Myth 5: People that self-injure are mentally ill

Many who self-injure fear they are going ‘crazy’ and while the behaviour is known to coexist with other disorders – eating disorders, substance misuse, depression and anxiety, for instance, albeit atypical behaviour, self-injury does not automatically indicate mental illness. Many who self-injure have not learned how to express their feelings in constructive ways. Perfectionism traits, low self-esteem, negative self-judgments, self-loathing, self-invalidation, and self-directed anger have also been positively correlated to self-injury.

Self-injury typically indicates that there are unresolved issues that need to be addressed and healed. Crucial, therefore, is to recognise that those who self-injure are doing their best to manage with the only skills they have available at their finger tips.

Myth 6: Those who self-injure suffer from Borderline Personality Disorder

Figure 2.2 provides an overview of diagnostic labels assigned to Internet respondents. Many reported receiving several of the diagnoses listed, hence the reason percentages are not included. Borderline personality disorder (BPD), deemed very difficult to treat, is a particularly controversial and unpopular diagnosis. To make a diagnosis of BPD (employing the criteria as set out in DSM-IV-TR, APA 2000), five or more of nine diagnostic criteria have to be met, one of which is ‘recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.’ (See Appendix 2 for DSM diagnostic criteria for BPD).

Dr. Leland Heller, an American family physician, author of the book Life at the Border: Understanding and Recovering from the Borderline Personality (1991), and founder of the BiologicalUnhappiness.com website (http://www.biologicalunhappiness.com/) is one among many practitioners who would welcome seeing a change of term. Indeed, in an Internet article entitled A Possible New Name For Borderline Personality Disorder (HealthyPlace.com, 1999–2007) he pulls no punches about his views on the term:

I think it’s a horrible, insulting label for a real medical illness. The name alone reduces serious research, stigmatizes victims, and implies the person is crazy. It denies the medical nature of the process, and implies simply a personality problem.

In the same article, Heller explains BPD as ‘a malfunction of the limbic system’, coining the term ‘Dyslimbia’ in preference to BPD. To clarify his choice of term he says that ‘Dys’ indicates ‘malfunctioning’ and ‘limbia’ refers to the ‘limbic system’. (See Chapter 3 for further information about the limbic system).

Difficult childhoods are reported to feature in the backgrounds of many people diagnosed with BPD, as pointed out by Colin Ross, MD (2000):

I have never met a borderline who had a childhood that was anywhere near normal or happy. I have given dozens of workshops in which I have asked whether anyone has ever seen a borderline with a normal childhood, and not one out of thousands of professionals have ever raised a hand. The “tough” childhood is part of the phenomenology of the disorder. (p.207)

You will note from Figure 2.2 that major depressive disorder followed by post-traumatic stress disorder (PTSD) were the two most reported diagnoses. Perhaps this is an indication of a move away from the stigmatising BPD label – let’s hope so. Many researchers argue that BPD is a form of ‘Chronic PTSD’ (symptoms persist for 3 months or longer). Acclaimed trauma researchers, Judith Herman (1998) and Bessel van der Kolk (1996) for example, make it clear that the diagnostic criteria for PTSD fails to encompass the acute symptoms caused by prolonged, recurrent and chronic trauma. Thus, they have proposed an alternative diagnosis (incorporating the relevant group of symptoms identified) for inclusion in future editions of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Whereas, Herman coins the term ‘Complex PTSD’ (CPTSD) for the proposed diagnosis, van der Kolk uses the term Disorders of Extreme Stress Not Otherwise Specified (DESNOS). (See Appendix 2 for DSM-IV-TR criteria for PTSD and BPD, and Disorders of Extreme Stress Not Otherwise Specified (DESNOS): Proposed Criteria).

Myth 7: Those who self-injure are a danger to others

Yet another common myth about self-injury is that individuals who do it are a danger to others, thus it’s safer to steer clear of them. This assumption is deeply offensive to some who practice the behaviour and who would never dream of striking out at anyone else. While it may be true that some people put their own lives in jeopardy by their actions, rarely do they appear to pose a risk to other people, as evidenced in the four testimonies below:

Myth 8: Self-injury is a response to child abuse

It is widely reported that self-injury is a response to child abuse, and whilst this may be partly true, it is not always the case.

Favazza and Conterio’s study of 240 women that self-injure (1989: 285) found the following childhood causal factors:

• Childhood abuse (62%)
• Childhood sexual and physical abuse (29%)
• Sexual abuse only (17%)
• Physical abuse only (16%)
• Over half described their childhood as “miserable”.

Arnold’s survey of 76 women that self-injure (1995:10–11) revealed a number of childhood factors that contribute to self-injury – these included:

• Sexual abuse (49%)
• Neglect (49%)
• Emotional abuse (43%)
• Lack of communication (27%)
• Physical abuse (25%)
• Loss/separation (25%)
• Sick or alcoholic parent (17%)
• Other childhood experiences (19%).

In many cases, the women reported suffering a number of traumatic experiences, ‘often including multiple forms of abuse and deprivation’. Adult experiences echoed many of the childhood experiences – the most common being rape, sexual abuse and harassment.

van der Kolk, Perry and Herman (1991:1665–1671) in their study of 28 self-cutters, discovered the following childhood causal factors:

• Significant childhood trauma (79%)
• Major disruptions in parental care (89%)
• Sexual abuse was most strongly associated with all types of self-destructive behaviour.
• ‘. . . the age at which trauma occurs plays a key role in both the severity and expression of self-destructive behaviour: the earlier the trauma, the more cutting’.

Only one respondent did not report childhood trauma or disrupted care. The authors concluded that: ‘Childhood trauma contributes to the initiation of self-destructive behavior, but lack of secure attachments helps maintain it’.

An unpublished Internet study of self-injury (Davies, S. C., 2002) revealed that almost seventy-five percent (75%) of respondents had suffered childhood abuse, and many reported experiencing several forms of abuse and neglect, which mainly occurred in childhood and continued over long periods. Noteworthy too, was that the age when the abuse occurred correlated significantly with the age of onset of self-harm. (See Chapter 5 for a summary of Davies’s findings).

Putting things into perspective

Favazza, in the introduction to the book A Bright Red Scream (2000) by Marilee Strong, stresses the importance of not making the automatic assumption that self-injury is a response to child abuse – he writes:

One caveat I would encourage readers to keep in mind is that the childhood physical and sexual abuse so dramatically and accurately described in the book applies to 50 to 60 percent of self-mutilators, which means that a fair number have not been abused. On several occasions I have had to rescue patients from therapists who were frustrated at not being able to find the cause of an individual’s self-mutilation and therefore assumed that he or she must have been abused. (p. xiv)

Myth 9: If the wounds are minor the problem’s not major

Another conjecture made about self-injury is that the severity of the wounds reflects the extent of the problem. However, what came across clearly from the Internet respondents’ testimonies is that the level of harm inflicted can vary from episode to episode, and is dependent on numerous factors, for example, stress and anxiety levels, the degree of anger, despair, self-hate, dissociation, emotional distress experienced, and the trigger severity. Further, the testimonies highlighted that the method used, the area of the body injured, and the duration of self-injury sessions may also vary depending on the degree of emotional suffering or the trigger. Below are a handful of testimonies received on this topic:

What needs to be borne in mind from these testimonies is that while individual episodes of self-injury may serve as a useful yardstick for gauging the motivation behind a specific episode, it’s important not to lose sight of the bigger picture as self-injury is rarely a one-off occurrence. Further, the degree of emotional suffering should not be judged by the extent of the injuries as everyone’s pain threshold is different – in other words, minor wounds may reflect similar levels of internal anguish as more serious wounds. The degree of dissociation experienced at the time of self-injury may also affect the amount of harm done. (See Chapter 8 for further information on dissociation and self-injury).

Myth 10: Those who self-injure are a burden on society

Another assumption made about those who self-injure is that they are a heavy drain on society in terms of NHS time and resources. Whilst it’s true that some people who self-injure may be well-known to A&E staff and the psychiatric services, there are a huge number of people who make a determined effort to steer clear of seeking help, thus lining the pockets of the first aid and skin camouflaging manufacturers rather than burdening the NHS with meeting the cost of their treatment. Also extremely important to recognise is that many people who self-injure lead fruitful lives: home making, raising children, running their own businesses, or holding down other responsible jobs – in nursing, teaching, social work, caring for the elderly, to name a few jobs that Internet respondents reported doing. What also became apparent from the Internet respondents’ testimonies is that many who self-injure are high academic achievers, or gifted writers and artists. In essence, what came across clearly was that many who self-injure are hardworking people living ordinary lives.

Key points:

• Self-injury happens in a wide range of settings.
• Self-injury is more about attention needing than attention seeking. In the main, the act is carried out in private and the wounds and scars from self-injury are carefully concealed beneath items of clothing, jewellery, bangles, or sweat bands.
• Self-injury occurs in all age groups, and can affect people from all walks of life. It is not an exclusively teenage, all female phenomenon. Men self-injure too. Nor is it a new trend.
• Self-injury serves effectively as an outlet for tears that cannot be shed, for pain and grief that cannot be expressed, as self-punishment for ‘being weak’ and wanting to cry, to prevent tears from spilling over, or to block out emotional pain.
• Whilst self-injury has been linked to a range of psychiatric disorders, it doesn’t automatically indicate that people who self-injure are mentally ill. Nor is it an automatic sign of Borderline Personality Disorder.
• The question of whether self-injury is becoming contagious among young people needs further investigation.
• People who self-injure rarely seem to present a danger to others.
• Self-injury is not rooted exclusively in child abuse; it has a broad range of predisposing factors.
• Minor wounds don’t necessarily signify that an individual’s issues are not significant: it’s important to look at the overall picture rather than at specific episodes as self-injury is rarely a one-off occurrence.
• Those who self-injure are not always a burden on society. Many lead constructive and fruitful lives.