What distinguishes DSI from NDSH?

Direct self-injury (DSI) is self-inflicted harm to the body severe enough to cause superficial or moderate wounds and the damage is immediate and usually visible. The resulting injuries are not generally life-threatening, and the degree of severity varies from relatively minor wounds that heal reasonably quickly, to more severe wounds that result in permanent scarring. The word usually is emphasised because some people injure themselves internally, in which case the damage may not be immediately apparent to the human eye. Typically, those who

engage in self-injury are fully aware of the fact that they have injured themselves. Emphasis is placed on the word typically, however, because some people are not aware of hurting themselves until after the event, as witnessed in the following respondent’s testimony: ‘Often in the past I don’t realise I’ve done it [self-injured] until it’s all over. I have a history of severe dissociation.’ What does the respondent mean by dissociation? Essentially, dissociation is an unconscious psychological process in which a sense of detachment between mind and emotions, or mind and body, is experienced. Since dissociation plays a pivotal role in self-injury for some people, it is talked about at various places throughout the book.

Non-direct self-harm (NDSH) is different to DSI because inflicting harm is rarely the aim of NDSH, the damage is not immediately evident or visible, and individuals who engage in non-direct forms may be oblivious to, or in denial of, the long-term physical or psychological consequences of their actions, as in the case of alcohol misuse, smoking, and pill popping for example.

Grey areas examined

What about self-poisoning (overdosing) – surely that is self-injurious? What about the modern trend to adorn one’s body with piercings or tattoos – isn’t that considered self-injury? Further, what about individuals who intentionally starve themselves, or who binge and purge – don’t they count as self-injury? These fuzzy areas are examined next.

Self-injury is not usually carried out with suicidal intent

Self-injury is often misconstrued as a death wish or failed suicide attempt when in all actuality, those who engage in the practice have no desire to die. Indeed, self-injury for many is a life saver, rather than a life taker – in essence it keeps people safe from suicide. Clear evidence of the life-saving function served by self-injury can be seen in the respondents’ testimonies that follow:

As noted in the above statements, some individuals who self-injure do experience suicidal thoughts, and sadly on occasions some do commit suicide if life becomes intolerable or if self-injury loses its efficacy as a coping method. However, this tends to be the exception rather than the rule. It needs to be borne in mind nevertheless that self-injury is a risky activity, and accidental death may occur as a result of loss of blood from a severed artery, or from cutting deeper than intended.

Self-poisoning (SP)

Self-poisoning (overdosing) is one of the most common reasons for emergency hospital admission in the United Kingdom. You will note that self-poisoning is included in Figure 1.2 under non-direct self-harm, the reason being that self-injury is now well recognised as a coping mechanism and survival strategy, whereas the intention behind self-poisoning is less clear. For example, say an individual arrives at Accident and Emergency (A&E) following an overdose. Does the treating doctor or nurse know whether the person intended, yet failed to end his or her life? Without further investigation they cannot know for certain. It could be a botched suicide attempt, it could be an accident, it could be a cry for help, or it could be a means of temporarily escaping from emotional turmoil. Depending on the motivation, it could also mean that the patient requires a different treatment regime to the patient presenting with self-injuries.

A further significant difference between self-poisoning and self-injury is that the extent of the damage from self-poisoning is invisible, whereas with self-injury (unless the injuries are internal) the extent of the damage is immediately visible.

My research suggests that the incentive behind self-poisoning is usually different from the impetus that drives self-injury and respondents’ testimonies supporting this theory are given later in the book. However, separating self-poisoning from self-injury is at odds with other researchers in the field, particularly UK researchers, many of whom group self-poisoning and self-injury together under the terms self-harm or deliberate self-harm. That said, it was reassuring to read recently that London based consultant psychiatrist, Leonard Fagin (Fagin, 2006) shares a similar view to my own – he writes: ‘I see self-injury as different from self-poisoning’ adding that ‘I believe

that people who poison themselves have different characteristics from those who injure themselves.’ This controversial issue is discussed further in Chapter 4. Figure 1.3 highlights the differences between self-poisoning and self-injury and illustrates how the two behaviours are grouped together by some researchers under the broad terms self-harm or deliberate self-harm.

Self-injury is not usually carried out with sexual intent

The motivation behind external sexual self-injury is usually aimed at stimulating sexual arousal and achieving orgasm, rather than the goal being to regulate emotional pain. Two out of eighty-two Internet respondents did, however, mention using sadomasochistic practices to alleviate emotional distress, which suggests that it may occur occasionally but is the exception rather than the norm. The reason emphasis has been placed on external is to distinguish the practice from internal self-injury which, as demonstrated later, serves a very different function.

Sexual masochism and sexual sadism are classified as paraphilias in DSM-IV-TR, along with hypoxyphilia (more commonly known as autoerotic asphyxiation or sexual hanging) (pp. 572–574). For clarification purposes these are explained briefly below.

• Sadomasochism (S&M) Sadomasochism is the combination of two words: sadism and masochism. Sadism refers to a person who gains sexual satisfaction and pleasure by inflicting pain and suffering on another person. The term sadism originated from the infamous French author and sadist, the Marquis de Sade (1740–1814). In contrast, masochism refers to a person who gains sexual satisfaction and excitement by enduring pain inflicted by another person. Sadomasochism refers to a person with a penchant for both sadism and masochism.
• Hypoxyphilia (autoerotic asphyxiation) Hypoxyphilia is a ‘dangerous form of Sexual Masochism’ which may be carried out ‘alone or with a partner’ (DSM-IV-TR: 572–573). Characteristically, a ligature is applied round the neck while the individual reaches orgasm. The decrease of blood to the brain is believed to intensify sexual excitement.

Self-injury is not usually carried out with decorative intent

Body modification has become an increasingly popular trend, especially amongst young people, and the question of whether it should be classified as self-injury is a hotly debated issue. As discussed here, body modification refers to piercing; tattoos; branding (creating a permanent design or image on the skin with a hot object – a process not unlike branding cattle), and scarification (similar to tattooing – involves cutting of the dermis [the second layer of skin] to produce permanent marks). Some argue that any form of body modification is self-injury; some make a clear distinction between the two; others (for example see Lader 2006) consider the dividing line between the two is thin.

The case against body modification being classified as self-injury

Many consider that body modification is rarely undertaken with the intention of hurting oneself, suggesting that the purpose has more to do with making a fashion statement, expressing individuality, to be accepted by peers, to rebel against conformity, or to enhance the appearance of the body. Moreover, people who choose to get their bodies modified generally do so with the aim of making themselves look different, to ‘stand out in the crowd’, or to improve their self-image, and opt to display their decorations with pride. This contrasts with self-injury which is rooted in shame and feeling different, thus, the scars are typically kept hidden. A further clarifying feature proffered is that with body modification the injuries inflicted are done by another person, whereas with self-injury the injuries inflicted are done to oneself.

Examining the thin dividing line

The question of whether the purpose of body modification might share any similarities with the reasons for self-injury has puzzled me for some time, and prompted an invitation to the Internet respondents to express their views on the topic. This produced some important insights, demonstrating clearly that body modification and self-injury are indeed bedfellows for some people. As this subject does not appear to have been widely discussed in the literature, rather than reporting second-hand the opinions articulated, you may be interested to read what the respondents had to say, thus a range of comments are given next:

Reviewing potential links

Figure 1.4 outlines potential links between body modification and self-injury identified from the respondents’ testimonies. Important to remember, however, is that a different picture might emerge if a group of people with no experience of self-injury were invited to express their opinions on the subject. The question also remains as to why so many people, young and not so young, are subjecting their bodies to the pain of not just one or two attractive pieces of body art, but to multiple, or head to foot, tattoos and piercings.

Disordered eating

Eating issues is another blurred area, which has been placed under NDSH in Figure 1.2, for the reason that the damage caused through disordered eating usually shows itself longer-term rather than immediately as in the case of direct self-injury. Certainly, there’s no question that eating disorders can be life-threatening and do result in loss of life. For example, much adored musician and singer, Karen Carpenter tragically died prematurely from anorexia at the age of 32; another casualty was child singing prodigy Lena Zavaroni who died at age 35, after a twenty two year battle with anorexia. Prior to her death she underwent an operation aimed at helping her to eat, but contracted an infection, sadly from which she wasn’t robust enough to recover.

No single cause has been established for the development of eating disorders, and their origins are complex. Research suggests that the following components may have some bearing on the development of an eating disorder:

• Biological factors – an inherited predisposition to an imbalance in serotonin (a brain neurotransmitter involved in a broad variety of tasks such as mood, appetite, hormonal balance).
• Socio-cultural factors – portrayal by the media that thin is beautiful, peers and/or family members’ jibes about being overweight.
• Psychological factors – anxiety, depression, low self-esteem, etc.
• Family dynamics – overprotective or controlling parents, high expectations to achieve and succeed, communication problems, a parent’s attitude/behaviour towards food.
• Personality traits – perfectionism.

Contributory factors to eating disorders identified from the small sample group findings for Healing the Hurt Within, 1st edition (Sutton, 1999. p. 206) included:

• Childhood abuse.
• Body shape not the media norm.
• Repulsed by own body.
• Obsessed by food/appearance/weight/shape.
• Marital conflict.
• Parents’ separation.
• Parental pressures.
• Lack of control over one’s life.
• Difficulties with boundary setting.
• Stress, depression, low self-esteem, anxiety, panic, self-hate, and lack of self-confidence.
• Feelings of powerlessness and worthlessness.
• Insecurity and rejection.

Functions served by eating disorders were identified as:

• Self-punishment.
• Self-control.
• Comforting, treating/rewarding self.
• Punishing others.
• A distraction from mental anguish.
• Relaxation.
• Produces a ‘high’.

These findings echo similarities with some of the motivations and functions served by self-injury. However, a marked difference between eating disorders and self-injury is that whilst those who self-injure tend to recognise that their behaviour is not the norm, those with eating disorders may not perceive their actions as harmful.

Summary

Thus far a range of issues have been addressed. The subjects of terminology, what characterises self-injury, what behaviours self-injury encompasses, and what distinguishes direct self-injury from non-direct self-harm have been examined. Attention has been given to several grey areas, namely: self-poisoning, sexual self-injury, body modification and disordered eating. Also highlighted is that the motivation to self-injure stems from a need to cope with unbearable psychological distress and to regain a sense of emotional stability, further that the act is usually carried out without suicidal, sexual or decorative intent.

Defining self-injury

This seems like an appropriate place to introduce you to a definition of self-injury, compiled in collaboration with the Internet respondents, and deemed to be the most accurate from nine draft definitions circulated for debate.

Self-injury is a compulsion or impulse to inflict physical wounds on one’s own body, motivated by a need to cope with unbearable psychological distress or regain a sense of emotional balance. The act is usually carried out without suicidal, sexual or decorative intent.
—Sutton, et al. (2000)

Compulsive self-injury

With compulsive self-injury, individuals experience a strong urge to inflict injuries on themselves – as one respondent explained, a compulsion is like ‘the brain flashing the message “do this, do this, do this, do this ...”’ Characteristically, compulsive self-injury stems from an irresistible craving to perform the act. Fuelled by fear of a disastrous outcome if the act is not carried out, individuals who engage in compulsive self-injury feel they have no other choice. On completion of the act, anxiety or other distressing symptoms experienced before the act are reduced, and a sense of improved well-being ensues. However, invariably, this enhanced feeling of well-being doesn’t last, and individuals find themselves repeatedly returning to self-injury to alleviate overwhelming emotional pain, thus getting caught in a vicious circle. Those who self-injure compulsively often become preoccupied with thoughts of hurting themselves even when not actively engaging in the process.

Impulsive self-injury

With impulsive self-injury the act is carried out spontaneously, with no previous planning and little thought to aftercare or the consequences. Instead of the ‘brain flashing the message “do this, do this, do this, do this ...”’ which can drive a compulsion, an impulsive act is driven by the ‘brain flashing the message “do this ”’ says the same respondent. Impulsive self-injury may be carried out occasionally when the need arises, rather then repetitively as is often the case with compulsive self-injury. Self-injury episodes carried out under the influence of alcohol are frequently of an impulsive nature. The following respondents’ testimonies clarify their views on whether they consider self-injury is compulsive or impulsive. From their comments you will see that an overlap between the two is not uncommon.

When asked if their most recent episode of self-injury was planned or unplanned, fifty four percent (54%) of the respondents reported planning the episode in advance, while a slightly lesser percentage, forty six percent (46%) reported that the episode was unplanned.

Repetitive self-mutilation (RSM): Proposed criteria

Favazza (1996: 253–254) argues a case for repetitive self-mutilation (RSM) to be listed in the DSM ‘on Axis 1 among the “impulse control disorders not elsewhere classified.”’ He hypothesises that self-injury ‘results from a failure to resist an impulse,’ and that those who self-injure ‘may brood about harming themselves for hours and even days and may go through a ritualistic sequence of behaviours, such as tracing areas of their skin and compulsively putting their self-harm paraphernalia in a special order.’

Several of the above respondents’ testimonies support Favazza’s theory that prior to self-injury the act may be dwelled upon for some time, further that a series of rituals may be engaged in beforehand such as careful planning and preparation, with relevant aftercare equipment being purchased in readiness. As confirmed by another respondent: ‘I mostly have a ritual, and I’ll plan and buy the necessary stuff (gauze, antiseptic) before.’ Other rituals may also be involved – these are now discussed.

Self-injury rituals

As well as planning self-injury in advance, spending time preparing, and taking preliminary precautions to reduce the risk of infections, the environment may be set up to lend an air of comfortable familiarity or certain ambiance to the proceedings. Objects for self-injuring (knives, razors), clean towels and aftercare equipment (bandages, steri-strips) may be laid out in a clinical fashion. Curtains may be drawn, lights dimmed, scented candles lit, and some melancholic music might be playing softly in the background.

Self-injury may be performed in a specific room (bedrooms and bathrooms appear to be common), or carried out at a certain time of the day – evenings and night time seem to be particularly common. Factors that may have a bearing on why it happens during these times may include the need for privacy, to avoid the risk of being discovered, anxiety about getting to sleep, fear of the dark or fear of being alone. Insomnia is a problem for many who self-injure. For trauma survivors who self-injure, evenings and night times are frequently a time of heightened anxiety, dread, and hypervigilance (many adult abuse survivors sleep with a light on). Self-injury acts like a sleeping pill – it calms people down and enables them to get to sleep – in other words, it’s easier to sleep with physical wounds than with painful traumatic memories, nightmares, night terrors, intrusive thoughts, fear-provoking images or overwhelming feelings. The emotional release from self-injury also appears to make people physically tired. In the following testimonies respondents describe what happens following self-injury. Several, as you will see emphasise the sleep-inducing characteristic of self-injury; others highlight that sometimes people are kinder to themselves following an episode:

In the following testimonies the respondents are explaining what they did after their most recent episode of self-injury:

Judith Herman, in her landmark book Trauma and Recovery (1992: 109) suggests that: ‘Self-injury is perhaps the most spectacular of the pathological soothing mechanisms ...’

Bearing in mind the respondents’ above comments, it certainly seems as if there is a comforting element in the act for some people.

Symmetry, symbols and dates

While self-injury rituals hold important meanings for some people, to others, carving names, symbols, or dates on their skin to remind themselves of significant people, events or tragedies that have occurred in their lives appears to be a noteworthy factor. Order and symmetry also seem to be imperative to some, for example they will make a specific number of cuts, equal the number of cuts on their arms, legs or torso, or cut a series of lines of equivalent length.

Obsessions related to symmetry, exactness and order are frequently associated with Obsessive Compulsive Disorder (OCD). To those who suffer from OCD things that are asymmetrical or imprecise can lead to marked distress.

Elaborating on the meaning of obsessions and compulsions

An obsession is a persistent intrusive thought, idea, impulse or image that enters a person’s mind and which causes significant unease or anguish. The individual may endeavour to stifle the obsessive thoughts or to defuse them by taking ‘compulsive’ action in response to the fixated thoughts, such as arranging things in a certain order, repeatedly checking the cooker to ensure it is switched off, continually checking doors and locks, or repetitively washing one’s hands or counting things. Individuals recognise that the thoughts stem from their own mind, but feel driven to perform a compulsive action against their will to relieve the anxiety caused by the thoughts, or to thwart a feared occurrence or situation.

Putting self-injury into context with other self-harming behaviours

In many ways self-injury serves a similar function to other harmful behaviours. For example, some people seek solace in alcohol to escape from stress while others chain smoke or comfort eat. Individuals who self-injure turn to their ‘tools’ as a means of preventing the ‘emotional melting pot’ from boiling over. Some injure periodically when the pressure gets too great and threatens to overwhelm; others do it on a regular basis to manage tension and stress (whether internally generated or situational).

A marked dissimilarity

An essential difference that is noteworthy, however, is that while many people imbibe a few glasses of champagne or similar, or overindulge on food to celebrate a happy occasion such as a wedding or anniversary, some people who use self-injury respond to happy events by hurting themselves, so strong is their belief that they are ‘bad’ and undeserving of happiness.

Discussion

Self-injury is a phenomenon that society finds hard to understand and accept – it would prefer that it didn’t exist. Yet sadly it does exist, moreover, it is much more common than generally realised. If society finds self-injury an uncomfortable issue to deal with, and would prefer to sweep it under the carpet, where does it leave those trapped in the behaviour? Many stay locked in a world of isolation, secrecy, shame, and silence, afraid to speak out lest they be judged and condemned.

Just as society has come to accept that substance misuse, eating disorders, and child abuse are serious problems in our midst, it must open its eyes and heart to the truth about self-injury – that it does exist, that it is a serious problem, and that it causes immeasurable suffering not only to those caught in its clutches, but also to those supporting someone that self-injures.

Self-injury isn’t an illness children are born with. It is a behaviour that develops to cope with life’s pressures and ills. Acceptance, awareness, education and empathy are crucial to enable those suffering in silence to step out of the closet of secrecy and shame, and to receive the help they need and deserve. Furthermore, as a society we have a responsibility to address the issue of why self-injury is becoming so prevalent in our midst.

Key points

• Self-injury is an expression of acute psychological distress.
• Self-injury is a coping mechanism. It transfers emotional pain into physical injuries that people find easier to deal with.
• Self-injury is an insurance policy to safeguard survival, rather than an act designed to end one’s life.
• Self-injury is not usually carried out with suicidal, sexual or decorative intent.
• Self-injury is referred to by a plethora of terms which causes confusion.
• Self-injury can be compulsive or impulsive – sometimes there is an overlap.
• Once started, self-injury often develops into a habitual pattern.
• Self-injury involves rituals for some people.
• Symmetry and order are important to some people that self-injure.
• The wounds from self-injury are rarely life-threatening.
• Self-injury does not occur in a vacuum – there are reasons why people self-injure, although they may not always be immediately aware of the reasons.
• Self-injury is symptomatic of an underlying problem. Recovery requires looking beyond the visible injuries and healing the invisible internal wounds.
• Letting go self-injury is not an easy process.