Deliberate self-harm is a troubling aspect of adolescence (and possibly even adulthood) that appears to be on the increase. Its relationship with pain is uncertain, but for many self-harm is not so much about the inflicting of physical pain as the cessation of emotional pain.

For many people the idea of deliberately harming oneself is difficult to conceptualize. Many of us may spend our time attempting to avoid harm to ourselves either in the short-term (wearing a seat-belt) or in the long-term (exercising regularly, eating a healthy diet). Many of us would flinch from the idea of wilfully inflicting acute damage to our own bodies. How then can we understand individuals for whom harming the self is not something that they avoid or find aversive but is something that they seek out?

Deliberate self-harm is a term that covers a wide range of behaviours some of which are directly related to suicide and some that are not. This is a relatively common behaviour that is little understood.

What is deliberate self-harm?
Deliberate self-harm is a term that covers a variety of behaviours, with a multitude of different functions and a wide range of intentions. Perhaps the most useful definition is from Professor Keith Hawton and colleagues at the Centre for Suicide Research in Oxford (Hawton et al, 2002):

An act with a non-fatal outcome in which an individual deliberately did one or more of the following:

• initiated a behaviour (e.g. self-cutting, jumping from a height) which they intended to cause harm to the self);
• ingested a substance in excess of the prescribed or generally recognized therapeutic dose;
• ingested a recreational or illicit drug (which they intended to cause harm to the self);
• ingested a non-ingestible substance or object (e.g. batteries, razor blades).
  

Two elements are crucial: there is acute damage to the self (this excludes, therefore, behaviours such as smoking or eating an unhealthy diet); and damage is intentional (therefore, excluding accidents or behaviours such as starving where the motive is to lose weight as in anorexia nervosa).

Some clinicians and researchers draw distinctions between forms of deliberate self-harm where there is or is not an intention to die, distinguishing attempted suicide from self-harm or self-mutilation. There is some validity to this distinction. For some people, deliberate self-harm is more about finding a way of coping with life rather than ending it.

Nevertheless, regardless of the method or motive, harming the self seems to put people at risk of more severe forms of self-harm over time. In addition, even for people who primarily think of self-harm (e.g. cutting) as a way of coping, they may at other times harm themselves in other ways where they do have the intention to die. The potential lethality of a method adopted by an individual is not always an accurate indicator of his or her intent. Very few people who harm themselves have sufficient knowledge about how the body works to judge the impact of their actions.

How common is deliberate self-harm?
This is a difficult question to answer accurately. Some methods of measuring the behaviour (e.g. counting everyone who attends an Accident and Emergency department after harming themselves) underestimate the milder forms of self-harm (e.g. self-cutting), much of which is carried out in secret. In a recent UK study with a community sample (Hawton, Rodham, Evans and Weatherall, 2002), 6.9 per cent of a school population of 15 and 16 year olds had engaged in an act of deliberate self-harm in the previous year. Only 12.6 per cent of these episodes had led to a hospital visit. These figures are similar to those from a US sample (Centers for Disease Control. Attempted Suicide among High School Students – United States 1990).

While deliberate self-harm is particularly common among adolescents and has been on the rise in recent years, it continues into adulthood. Its incidence and prevalence in adulthood is also difficult to estimate accurately, and figures based on hospital attendance again probably underestimate its impact. One review (Favazza and Rosenthal, 1993) reported prevalence estimates of between 400 and 1400 per 100 000 of population per year.

While there is an increasing awareness of the risk of suicide in older adults, less is known about deliberate self-harm in the older population. It has often been assumed that the behaviour declines as people age. It may be, however, that the behaviour is even more taboo in older adults than in the young.

Who is at risk?
There are a number of risk factors for the development of deliberate self-harm. Females are more likely to engage in the behaviour than males, although rates in males have been rising recently. Also, males in particular are at more risk of suicide. Some of the other main risk factors are:

Childhood experiences

• Sexual abuse
• Neglect
• Emotional abuse
• Physical abuse
• Loss or separation
• Parental mental health problems
• Parental substance misuse.

Current experiences:

• Rape/sexual abuse
• Domestic violence
• Psychiatric diagnoses
• Substance misuse (both alcohol and drugs).
  

Not everyone that experiences these events goes on to self-harm. So what are the links between these experiences and the development of deliberate self-harm?

There are a number of different theories but two common themes are apparent. The first is the experience of intense and distressing emotions. These may be related to particular experiences, such as sexual or physical abuse.

The second factor is the absence of the right kind of emotional support. In other words, the child (or in some cases the adult) is not provided with the assistance to recognize and understand their responses to the events they are experiencing. In some cases, for example sexual abuse in childhood, the fact that the experience occurred at all may be denied. The absence of recognition and support in the context of extreme and distressing events leads to a sense of powerlessness, and an incapacity to understand and manage painful feelings. Linehan (1993) refers to these environments as 'invalidating' because the individual's experience of reality and their responses to it go unrecognized and unsupported.

Why do people deliberately self-harm?
In the context of intense and distressing emotions and the absence of emotional support, deliberate self-harm can come to fulfil a number of different functions (Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001):

• Deliberate self-harm as a coping mechanism. Deliberate self-harm can help in the short-term management of problematic emotions (harming the self seems to decrease the intensity of some emotions) and can therefore be experienced as stress-relieving. For some, the desire to terminate unpleasant emotional states is so strong that they want to interrupt consciousness either temporarily by sleep or permanently by death.
  
  However, the emotion-reducing effects rarely last for long (minutes to a few hours), and self-harm in the longer term can be a source of stress in itself. People may feel ashamed of the behaviour, or distressed by the scars that are left. In addition the disapproval or worry of others around them may lead to interpersonal conflict. Also, the short-term nature of the relief can lead to a sense of not really being successful in solving the problem.
  
  As well as helping in the regulation of emotions, deliberate self-harm can also help some people regulate unpleasant self-states, for example dissociation (feeling disconnected from reality) or depersonalization (feeling unreal or in some extreme cases as if you are dead). These self-states, relatively common after trauma, are extremely distressing and unsettling. Harming the self can bring an abrupt return to the reality of the moment or to an increased sense of being 'alive'.
  
  The short-term effectiveness of deliberate self-harm in reducing emotions, or in effecting a 'return to reality', can provide an increased sense of mastery and control, which may be important for individuals who feel out of control and powerless to change their circumstances or experiences.
  
  
• Deliberate self-harm as a form of self-punishment: For many individuals, the behaviour acts as a re-enactment of past experiences where they have been traumatized and abused. Following a history of abuse or neglect it is not uncommon for people to believe that they are evil or bad (they may have been told this directly by the person who harmed them or they may believe this was why they were being harmed) and deserve to be punished. Harming the self is a way of delivering the punishment that they feel they deserve for being 'bad' and to blame.
  
  
• Deliberate self-harm as a means of validating the self: As described earlier, for many individuals who have been traumatized or abused or neglected there was no recognition of their experiences and the events that so damaged them may have been actively denied. For such individuals, deliberate self-harm is a way of testifying to the enormity of their experience and a way of remembering events that others may have forgotten or denied. For some it is a way of confirming or authenticating that what they suffered really was as traumatic as they remember.
  
  
• Deliberate self-harm as a means of influencing others: In some circumstances harming the self can be a way of communicating distress that is not heeded when communicated in words. At other times self-harm can be a means to influence others, either to care for the person who has harmed or to keep others at a distance.
  
  Often, more than one function may be relevant. For example, cutting the self may serve both to regulate anxiety and to validate the severity of current emotional pain. It is very important not to make assumptions about the function of a particular episode of self-harm without understanding both the behaviour itself and the person who has harmed.
  
  Often professionals and family members make the mistake of assuming that all episodes of self-harm are about influencing them or other key people in the environment, because the other aspects (reduction of emotional pain, self-validation) are hidden to the outside observer. Because they are experiencing a response to the self-harm, they make the (often mistaken) assumption that the person who has self-harmed intended to make them feel this way. This is not always the case.
  
  

Deliberate self-harm and pain
The above suggests that the experience of physical pain may only be relevant in some forms of deliberate self-harm, for example, cutting. Other actions (e.g. taking an overdose) do not involve any immediate physical pain. Also, the experience of pain will vary from person to person and from episode to episode. Some individuals feel little or no pain at the time of the injury but do so later. Others experience pain at the time, and it is the experience of physical pain that is essential in the relief of the emotional pain. For many, handling physical pain (in the short run) is described as 'easier' than dealing with the enormity of their emotional pain.

The biological bases of the relationship between self-harm and pain is, as yet, unclear. Some theorists have argued that early experience of trauma damages certain neuroanatomical pathways in the brain related to the release of endorphins, which are implicated in the regulation of emotional states. In individuals whose neural pathways are affected in this way, it is suggested that deliberate self-harm may offer a means of releasing endorphins. Others have noted changes in the brain systems utilizing the neurotransmitter serotonin in both suicide and deliberate self-harm. The role of these systems in both the development and maintenance of deliberate self-harm behaviours remains to be fully elucidated.

Treatment interventions
The National Institute of Clinical Excellence (NICE) is in the process of producing a guideline on the management of deliberate self-harm. For this guideline a thorough review of available treatments was conducted. The evidence base was found to be very small and consequently it was difficult to make firm recommendations about effective treatments at this stage. The draft guideline can be located on the NICE website.

There is some debate among therapists and people who self-harm about whether deliberate self-harm should form a primary focus of treatment. Some therapists advocate addressing the underlying problems in the past (and also in the present) that lead to the behaviour, rather than focusing on the behaviour itself. They argue that when these problems are resolved the behaviour will cease.

Other therapeutic schools suggest that the deliberate self-harm should be a primary focus for treatment, particularly when the behaviour is especially frequent or particularly severe, or associated with significant mental health disorders, as failure to do so places the person at risk. Which is the effective option for any one individual is likely to depend on a number of factors, such as the severity of the self-harm, whether the individual is highly suicidal or not, their capacity to function generally, their own preference for therapeutic approach and a thorough understanding of how the deliberate self-harm relates to other aspects of the person's life.

For individuals who harm themselves who also present with very severe and complex mental health problems that would fit the diagnostic criteria known as borderline personality disorder, there is relatively good evidence for the effectiveness of dialectical behaviour therapy (Linehan, 1993). This therapy recognizes the importance of both managing problematic emotions and situations when they arise, by using a wide range of techniques derived from cognitive behaviour therapy, as well as understanding why it is that deliberate self-harm and other behaviours that may also be considered impulsive are effective for people with very traumatic pasts.

Further reading
Babiker G and Arnold L (1997) The Language of Injury: Comprehending self-mutilation. Leicester: BPS books.

Centers for Disease Control (1990) Attempted Suicide among High School Students – United States.

Favazza A R and Rosenthal R J (1993) Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44(2), 134–140.

Gratz K (2003) Risk factors and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology Science and Practice, 10, 192–205.

Hawton K, Rodham K, Evans E and Weatherall R (2002) Deliberate self-harm in adolescents: self-report survey in schools in England. British Medical Journal, 325, 1207–11.

Linehan M (1993) Cognitive-Behavior Therapy for Borderline Personality Disorder. New York: Guilford Press.

Williams J M G (2001) Suicide and Attempted Suicide: Understanding the Cry of Pain. London: Penguin.