The term self-harm refers to all those behaviors deliberately aimed at causing physical pain.
These behaviors do not necessarily have to do with suicide attempts or the desire to take one’s own life. Instead they include, for example, cutting your skin with different types of sharp objects, inflicting burns, and branding yourself with cigarettes or hot objects.
In fact, self-harm is defined as “deliberate and self-inflicted harm to one’s body without suicidal intent and for non-socially accepted purposes” (International Society for the Study of Self Injury, 2018).
Criteria for the diagnosis of self-harm
DSM-5 (2013) includes “Not Suicidal Self Injury” (NSSI: Not Suicidal Self Injury) as a distinct diagnostic category. He defines it as a series of intentionally self-harming acts against his own body conducted for at least 5 days in the last year.
Self-injurious conduct to be such must be preceded by one or more of the following expectations:
- getting relief from a negative feeling / cognitive state;
- resolve a relational situation;
- induce a positive feeling.
Additionally, self-injurious behavior must be associated with at least one of the following symptoms:
- interpersonal difficulties or negative sensations / thoughts / feelings prior to the self-harm;
- uncontrollable concern for the gesture;
- frequent self-damaging thoughts.
Finally, to be such it must cause significant discomfort.
Causes of self-harm
Self-harm as a maladaptive coping strategy
Performing self – harm allows you to focus your attention on physical pain.
The motivations underlying the implementation of self-harm are generally related to the need to get out of a perceived state of profound emptiness to reconnect to reality and the management of unpleasant emotional states perceived as otherwise unmanageable.
The self-injurious behavior such shifts attention from emotional pain to the physical, experienced as more tolerable.
Physical pain at first releases tension, generates relief, and removes emotional experiences that you don’t want to experience.
Over time, however, this risks generating new unpleasant emotional experiences, such as guilt and shame for engaging in the behavior.
The effectiveness of self-harm , in relation to both the functions described, increases the possibility of putting it back into action again, and therefore favors the establishment of vicious circles that maintain the problem over time.
Self-harm as a punishment
Self-harm can also represent a form of self-punishment : guilt and self-criticism can elicit self-harming behaviors in vulnerable individuals.
Self-harm as a search for attention
Finally, self-injurious behavior can represent a dysfunctional way to seek attention , request help or communicate your discomfort to others.
An extreme gesture used in order to shout to the world one’s existence / presence and the suffering that one is unable to communicate in words.
Risk factors
Individual
There are various individual risk factors including:
- Presence of mental disorders ( borderline personality disorder , anxiety , depression , eating disorders and conduct disorders)
- Temperamental traits (loss of control, impulsivity and emotional dysregulation)
- Negative feelings about your body ( dissatisfaction , shame , control)
- Substance abuse
- Internalizing and externalizing behaviors
- Problems in the school environment
- Lack of self-esteem and self-efficacy
Social
- Stressful events
- Experiences of abuse (sexual, physical and / or emotional)
- Family problems (neglect and conflicts)
- Negative relationships with peers ( bullying , isolation and lack of support)
- Messages presented by social / video games / tv (addiction, normalization, generalization and encouragement to self-injurious behavior)
Self-harm and suicide
Although self-harm is of a different nature than suicide attempts , there is a strong predictive link between the former and the latter.
Self-harming behaviors are more frequent and involve behaviors with less serious consequences than those used in true suicide attempts. Furthermore, the people who implement them are not moved by the desire to end their existence.
Research shows that self-harming behaviors are risk factors for suicide as they are more closely related to stories of suicide attempts. In addition, there are numerous studies that show that self-harm is a greater predictor of suicide than repeated and previous suicide attempts.
Self-injurious behaviors are a risk factor for suicide. This is because over time they can desensitize people from physical pain thus increasing their ability to put it into action.
Prevalence of self-injurious behavior
The ‘ self-harm is a widespread phenomenon among teens (15-20%). This behavior sometimes persists even in early adulthood, but so far the research has not revealed many data on the factors that can influence the persistence of self-injurious behavior over time.
The self-injurious behavior is higher in psychiatric populations ( mood disorders and / or anxiety disorders , substance abuse , eating disorders , dissociative disorders , disorder, post traumatic stress disorder , schizophrenia and personality disorders ). It is often associated with borderline personality disorder but in this case the picture is more serious, the behavior is repeated and the self-harm modalities are various.
Maintenance of self-harm over time
The survey conducted by Kiekens G. et al. (2017), and published in the Journal of Nervous & Mental Disease , highlights the possible factors associated with the persistence of self-injurious behavior over time.
Using the data from a three-year longitudinal study, the authors compared the levels of some variables on a sample of 101 young adults. Of these, 51 continued to engage in self-harming behaviors after adolescence. 50, on the other hand, stopped such behavior.
In addition to the characteristics of self-harm behaviors , in terms of function performed and severity, the study evaluates the levels of many factors. Both interpersonal (perceived social support, perceived family support) and intrapersonal factors (sexual orientation, perceived emotional regulation skills, emotional distress, academic stress, self-esteem , life satisfaction).
Severity of self-injurious behavior
The results found that a greater severity of self- injurious behaviors in adolescence, in terms of greater frequency and use of different methods, was associated with a greater persistence of the behavior in early adulthood.
It was also found that the number of methods used correlated with suicide attempts much more than the frequency of the behavior.
Function of self-harm
In relation to the functions performed by the self-injurious behavior , both the presence of positive consequences deriving from the arousal stimulation (arousal, autonomic activation) and the perceived difficulty in controlling the behavior are relevant.
In fact, the motivations that were based on positive reinforcement mechanisms, such as obtaining a discharge of energy and the perception of not being able to resist the impulse to implement the behavior, were associated with the permanence of the behavior over time.
Interpersonal and intrapersonal factors
In relation to the other factors examined, the persistence of self-injurious behavior over time was found to be associated with higher levels of academic and emotional distress. But even at lower levels of peer support, life satisfaction, and perception of competence over one’s emotional regulation skills.
However, factors such as homosexuality and perceived family support were not relevant, unlike what the literature indicates as relevant factors for the implementation of behavior in adolescence.
Emotional distress and perceived emotional regulation
Finally, the study also evaluated the role of emotional distress and perceived emotional regulation skills. All elements that could mediate the effect of the other factors considered in maintaining the problem over time.
Perceived emotional regulation skills were found to be an important factor in stopping self-harm . Low levels of perceived emotional regulation skills (understood as the presence of negative beliefs about one’s ability to regulate emotions) mediated the effect of the factors “perceived social support” and “satisfaction with one’s life”.
Furthermore, emotional distress had a lower predictive value for maintaining behavior over time than perceived emotional regulation abilities.
The authors themselves therefore indicate that the perception of being competent in regulating one’s emotions in the face of adversity appears to be a more important factor than the objective levels of perceived distress.
Treatment of self-harm
The most widespread and effective treatment to intervene on self-injurious behaviors is cognitive-behavioral psychotherapy .
The cognitive-behavioral approach involves the use of techniques (cognitive restructuring and relapse prevention) useful to help adolescents and young adults to deal with any situations that elicit self-harm.
As emerges from the aforementioned survey, for example, in addition to the general assessment of emotional regulation skills, it is important to note the perception that children have of their ability to regulate their emotions. It therefore becomes important to change dysfunctional beliefs about it, when present.
Cognitive-behavioral tools such as functional analysis could be valuable in identifying the antecedents and the situational, cognitive and emotional consequences of the self-injurious act.
They are used to detect the risk factors for the continuation of the problem over time (strong elicitation of positive arousal and implementation of the behavior because it has now become conditioned, therefore with little perception of control).
This allows to identify the most suitable therapeutic strategies. This in order, for example, to modify the environmental contingencies that act as a trigger for the implementation of self-harm behavior and / or to learn new, more functional ways to increase the perceived positive sensations.
Finally, the research shows the efficacy of Dialectical Behavioral Therapy (DBT) in the treatment of self- harm in subjects with Borderline Personality Disorder. This focuses attention on the acceptance / tolerance component of suffering in order to reduce emotional dysregulation.
