‘I think it’s really important to communicate what the variety and dynamics and techniques of self-injury are. It seems really important to me for caregivers to have some comprehension of the creativity and diversity of injury.’

‘All my ideas of harming myself have come from me and me alone . . . And, whatever implements I have used to cut myself have been of my own thoughts.’

Caution: This chapter includes information that those who self-injure, or have self-injured in the past might find potentially ‘triggering’. Please make sure you keep safe.

What methods do people use to self-injure? Do cutting and burning serve different purposes? Why the need to see blood? Is there a link between alexithymia and self-injury? What implements do people use to self-injure? Where do people self-injure?

Is there significance to the areas chosen? How long does self-injury last? What do people think of their scars? Is self-injury addictive? Do endorphins play a role in self-injury? These questions are addressed in this chapter, together with a glimpse into the effects of post traumatic stress symptoms on the brain.

Because of my concern that discussing methods and implements used to self-injure could prove distressing to those who practise the act, or might pose a risk by giving people ideas, I decided to seek a number of Internet respondents’ views on whether these topics should be included. The general consensus was that to omit the material or ‘water it down’ would make ‘it a book that is lacking in information’. Several respondents thought that inclusion of the material would be helpful to professionals, other caregivers and lay people in general:

Several agreed that the material could be potentially ‘triggering’ but considered it should still be included:

Other respondents went some way to allaying my foreboding that including the material might give people ideas:

What methods do people use to self-injure?

Research has consistently shown that skin cutting is the most common method of self-injury. Figure 3.1 highlights methods used to self-injure compared across three studies.

Cutting is rarely the only form of self-injury used

As evidenced from Figure 3.1, while cutting appears to be peoples’ ‘preferred method’ to self-injure, burning is also fairly common: it is also interesting to note that the percentages on burning from all three studies are very close. This set me thinking about whether cutting and burning might serve difference functions.

Do cutting and burning serve different purposes?

Surprisingly, a literature search for information addressing the question of whether cutting and burning might serve different functions revealed this to be virtually uncharted territory. Thus, in order to ascertain whether there might possibly be a distinction between the two lead once more to inviting the Internet respondents to comment on the subject. They were asked to respond to the following questions: ‘If you cut and burn, do they serve different functions for you? Can you explain?’ Here are a range of replies received:

Note: The final testimony is from a respondent diagnosed with Dissociative Identity Disorder (DID). Hence, the reason she refers to herself as ‘we’ and ‘ourselves’. This is fairly common practice among people with DID. The subject of dissociation and DID is discussed in various chapters later in the book.

Summary

As can be seen from the testimonies, cutting and burning serve a similar purpose for some, while for others they serve different purposes. The list below provides an overview of possible reasons why people may choose burning over cutting, identified from the responses. However, there does appear to be a degree of overlap in some cases, for example either behaviour may be used to terminate dissociative episodes (feeling numb, unconnected). Also, the choice of method may depend on the trigger and can go either way. This made it difficult to determine whether a clear distinction can always be made. What did come across is that if the sight of blood is important, cutting is more likely to be chosen over burning. Further, to quote a male respondent’s interesting observation, perhaps: ‘Fire and so on is more anti-dissociative whereas blades are more anti-emotional.’ (Emphasis added).

• Burning provides a more immediate pain than cutting, it hurts more, and the pain and discomfort lasts longer (‘it is the gift that keeps on giving’). This suggests that burning may serve the purpose of distracting one’s thoughts away from the internal emotional pain for a longer period than cutting.
• There is more uncertainty about burning than cutting, and it is can be a more damaging and dangerous method.
• Burning may be chosen over cutting to cope with exceptionally high levels of stress, when a higher level of pain or more damage is needed, when feeling the need to suffer more or to punish oneself more, or to manage intense feelings of anger or powerful negative feelings of self-hatred or self-disgust towards oneself.
• Burning may be selected over cutting to terminate incapacitating episodes of dissociation (feeling exceptionally numb) or when a quick ‘snap back to reality’ is needed.
• Burning may be used to prove to oneself that if one can get through the excruciating pain of burning oneself, one can get through the pain of anything.
• Burning may be chosen if a ‘quick fix’ is needed or if cutting is insufficient to ‘cut’ through the psychological pain.
• On a practical level, burning may be the method of choice for the sake of convenience – it can be carried out quickly, easily, with relatively little mess. It may also be used as a substitute if a person’s ‘cutting tools’ are not readily to hand, and can be passed off more easily as an accident.

Why the need to see blood?

As mentioned, the sight of blood is important to many people who self-injure. There are several explanations for this. The following respondents’ comments (Sutton, 1999, p.121) clarify some of the reasons:

Alexithymia and self-injury: is there a link?

Problems recognising and describing emotional states in words appears to be a common occurrence among people that self-injure. Similar characteristics feature in alexithymia. Alexithymia, a term coined by Peter Sifneos in 1973, is derived from the Greek language (“a = lack, lexis = word, thymos = emotion”). Literally it means ‘a lack of words for emotions’. Alexithymia, refers to a psychological construct, rather than an illness.

It is important to understand however, that alexithymia does not equate to a deficiency of emotions; rather it means a disengagement from emotions, which in turn hinders the processing of emotions through the language of words. Alexithymia can also have specific consequences. For example, the risk of being repeatedly overwhelmed or swamped with potent yet nameless feelings or memories, or frustration at not being able to communicate to others what one is experiencing internally.

In addition to difficulties recognising and describing emotional states, other characteristics of alexithymia include an externally oriented thinking style, and a limited imaginative capacity (impoverished fantasy life). (Taylor, 1997: 28–31)

Studies of alexithymia

A study by Zlotnick, et al. (1996) found a higher degree of alexithymia and dissociative symptoms among people that self-injure than amongst those who didn’t. Further, alexithymia has been positively associated with two psychiatric disorders frequently linked to self-injury: post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD) (Zlotnick et al., 2001).

For further information on alexithymia see the useful resources section at the end of this chapter.

What implements do people use to self-injure?

Figure 3.2 (Internet respondents: implements used to self-injure) reveals the wide range of implements that people use to self-injure. As can be seen people can be extremely innovative if the urge to self-injure strikes.

Other implements and methods reported

• Cutting and gouging: Broken crockery, house keys, rings, screws, screwdriver, scalpel, staples, notebook wires, blades of figure skates, tin cans, saws, chisels, cheese grater; pins/bobbi pins, paper clips, zippers, compass, retractable stencil knives, pencil sharpener blades/erasers, broken CDs, nail files, plastic knives, wood splinters, manicure set, box cutter, exacto knives, craft scissors, bits of wire, wire hanger, steel, plaster, wood, anything sharp/broken with edges (e.g. furniture), sharp part of an earring, pointy end of a mascara make-up tool, tweezers, dog lead.
• Burning and scalding: Candle flames and hot wax, blowtorch, curling iron, lighted matches, heated metal, boiling hot showers, hot radiators, hot baking trays, industrial laminating machine, acid/corrosives/chemicals.
• Hitting/knocking/scratching/biting: Thumping walls and dragging knuckles across bricks, banging self, head or knuckles against walls until black and blue; bruising/punching self with fists and hands; throwing self against doors, shutting arms and other parts of body in doors; banging head with hands; hitting self with door wedge, weights, rocks, bricks, concrete blocks and wooden mallet; biting self; erasing skin with sandpaper.

Where do people self-injure?

Research has consistently shown that cutting the arms is the most common form of self-injury, however, as highlighted in Figure 3.3 (Internet respondents: reported areas of the body self-injured) numerous areas of the body may become targets. Percentages have not been included as many respondents reported injuring various parts of the body.

Is there significance to the areas chosen?

The following testimonies which come from respondents who completed the survey for Healing the Hurt Within, 1st edition (Sutton, 1999:37–40) suggest that there is a meaning to why people target specific areas.

Six chose areas of easy access or the most available parts of the body:

Two chose areas that could be seen:

Two chose areas that couldn’t be seen:

One chose a hated area/area of easy access:

Another chose an area that caused personal offence:

Five identified a variety of reasons:

One chose areas associated with sites of sexual abuse:

Another chose areas associated with sites of abuse, touch and torture:

How long does self-injury last?

Figure 3.4 shows the duration of self-injury as reported by the Internet respondents. The survey for Healing the Hurt Within, 1st edition (Sutton, 1999: pp. 35–36) revealed that 27% of the sample group had been self-injuring for over 20 years, 19% for between 10–20 years, 24% for between for 5–10 years, and 30% under five years. Favazza (1996:254) argues that ‘In many patients the disorder lasts ten to fifteen years, although isolated episodes of self-mutilative behaviour may persist.’ However, clearly evident from both sets of data is that a significant number of the sample groups had been self-injuring for over 15 years. Further, the data shows that self-injury is plainly not a new phenomenon.

What do people think of their scars?

Self-injury scars hold a myriad of meanings. To some they are an enormous source of shame and embarrassment, and people take great pains to conceal them. Long sleeved tops, blouses or sweaters, and long trousers or jeans may be worn all year round; the wearing of swimsuits or bikinis may be avoided, and camouflage creams may be invested in.

Souvenirs of survival

In contrast, some have a fond relationship with their scars, viewing them as living proof of survival of hard-fought psychological battles, or as evidence that their emotional pain is real. To others, they represent willpower and self-control, a sign of uniqueness (almost like a birthmark), a painful life story etched on the skin, or they serve as a reminder of significant life events such as the loss of a loved one.

Is self-injury addictive?

Fifty-four percent (54%) of the sample group for Healing the Hurt Within, 1st edition, (p.149) and eighty-four percent (84%) of the Internet respondents considered self-injury was addictive (see Figure 3.5). In Favazza and Conterio’s 1989 study, seventy-one percent (71%) of the sample group reported that their self-injurious behaviour was an addiction. The latter figure compares with the findings of a more recent study (Nixon et al., 2002), in which 33 of 42 self-injuring adolescent patients (78.6%) admitted to a psychiatric hospital over a four month period reported almost daily urges to self-injure.

No pain – no gain

Some experts in the field disagree that self-injury is an addiction in the true sense of the word. For example, Conterio and Lader, in Bodily Harm (1998:22–26) state that ‘self-injury shares certain characteristics with addiction’ but argue that it is an ‘addictive solution to emotional distress.’ In contrast, Turner, in Secret Scars (2002:49), a book written from an addictions perspective, asserts, ‘The experience of pain becomes addictive. The self-injurer comes to like pain, and she eventually craves it.’

The lure of what comes after

Conterio and Lader’s hypothesis about self-injury being an ‘addictive solution’ makes sense. Perhaps it’s not so much a question of getting pleasure from pain (masochism) but more the lure of what comes after (the euphoric high, the buzz, the good feeling) that keeps people hooked on the act. Simply put, and as evidenced by the following testimonies, people tolerate or live with A to get to B.

Do endorphins play a role in self-injury?

The above testimony provides useful information about the respondent’s goals of self-injury. Of particular interest to the current topic is the ‘rush’ and ‘numbness’ she says she wants to achieve – these appear to be common reasons for self-injury. One theory is that self-injury stimulates the production of endorphins, which could explain the rush, numbing, and the sense of peace and calm that many people report experiencing following the act.

What are endorphins?

The word endorphin is an abbreviation of two words: endogenous (internally generated) and morphine (a pain-reliever). Endorphins (neurotransmitters, endogenous opioids) occur naturally in the brain and contain analgesic properties similar to morphine. Painkilling drugs, such as morphine (derived from opium) and codeine (produced from morphine), are commonly used in the medical arena to relieve severe pain caused by physical injuries, or to manage chronic pain in ongoing illnesses. Heroin, another semi-synthetic opium derivative (known to be highly addictive) also comes from morphine. Many street drugs mimic or activate endorphins. Put simply, endorphins are the body’s natural pain killers. In addition to acting as a pain regulator, endorphins are also thought to suspend fear, increase perception, and have been linked to physiological processes such as appetite control, the release of sex hormones, euphoric feelings (providing a ‘rush’ similar to adrenaline), and shock. Activities believed to stimulate endorphins include prolonged physical exertion (the ‘runner’s high’), consuming chocolate and spicy foods (hot chillies), meditation, acupuncture, and a hearty laugh. Thus, as well as relieving pain, endorphins produce an increased sense of well-being (the ‘feel good’ factor).

If the endorphin theory is correct, and self-injury brings with it rewards such as decreased stress, increased relaxation, and an enhanced sense of well-being, this could perhaps explain why the behaviour continually beckons people.

Recap

Mounting evidence suggests that self-injury can rapidly shift a person’s mood from one of dysphoria (an uncomfortable emotional state) to one of euphoria (a feeling of well-being). However, a major missing link in our current understanding of self-injury is that if the act does alter brain chemistry, is it simply via the release of endorphins, or could there be other biological factors at work?

Post-traumatic stress symptoms and brain functioning

Numerous people who self-injure report experiencing post-traumatic symptoms, such as flashbacks, intense emotional arousal or physical reactions on exposure to external or internal reminders of an aspect of the traumatic event, difficulty getting to sleep or staying asleep, and hypervigilance, etc. (See Appendix 2 for DSM-IV-TR diagnostic criteria for PTSD).

In recent years significant progress has been made in understanding the effects of trauma on brain functioning, and the general consensus is that traumatic experiences can have a marked impact. While the full consequences are not yet fully understood, trauma experts, such as international expert, Dr. Bessel van der Kolk, Medical Director of the Trauma Center (http://www.traumacenter.org), are hard at work investigating the effects of trauma on brain structure and development.

The amygdala and the hippocampus, two brain structures housed within the limbic system, ‘have been implicated in the processing of emotionally charged memories’ posits van der Kolk (1996, p.230), adding that ‘A recent series of studies indicates that people with PTSD have decreased hippocampal volume.’ (p. 232).

Unfortunately, space does not permit further exploration of this fascinating topic. For those interested in learning more about this topic see suggested further reading sections at the end of the chapter.

Key points

• Cutting appears to be the ‘preferred form’ of self-injury, but a wide range of other methods are used.
• Cutting and burning serve different functions for some people.
• Seeing the blood holds a significant meaning for some people who self-injure.
• Problems recognising and describing emotional states in words to other people, and discriminating between feelings and the bodily sensations of emotional arousal appear to be common occurrences among people that self-injure. Similar characteristics also feature in alexithymia.
• People use a wide range of implements to self-injure, and they can be extremely innovative if the urge to self-injure strikes.
• The arms are the most common target for self-injury, but numerous other areas of the body may be targeted.
• Self-injury may persist over many years: it is clearly not a new phenomenon.
• To some people the scars from self-injury are a source of shame and embarrassment; to others they are a souvenir of survival.
• Many people who practice self-injury describe it as addictive.
• An ‘endorphin rush’ following the act is reported by many people that self-injure.
• Numerous people who self-injure report experiencing post-traumatic symptoms, such as flashbacks, intense emotional arousal or physical reactions on exposure to external or internal reminders of an aspect of the traumatic event, difficulty getting to sleep or staying asleep, and hypervigilance, etc. The question of whether brain functioning plays a key role in the development of post-traumatic symptoms is currently under investigation by trauma researchers.

Useful resources

Alexithymia

Trauma information

David Baldwin’s trauma information

An award winning, firmly-established and informative site that provides information on emotional trauma and traumatic stress (including PTSD [Post-traumatic stress disorder] and dissociation) for clinicians and researchers working in the traumatic-stress field. Retrieved June, 11, 2007, from, http://www.trauma-pages.com/

The Trauma Center (Founder and Medical Director Dr. van der Kolk)

‘The Research Department conducts studies on traumatic memory and how treatment effects trauma survivors’ minds, bodies, and brains.’ Retrieved June, 11, 2007, from, http://www.traumacenter.org/

Suggested further reading