain mental disorders, such as borderline personality disorder, depression, anxiety disorders, post-traumatic stress disorder and eating disorders.
- Excessive alcohol or drug use. People who harm themselves often do so while under the influence of alcohol or recreational drugs.
Complications
Self-injury can cause a variety of complications, including:
- Worsening feelings of shame, guilt and low self-esteem
- Infection, either from wounds or from sharing tools
- Permanent scars or disfigurement
- Severe, possibly fatal injury
- Worsening of underlying issues and disorders, if not adequately treated
Suicide risk
Although self-injury is not usually a suicide attempt, it can increase the risk of suicide because of the emotional problems that trigger self-injury. And the pattern of damaging the body in times of distress can make suicide more likely.
Diagnosis
Although some people may ask for help, sometimes self-injury is discovered by family members or friends. Or a doctor doing a routine medical exam may notice signs, such as scars or fresh injuries.
There’s no diagnostic test for self-injury. Diagnosis is based on a physical and mental evaluation. A diagnosis may require evaluation by a mental health provider with experience in treating self-injury.
A mental health provider may also evaluate you for other mental illnesses that may be linked to self-injury, such as depression or personality disorders. If that’s the case, evaluation may include additional tools, such as questionnaires or psychological tests.
Treatment
There’s no one best way to treat self-injuring behavior, but the first step is to tell someone so you can get help. Treatment is based on your specific issues and any related mental health conditions you might have, such as depression.
Treating self-injury behavior can take time, hard work and your own desire to recover. Because self-injury can become a major part of your life, you may need treatment from a mental health professional experienced in self-injury issues.
If the self-injury behavior is associated with a mental health disorder, such as depression or borderline personality disorder, the treatment plan focuses on that disorder, as well as the self-injury behavior.
Psychotherapy
Known as talk therapy or psychological counseling, psychotherapy can help you:
- Identify and manage underlying issues that trigger self-injuring behavior
- Learn skills to better manage distress
- Learn how to regulate your emotions
- Learn how to boost your self-image
- Develop skills to improve your relationships and social skills
- Develop healthy problem-solving skills
Several types of individual psychotherapy may be helpful, such as:
- Cognitive behavioral therapy (CBT), which helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones
- Dialectical behavior therapy, a type of CBT that teaches behavioral skills to help you tolerate distress, manage or regulate your emotions, and improve your relationships with others
- Psychodynamic psychotherapy, which focuses on identifying past experiences, hidden memories or interpersonal issues at the root of your emotional difficulties through self-examination, guided by a therapist
- Mindfulness-based therapies, which help you live in the present, appropriately perceive the thoughts and actions of those around you to reduce your anxiety and depression, and improve your general well-being
In addition to individual therapy sessions, family therapy or group therapy also may be recommended.
Medications
There are no medications to specifically treat self-injuring behavior. However, if you’re diagnosed with a mental health condition, such as depression or an anxiety disorder, your doctor may recommend antidepressants or other medications to treat the underlying disorder that’s associated with self-injury. Treatment for these disorders may help you feel less compelled to hurt yourself.
Psychiatric hospitalization
If you injure yourself severely or repeatedly, your doctor may recommend that you be admitted to a hospital for psychiatric care. Hospitalization, often short term, can provide a safe environment and more intensive treatment until you get through a crisis. Day treatment programs also may be an option.
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Why Do Teens Hurt Themselves? The Science of Self-Injury
by Rachael Rettner, Senior Writer
A recent study on the mental health of college students, presented in August at the American Psychological Association Meeting, found empirical evidence to document these observations. The results show that at one university, the rate of non-suicidal self-injury doubled from 1997 to 2007.Over the last couple decades, more young people appear to be pulling out razor blades and lighters in order to injure themselves, according to anecdotal reports from counselors. Their intent is not to die, just to inflict harm, a behavior known as non-suicidal self-injury.
However, scientists aren’t sure whether the behavior actually is becoming more rampant, or if they’re simply detecting more cases due to increased awareness. And some researchers say that while there might have been an increase in the 1990s to early 2000s, it has likely hit a plateau by now. [See: Are More Kids Intentionally Hurting Themselves?]
Nonetheless, the widespread prevalence of non-suicidal self-injury does represent a public health concern. Several recent studies have found some 17-28 percent of teens and young adults say they have engaged in the behavior at some point in their lifetimes.
Scientists are now analyzing non-suicidal self-injury in an unprecedented way, trying to answer a number of questions, including: Why do people hurt themselves? Are some people hard-wired to self-injure? And what treatments work best to stop the cutting?
The consequences of the behavior go beyond physical harm and include depression, anxiety, social isolation and an increased risk for attempting suicide, said Peggy Andover, a psychology professor at Fordham University in New York.
“All of these negative consequences put together, coupled with the fact that this is such a highly prevalent behavior in our high schools, in our colleges, just in our community, it really highlights the fact that we really need to address this behavior,” Andover said.
The “disorder” could also become official in the upcoming revision to the Diagnostic and Statistical Manual of Mental Disorders, or DSM, also known as the “Psychiatric Bible”.
Suicide primer?
Non-suicidal self-injury is commonly defined by scientists as “deliberate discrete destruction of body tissue without the intent of suicide,” said Kimberly Harrison, postdoctoral practitioner at Park Center Inc., a mental health treatment center in Fort Wayne, Ind. “You’re trying to destroy your body in some way without trying to kill yourself,” Harrison said.
A wide range of behaviors fit this description, including cutting, burning and carving of the skin to breaking bones, preventing wound healing and sticking yourself with pins and needles.
People usually start self-injuring in early adolescence, between the ages of 11 and 15.
Estimates for exactly how prevalent the behavior is in adolescents and young adults vary widely, from as low as 4 percent to as high as 38 percent.These estimates are mostly based on studies of small populations involving a few hundred people. But taken together, experts agree the percentage falls somewhere in the high teens to low 20s.
The most obvious harms from self-injury arise from the wounds themselves, which pose a risk of infection.But there are psychological consequences as well, including feeling shame about the behavior and fearing social rejection if the self-injurers do admit to hurting themselves.
There is also some evidence that people who engage in non-suicidal self-injury are at an increased risk of suicide, although the link is strongest among psychiatric patients. Researchers have speculated that self-injury might prime people for suicide in that they are able to overcome the fear and pain that comes from hurting themselves.
But “the vast majority of people who report non-suicidal self-injury are not trying to end their life, they’re trying to cope with life,” said Janis Whitlock, a researcher at Cornell University in Ithaca, N.Y., who recently published a review article on non-suicidal self-injury. “It’s absolutely the opposite of what suicide is.”
Like drugs and sex
Indeed, experts say most people engage in self-injury as a way to cope with their emotions, particularly negative ones. And most self-injurers report that it works – it calms them and brings a sense of relief.
These soothing feelings most likely result from the release of endorphins, brain chemicals that relieve pain and can produce euphoria.
“People use self-injury in a lot of ways that other people use drugs or alcohol, or food or sex…to try to feel better in the short run,” Whitlock said.
People might also self-injure as a form of punishment.
Matthew Nock, a professor of psychology at Harvard University, has come up with four main reasons for engaging in self-injury, both personal and social. His model, which he recently discussed at the APA meeting, suggests that people self-injure to:
- relieve tension or stop bad feelings;
- feel something, even if it’s pain;
- communicate with others to show they are distressed;
- get others to stop bothering them.
There is also evidence that people are more likely to self-injure if they have a negative body image coupled with strong negative emotions and poor coping skills.
“It makes it easier for them to harm the body,” said Jennifer Muehlenkamp, a psychology professor at the University of Wisconsin-Eau Claire, who studies the condition.
A few studies also suggest biology is at play. For instance, research published in the July issue of the Journal of Affective Disorders found that non-suicidal self-injurers had lower levels of opioids in their bodies (endorphins are a type of opioid) than those who did not self-injure. One hypothesis is that people who self-injure have an opioid deficiency and do it to boost their natural opioid levels.
Recent research involving patients diagnosed with borderline personality disorder, a condition in which people often self-injure, found that self-injury could inhibit brain regions often involved in processing emotion.
Something about adolescence
Adolescence is a prime time for the behavior.
“From a developmental perspective, you’ve got a perfect storm for self-injury,” said Whitlock, the Cornell researcher.
Not only do the young have to navigate a growing number of personal relationships, their brains and bodies are undergoing changes as well.
In early adolescence, part of the brain involved in emotion, the amygdala, and part of the brain involved in higher thinking, the cortex, are not fully connected, and as a result, they don’t communicate as well as they do later in life.
“It’s very common for adolescents, particularly early adolescents, to feel high levels of emotion and really not have many skills to deal with the emotion,” Whitlock said.
When the children’s brains are fully developed, they may learn other, more positive methods for coping with their emotions, such as talking to a friend, going for a run, or meditating. Self-injury does seem to be a behavior many adolescents grow out of, with around 80 percent reporting that they stopped injuring themselves within five years of starting, according to Whitlock’s review, published in the May Issue of the journal PLoS Medicine.
From a practical point of view, self-injury is an easily accessible behavior for teens who might have a hard time getting a hold of drugs and alcohol.
Gender differences
Earlier research had suggested that self-injury is a more common behavior among girls, but recent studies show a more even split between the genders. A study of college students by Harrison, the Park Center scientist, found a higher rate of the behavior among males.
However, girls and boys might use different methods for hurting themselves.
For instance, a 2010 study by Andover, the professor at Fordham, found that girls are more likely to use cutting while boys are more likely to burn themselves. The researchers aren’t certain the reason for the gender difference, but suggest it involves the idea that some injury methods are perceived as being more masculine, and others more feminine.
It’s also unclear whether the genders differ in why they hurt themselves in the first place. For instance, it’s possible males seek a display of physical toughness rather than a way to cope with emotions. However, much more research is needed in this area.
Lack of treatment options
There are no specific treatments for non-suicidal self-injury, although a technique known as dialectical behavioral therapy, used for borderline personality disorder, has been employed with some success.
“It’s very, very intensive treatment,” Andover said, and may not be appropriate for everyone with non-suicidal self-injury.
The majority of self-injurers likely overcome the behavior without seeking treatment, Muehlenkamp said, but treatment for these individuals might still be helpful.
“Anyone who’s engaged in self-injury, even if it’s one time in their life, they still report many more difficulties in their life, psychologically [and] socially,” she said. “So even if you have someone who’s self- injured one time, it may not be a bad idea for them to consider seeking some type of help.”
