Self-injury manifests itself in symptoms such as scratching or cutting yourself. Self-injury occurs when people deliberately injure themselves. Self-injury or self-harm mainly involves cutting. Patients injure themselves with all available means, such as scissors, knives, glass, drawing pins and even their nails. It is difficult to understand behavior. People do not injure themselves to manipulate their environment. That is a widespread misunderstanding. Self-injury is a functional behavior for the person who does it and is therefore difficult to change. Left untreated, self-injury and self-harm can lead to all kinds of complications. The cause of self-harm often consists of a combination of genetic, environmental and psychological factors.
- Self-harm in psychiatric patients
- Terms: self-injury, self-harm and self-mutilation – a definition
- Self-injury
- Self-harm
- Self-mutilation
- Preventing self-harm
- Symptoms of self-harm and self-harm
- Behavioral symptoms
- Physical symptoms
- Cognitive symptoms
- Psychosocial symptoms
- Reasons and causes (motives) of self-injury
- Reducing and channeling intense emotions
- Breaking numbness
- Triggers of self-harm
- Consequences of self-harm
- Positive consequences of self-harm
- Negative consequences of self-harm
- Recommendations for practice
- To understand
- Discuss
- Seek behavioral alternatives
Psychotherapy for self-injury / Source: Wavebreakmedia/Shutterstock.com
Self-harm in psychiatric patients
The Mental Health Monthly Magazine (MGv) no. 5 from 2011 contains a review of qualitative research into patients’ motives and consequences regarding self-injury from the patient’s own perspective.¹ From what patients themselves say about it, advice can be derived for a different approach to the problem.
Why do patients harm themselves? What motivates them to scratch their arm or other body part with a thumbtack or knife? The article in MGv describes the reasons and motives of patients, as well as the behavioral triggers and the positive and negative consequences of the behavior.
Terms: self-injury, self-harm and self-mutilation – a definition
The terms self-injury, self-harm and self-mutilation are often used interchangeably. However, there are important differences.
Self-injury
Self-injury is behavior in which someone repeatedly and directly inflicts mild to severe injuries to the surface of their own body. This has a low chance of a fatal outcome and is done without suicidal intent.
Self-harm
Self-harm is a more general term that also refers to actions in which the person causes indirect harm to themselves, such as taking an overdose of medication or consciously engaging in risky behavior where the risk of damage to the body is very high.
Self-mutilation
self- mutilation is a commonly used medical term reserved for those actions that are seriously mutilating and that often take place under the influence of psychotic episodes. This could include amputating body parts, such as the penis.²
Preventing self-harm
Research shows that care providers often come into contact with self-injury and an estimated 33% of patients with a psychiatric diagnosis injure themselves. This figure may even be higher. It occurs among all age groups. It often starts around the age of 12 and the prevalence is highest in the age group 18 to 25 years. It is a misunderstanding that more men than women injure themselves. Recent research shows that just as many men as women do this. Nor is it reserved for a particular ethnic group. It occurs in all ethnic groups.
Symptoms of self-harm and self-harm
It can be very difficult to discover that a loved one or friend is engaging in self-harming behavior because it is often done in private. The symptoms of self-harm depend on the methods a person uses and can include:
Behavioral symptoms
Symptoms of self-harm include:
- wear long pants and long-sleeved shirts, even on hot days
- often dismiss injuries as an ‘accident’ or as a result of clumsiness
- need a lot of time to be alone
- difficulty with friendships and intimate relationships
- keeping sharp objects or tools at hand with which someone could injure themselves
- withdrawing from activities in which someone previously participated
- unpredictable, impulsive behavior
Physical symptoms
Physical symptoms of self-harm include:
- scars
Bruising can be the result of self-injury / Source: KoS, Wikimedia Commons (Public domain)
- fresh scratches or cuts
- bruises or bruises
- broken bones
- places without hair
Cognitive symptoms
Cognitive symptoms of self-harm include:
- asking ongoing questions about personal identity
- helplessness
- hopelessness
- worthlessness
Psychosocial symptoms
Psychosocial symptoms of self-harm include:
- emotional flatness
- emotional instability
- mood swings
- depression
- increased feelings of anxiety, especially if self-injury fails
- debt
- shame
- horror and aversion
Reasons and causes (motives) of self-injury
Reducing and channeling intense emotions
First, self-harm is a strategy to make unbearable emotions bearable. Patients who self-injure experience intense feelings of emotional pain, loneliness, anger, etc. These emotions build up until, in the patient’s experience, they almost explode. Self-injury is a way to regulate these emotions. The self-injury has a discharging effect. The built-up emotions find their way out in cutting or scratching.
Breaking numbness
Opposite to this is the experience of numbness that patients experience. This includes concepts such as alienation, living in a fog and a strange, machine-like feeling. They are out of touch with their emotional and physical needs and wants. Patients in this state feel numb, numb and restless. Self-injury is a way to eliminate this (self)alienation. Patients find
the physical pain that self-injury causes more manageable than the emotional pain they experience.
Triggers of self-harm
Patients cite memories of psychological trauma, such as the death of important people or sexual abuse, as important triggers of self-harm. In certain studies, patients also make a direct connection between their psychiatric disorder and their self-injurious behavior. The patients then see this behavior as a symptom or inevitable consequence of, for example, the borderline personality disorder or depression from which they suffer.
Alcohol as self-medication / Source: Istock.com/AndreyPopov
Substance use can worsen self-injurious behavior, the patients said. Alcohol and/or drugs are often used as a kind of self-medication and to escape from the dominant negative emotions. However, alcohol and drugs also lead to reduced impulse control, which lowers the threshold for self-injury.
Consequences of self-harm
It goes without saying that self-injurious behavior has consequences for the patient and his or her environment. These consequences can in turn be a reason and motive for self-injurious behavior, which leads to a negative spiral. A distinction is made between positive and negative consequences.
Positive consequences of self-harm
A positive consequence of self-injury is the (temporary) feeling of relief. It leads to a rapid reduction of tension. They are momentarily freed from the overload of emotions or their state of numbness. The pain is gone; they can cope with the situation again and they are able to contact the world around them again.
A second, sometimes unintentional, effect of self-injury is that their pain, sadness or anger is made known to those around them. Self-injury can be a way to direct contacts with the environment and to gain attention for their underlying emotions.
Finally, self-injury gives patients a sense of autonomy and control over their own lives.
Negative consequences of self-harm
Guilt is a possible negative consequence of self-injurious behavior. In addition, the visible scars can evoke negative behavior in the outside world. It can also lead to stigmatization. These reactions can cause emotional dysregulation in the patient.
Self-injurious behavior is a patient’s survival strategy to avoid being overwhelmed by intense emotions or to relieve numbness when it threatens to become too much. Care providers are sometimes inclined to see this behavior as something that needs to be stopped as quickly as possible. The patient should act normally. But it’s not that simple. Such an attitude is also not desirable. The alternative to self-harm for patients is a total loss of self-control, which can lead to decompensation and possibly even suicide. Self-injury is inadequate but effective. Despite all the shipwreck and damage that a patient has suffered in his or her life, he or she regains control over himself and the environment through self-injury.
Recommendations for practice
Control-oriented interventions by care providers can be counterproductive. According to the authors of the article in MGv, self-injury can better be seen as a form of indirect communication, an indirect message. What recommendations do they give on how to deal with self-injury in care practice?
To understand
It is first of all important that care providers try to understand the function and meaning of the patient’s self-injurious behavior and what underlying problems are present. An open attitude, the relationship between care provider and patient and empathy are important concepts.
Discuss
Second, the authors recommend that care providers discuss the motives for self-harm with the patient. Direct and open communication about this behavior can potentially prevent the patient from attempting to initiate contact through self-harm. The care provider must show that he or she recognizes the patient as a valuable person despite his or her behavior.
Seek behavioral alternatives
Third, the care provider must work with the patient to look for behavioral alternatives to self-injury. This is no small feat, as self-injurious behavior is extremely powerful and functional. Having patience and a persistently stimulating attitude are indispensable.
Notes:
- S. Verschueren, N. Kool-Goud Sword, M. Kroes & B. van Meijel. Self-injury from a patient perspective . MGv, 5, 2011, 319-329.
- Vandereyken, W. (2001). Tackling self-injurious behavior in psychiatric patients . Psychopraxis, 3, 94-98.
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