Self-harm is increasing among adolescents and the age of onset is dropping to the point where children as young as six are cutting or burning themselves. ER staffs believe they are seeing a drastic increase in the frequency of adolescents and pre-adolescents presenting with self-harm. A recent study by the Samaritans concluded that 1:10 adolescents had deliberately cut themselves at one time or another; girls are almost four times as likely as boys to do so; and that less than 1:7 self-harm victims present for medical care.
As much as envisioning this epidemic of self-inflicted injury makes most people cringe, some mental health professionals suggest that it is not as abnormal as it sounds and not necessarily a sign of mental illness. Self-inflicted injury, one psychiatrist interviewed suggests, may serve to:
- release tension to cope with an unpleasant situation, e.g. because physical pain is more bearable than emotional
- impose the illusion of control over uncontrollable externally-imposed pain
- validate or demonstrate internal suffering with external evidence
Images of self-harm are all around us, particularly in religious iconography. Christianity is founded on the notion that Christ suffered for the world’s sins and there have been sects which practised self-flagellation and mutilation throughout history. Pain and the spilling of our own blood are seen as ways of cleansing ourselves. Likewise, when teenagers cut themselves they often say it is a release, a way of punishing themselves or others.
As a psychiatrist, I agree with the notion of self-harm as a culturally-conditioned coping strategy rather than necessarily a manifestation of a mental illness. Although it occurs in the setting of mental distress, it often should not be a focus of treatment in itself. The mental health field as a whole, however, has not been thoughtful about this distinction. Because it seems to many such a crazy, abhorrent thing to do, those who do it must necessarily be crazy. The adolescent psychiatric units are full of girls who have been hospitalized after an assessment from some ER that has gone no deeper than establishing that they have cut themselves superficially; the rationale for locking them up is, broadly, that they are ‘a danger to themselves’. No distinction is drawn between self-cutters and those who truly need hospitalization because of dangerousness to self, i.e. those with suicidal intent. To be fair, self-harm without intent to end one’s life can, of course, result in severe injury or death by miscalculating or overzealous efforts, especially while intoxicated, but self-cutting is usually quite superficial. It is easy to draw blood or induce pain without doing severe or lasting damage…
But when I suggest to crisis teams, parents or other inpatient mental health professionals that self-harm does not necessarily threaten the perpetrator’s life, that it is probably the best way of coping the person can manage for the moment (although, of course, we would like to help them develop better coping strategies in the long run), that in and of itself does not warrant hospitalization, and that we would need to formulate the continued need for hospitalization, if there is any, in terms of targeting underlying distress which the self-harm is addressing, rather than the self-harm itself, I get blank uncomprehending stares in return. Hospitalizing and diagnosing girls who cut themselves is often not doing them any favors, for a number of reasons including pathologizing them in their own and their families’ eyes, teaching them maladaptive coping strategies, reinforcing pathological dependency, allowing regression, etc., as well as reinforcing the impression that it is the self-injury, rather than another more far-reaching way of conceptualizing their difficulty, that should be the focus of ongoing therapy. With the epidemic presentation of self-harm, a further factor is that the ERs (which are motivated to hospitalize all potentially self-injurious patients rather than accept the liability of doing a possibly inaccurate assessment of actual risk) and the hospitals (which often accept all referrals in order to keep bed occupancy rates up for fiscal reasons)
Self-harm may be increasing in incidence, or we may just be becoming more aware of it. I suspect the former, and that it has something to do with the failure of more robust coping skills as the social fabric erodes and young people attempt to deal with their distress in more solitary ways. Peer pressure may play a role as well; research has established that people who self-cut are more likely to have friends or family members who do so as well, although that might not necessarily reflect social contagion as the possibility that self-injury clusters in communities because of shared sociocultural conditions.
I have also heard several other explanations of their self-harm from patients who perform it. Some feel self-injury satisfies a need to punish themselves for guilt over imagined transgressions. Some feel numb or dead and inflicting pain or seeing blood is a way to feel alive, better than feeling nothing at all. Some have an obverse motivation; they feel too much and inflicting injury is numbing. Self-abuse is intimately associated with a history of abuse and the psychiatric conditions that abuse engenders, including PTSD (post-traumatic stress disorder) and borderline personality disorder. If the incidence of self-abuse is increasing, or if we are becoming more aware of it, that may have soemthing to do wtih the commensurate increase in sexual abuse of girls or in societal awareness of it.
Boston psychiatrist Bessel van der Kolk, who has made his career of the study of victims of extensive psychological trauma (sexually abused children as well as combat trauma veterans), has integrated a sophisticated neurobiological explanation with the coping strategy model. He says that, at the times of their exposure to extreme stress, the brains of trauma sufferers were bathed in high levels of endogenous opiates (“endorphins”) released as part of the body’s acute coping mechanism (this is the well-known reason for the oft-cited observation that people don’t feel pain from even extensive injuries until later). With repeated trauma, their brains get used to such high levels of endorphins and are, in effect, addicted to their own endogenous opiates. Soem of the post-traumatic manifestations may be interpretable as a perennial state of withdrawal from that addiction, and some of the patients’ actions as attempts to restimulate such bursts of endorphin release to deal with the dysphoria from that withdrawal state. Risk-taking activity and self-abuse, both common in patients with PTSD, are both ways to stimulate such endorphin release. PTSD sufferers also have a proclivity for the abuse of (external) substances as well, which may function in a similar way.
Consistent with this model, I and other psychiatrists have had some success blocking self-harm, in patients who are motivated to stop doing so, by giving opiate-blocking agents that stop the satisfaction from the putative endorphin release, as part of a more comprehensive thearpy program to deal with the sequelae of traumatic experiences. If the self-harm is a strategy to stress conditioned by the reinforcement of the endorphin release, the opiate blockers stop any further reinforcement of this effect and gradually allow the motivated patient to give up the strategy. Consistent with this model, it only works if the patient wants to give up the strategy, usually at a point in their treatment that they are able to mobilize other stress coping techniques and can give up their reliance on one that their families, friends, treaters and society at large finds so alien, disturbing and abhorrent.
