What Do We Know About Self-Injury? (page 3)
On this page
- What is self-injury?
- Who self-injures?
- How common is self-injury among adolescents and young adults?
- When does self-injury start and how long does it last?
- Why do people self-injure?
- Is self-injury a suicidal act?
- What factors contribute to self-injurious behavior?
- Is self-injury addictive?
- Is self-injury contagious?
- Are rates of self-injurious behavior increasing in the adolescent and young adult population?
- Detection, Intervention, & Treatment
Sometimes called "deliberate self-harm," "self-injury," "self-mutilation," "cutting," or "non-suicidal self-injury", self-injury typically refers to a variety of behaviors in which an individual intentionally inflicts harm to his or her body for purposes not socially recognized or sanctioned and without suicidal intent (Favazza, 1996). Self-injury can include a variety of behaviors but is most commonly associated with intentional carving or cutting of the skin and subdermal tissue, scratching, burning, ripping or pulling skin or hair, swallowing toxic substances, self bruising, and breaking bones. Tatoos and body piercing are not typically considered self-injurious unless undertaken with the intention to harm the body. Favazza (1996) identifies four primary forms of non-socially sanctioned self-injury: major, stereotypic, compulsive and impulsive. The first two forms are rare associated primarily with populations with significant psychiatric disorders. The second two are more common and are those most likely to be encountered in general populations of adolescents and young adults. Studies of self-injury characteristics in community populations show considerable variation in the frequency and forms of behaviors reported. For example, reported lifetime frequency varies dramatically – from single incidents to hundreds of incidents (Laye-Gindhu & Sconert-Reichl, 2005; Whitlock, Eckenrode, & Silverman, 2006).Similarly, although non-clinical samples often endorse a greater number of low-lethality forms than clinical samples (see Skegg, 2005), community studies show that individuals use a myriad of forms which vary dramatically in the capacity to cause tissue damage. Although cutting is one of the most common and well documented forms, over 16 forms have been documented in a college population (Whitlock, Eckenrode, & Silverman, 2006). Moreover, several studies have shown that the number of forms used by an individual varies significantly; from 1 to over 10 (Laye-Gindhu & Schonert-Reichl, 2005; Whitlock et al., 2006). Self-injury can be and is performed on any part of the body, but most often occurs on the hands, wrists, stomach and thighs. The severity of the act can vary from superficial wounds to those resulting in lasting disfigurement. Among respondents in a two college study, 1 in 5 self-injurious students indicated that they had hurt themselves more than intended at least once and 1 in 10 indicated that they had hurt themselves so badly that they should have been seen by a medical professional; only 6.5% had ever been treated for any of their wounds (Whitlock, et. al., 2006).
It is commonly assumed that females are significantly more likely to self-injure than males. Although multiple studies support this assumption (Laye-Gindhu & Schonert-Richl, 2005; Hawton, Rodham & Evans, 2006; Whitlock et al., 2006), there are other studies which suggest that males are equally likely to self-injure as females, particularly among non-clinical samples (Garrison, Addy, McKeown, & Cuffe, 1993; Gratz, 2001; Klonsky, Oltmanns, & Turkeheimer, 2003; Muehlenkamp & Gutierrez, 2004). Some of our recent works suggests that there may be different self-injury groups or "classes," one of which consists largely of men who use self-injury forms which can be described as "self-battery." Members of this class are likely to engage in these for shorter periods of time than the groups with more females than males but face heightened risk for other adverse conditions, such as suicidality and psychological distress, when compared to their non-self injurious peers (Whitlock, Muehlenkamp, & Eckenrode, 2007). Similarly, findings with regard to race and NSSI are mixed, with some studies suggesting that it may be more common among Caucasians (Bhugra, Singh, Fellow-Smith & Bayliss, 2002) and others showing similarly high rates in minority samples (Marshall & Yasdani, 1999; Whitlock et al., 2006). Although parallels between NSSI and eating disorders have led some to speculate that NSSI is likely to be most prevalent among middle and upper income individuals (Strong, 1999), no existing research supports this contention. Indeed, the link between self-injury and trauma would suggest that self-injury might be found in high rates among low income populations as well, an assumption supported by early work in this area (Favazza & Conterio, 1989).
Because it so often occurs in private, it is very difficult to identify one or more discrete self-injurer "profiles." Unless being treated for related conditions, such as depression or anxiety, detecting self-injurious individuals can be very difficult. Thus, most studies of self-injury have relied on samples in clinical settings being treated for other disorders (Brodsky et al., 1995). The few studies which have been conducted in U.S. community samples of young adults and adolescents are limited by small convenience-based samples and vary in estimates of self-injury prevalence from 4% to 38% percent (Briere & Gil, 1998; Favazza, 1996; Gratz, Conrad, & Roemer, 2002; Muehlenkamp & Guiterrez, 2004). A 2006 representative study of two universities showed a 17% lifetime prevalence rate with about 11% indicating repeat self-injury (Whitlock et al., 2006) and recent studies of high school populations in the US and Canada consistently show a 13 to 24% prevalence rate (Laye-Gindhu; & Schonert-Reichl, 2005; Muehlenkamp & Gutierrez, 2004; Muehlenkamp & Gutierrez, 2007; Ross & Health, 2002). Similarly, recent large studies in Britain estimate that approximately 10% of youth aged 11-25 self-injure (Young People and Self-Harm: A National Inquiry, 2004).
Self-injury can start early in life. Our research suggests that early onset self-injury is common around the age of 7, although it can begin earlier. Most often, however, self-injury behaviors begin in middle adolescence between the ages of 12 and 15 (see Yates, 2004 for review) and can last for weeks, months, or years. For many self-injury is cyclical rather than linear meaning that it is used for periods of time, stopped, and then resumed. It would be erroneous, however, to assume that self-injury is a fleeting adolescent phenomenon. Data from college studies suggest that 30% - 40% of college respondents report initiating self-injury while 17 years old or older (Whitlock, et. al, 2006). Although the majority of college students surveyed report stopping within five years of starting, it is also clear that the behavior can last well into adulthood. Whether or not there exist particular self-injury trajectories that vary based on age and context of onset is unclear but constitutes an important area for investigation.
Reasons given for self-injuring are diverse. Many individuals who practice it report overwhelming sadness, anxiety, or emotional numbness as common emotional triggers. Self-injury, they report, provides a way to manage intolerable feelings or a way to experience some sense of feeling. It is also used as means of coping with anxiety or other negative feelings and to relieve stress or pressure. Those who self-injure also report doing so to feel in control of their bodies and minds, to express feelings, to distract themselves from other problems, to communicate needs, to create visible and treatable wounds, to purify themselves, to reenact a trauma in an attempt to resolve it or to protect others from their emotional pain (Klonsky, 2007; DiLazzero, 2003). Some report doing it simply because it feels good or provides an energy rush (although few report doing only for these reasons). Regardless of the specific reason provided, self-injury may best be understood as a maladaptive coping mechanism, but one that works – at least for a while.
There are important distinctions between those attempting suicide and those who practice self-injurious behaviors in order to cope with overwhelming negative feelings. Most studies find that self-injury is often undertaken as a means of avoiding suicide. Perhaps one of the most paradoxical features of self-injury is that most of those who practice self-injury report doing so as a means of relieving pain or of feeling something in the presence of nothing. Nevertheless, the particular relationship between self-injury undertaken without suicidal intent and self-injury undertaken with suicidal intent are not clear since individuals who report the former are also more likely to report having considered or attempted suicide (Whitlock, Eckenrode, & Silverman, 2007; Muenhelkamp & Guitierrez, 2004; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein,, 2006; Hawton, Fagg, Simkin, Bale, & Bond, 2000;). Moreover, although it is common to assume that non-suicidal self-injury may be linked solely to suicidal ideation, a recent studies show that individuals with a history of non-suicidal self-injury were over nine times more likely to report suicide attempts, and seven times more likely to report a suicide gesture and nearly six times more likely to report a suicide plan than individuals without a history of non-suicidal self-injury (Whitlock & Knox, 2007). Nevertheless, since the majority of individuals with self-injury history report not considering suicide, non-suicidal self-injury may be best understood as a symptom of distress that, if unsuccessfully mitigated, may lead to suicide behavior.
In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse (Brodsky, Cloitre, & Dulit, 1995; Kolk, Perry, & Herman, 1991). In addition, there is evidence that earlier, more severe abuse and abuse by a family member may lead to greater dissociation and thus greater self-injury (Brodsky et al., 1995). Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders (see Yates, 2004, for review). The lack of empirical research in non-clinical populations reinforces the assumption that most or all of SIB is a product of pre-existing disorders, although more recent research in general populations of adolescent and young adults challenges this assumption (Kokaliari, 2004; Whitlock, et. al., 2006).
Most self-injury researchers agree that self-injury does show some addictive qualities and may serve as a form of self-medication for some individuals. In our recent research with college students, a significant number of individuals who practice self-injury report having a difficult time controlling their urge to self-injure and interviews conducted for several of the studies associated with this project shows that many self-injurers describe both the immediate effect and overall practice as something with addictive properties. For example, many interviewees talk about moments of feeling the strong need to injure even when there is no obvious trigger and about having "self-injury free" hours or days. They also liken it to other drugs and talk about needing increasingly more or deeper injuries to feel the same effect. Recognition of the addictive properties of self-injury for some individuals is the basis for the "addiction hypothesis" noted by Grossman and Siever (2001) and summarized by Walsh (2005). The addiction theory suggest that self-injurious acts may solicit involvement of the endogenous opioid system (EOS) which regulates both pain perception and levels of endogenous endorphins which occur as a result of injury (Winchel & Stanley, 1991). Overestimation of the EOS can then lead to actual withdrawal symptoms which in turn lead to more self-injurious behavior.
The seemingly rapid spread of self-injurious behavior among community populations of youth suggests that there may be a contagion factor at work. Indeed, self-injurious behavior has been shown repeatedly to follow epidemic-like patterns in institutional settings such as hospitals and detention facilities (Matthews, 1968; Taiminen et. al., 1998; Rosen & Walsh, 1989). For many, self-injury is a very private, hidden act. Over one third of respondents in our college study indicated that no one knew that they had self-injured and research confirms that the majority of habitual self-injurers discover it through private or accidental experimentation (Favazza & Conterio, 1989). However, anecdotal reports from adults working with youth in school settings report a fad quality to the behavior (Walsh, 2005; Whitlock & Purington, 2007; Heath, Toste, & Beettam, 2006), similar to that which occurs with eating disorders. Consistent with this, survey results of secondary school nurses, counselors and social workers suggest that there may be multiple forms of self-injury in middle and high school settings – some of which include groups of youth injuring together or separately as part of a group membership (Whitlock & Purington, 2007). Causes for the spread of the behavior in non-clinical populations have left many wondering what larger contextual factors might be at work. Our research suggests that the Internet and the increasing prevalence of self-ijnury in popular media, such as movies, books, and news reports (Whitlock, Powers, & Eckenrode, 2006; Whitlock, Purington & Gershkovich, in press) may play a role in the spread of self-injury.
This is impossible to know because we have no idea how common self-injury used to be in community populations of adolescents and young adults. There is broad consensus, however, among researchers and those who work directly with young people that the phenomenon is increasingly popular. In a recent survey we conducted of college mental health providers and secondary school counselors, nurses, and social workers, virtually all respondents indicated that self-injurious behavior has becoming increasingly prevalent in the last several years (Whitlock, Eells, Cummings, & Purington, 2007; Whitlock & Purington, 2007). In a recent decade long longitudinal cohort study of adolescent self-injury in Great Britain, researchers found a 28 percent increase in the number of adolescents who presented for self-injurious treatment at a general hospital in Oxford, England (Boyce, Oakley-Browne, & Hatcher, 2001). Although no such study has been conducted within the US, the presence of self-injury in new and popular forms of media, such as in newspapers, have increased dramatically in the past several years (Whitlock, Purington, and Gershkovich, in press). A 2004 Los Angeles Daily News article report maintained that referrals for cutting and other forms of self-injury within the Los Angeles Unified School District increased dramatically in a one year period and the School District's suicide-prevention hotline fielded 600 calls on self-mutilation in a single 18 month period (Radcliffe, 2004). Whether the increasing attention to self-injury is due to the fact that more youth are actually engaging in the behavior, to increased likelihood to seek help, or to an increasing ability among service providers to correctly identify and report the behavior is unclear. It may very well be a combination of all three.
Reprinted with the permission of the Cornell Research Program on Self-Injurious Behavior.
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