Self-mutilation is essentially the thorough, intentional, non-suicidal damage or amendment of a person’s own body. Self-mutilation is a disorder that can be described by using many different terms such as self-injury, self-harm, self-injurious behavior syndrome (SIBS), or the deliberate self-harm syndrome.
Self-mutilation has been a problem that has existed for a long time. However, it has only been recently that this issue is being recognized more clearly in regards to research, media attention, publications, and those seeking treatment for this problem. Self-mutilation is becoming a serious problem among adolescent girls especially. Many mental health and medical health professionals and experts strongly believe that Self-mutilation is one of the most rapidly growing problems among adolescents. Unfortunately adolescent girls have a common and frequent complaint regarding self-mutilation and the numbers of adolescents in general that self mutilate is growing by the week. In a study that was conducted in the 1990’s, nearly 800 California high school psychologists were surveyed and it was found that each psychologist knew of at least 2 students per high school who self-injured (Turner, 2002).
It is becoming too common for girls nowadays to deal with their emotional and internal conflicts and pain by harming, injuring, or mutilating their bodies by means of picking their skin, cutting themselves with sharp objects like razor blades or knives, and burning themselves. Those are just a few ways girls mutilate themselves. Self-mutilation has indeed become a widespread problem. In the way that depression can be considered internal anguish, Self-mutilation can be considered internal psychic pain that exists in the most physical manner possible (Strong, 1998).
Why do girls deal with their pain this way? First of all, girls nowadays are more stressed about numerous factors in their life and have less truly effective strategies to cope with such stress. Girls also have fewer reliable resources, both internal and external. Once teenage girls initially injure themselves, the behavior is likely to continue because it becomes cathartic. Injuring themselves allows girls to calm down and ultimately relax (Levenkron, 1998).
Within 1983, Mansell Pattison anticipated that a classification of Self-mutilation needed to be created or developed based upon how direct the harmful behavior was on one’s self, how frequent the behavior occurred, and the severity of the behavior’s damage or lethal potential. Such a classification has finally been developed by Armando Favazza, M.D. and two psychiatrists, Daphne Simeon and Richard Rosenthal. Self-mutilation now exists in three types which are major Self-mutilation, stereotypic Self-mutilation and moderate or superficial self-mutilation (Strong, 1998).
Major Self-mutilation is not very common and includes infrequent behaviors that are extremely harmful such as castration, eye nucleation (removal of one’s eyes), and even amputation of an individual’s own limbs. Major self-mutilation often exists in conjunction with psychosis, alcoholism, and drug intoxications, and also is found in transsexuals. Explanations for such extreme behavior are usually based on sexual or religious themes. Examples include a desire to be of the opposite sex or adhering to a bible verse regarding tearing out the eye of the offender or cutting off the offender’s hand (Strong, 1998).
Stereotypic self-mutilation often occurs within those who are severely or moderately mentally retarded, autistic, or who suffer from Tourette’s syndrome. Stereotypic self-mutilation describes repetitive, monotonous, and many times rhythmic acts such as hitting, self-biting or head and wrist banging. The most common type of self-mutilation, especially among adolescent girls is moderate or superficial self-mutilation. This type of self-mutilation exists in all social classes throughout the entire world. Superficial self-mutilation usually begins in the early years of adolescence. The most common acts are skin scratching or picking, hair-pulling, skin-cutting, burning, carving, needle sticking, wound healing interference, and bone-breaking. Skin-scratching or picking and hair-pulling are compulsive acts while the rest such as cutting and burning are episodic yet repetitive acts. In fact, skin cutting and burning are the most common acts of all self-mutilation (Strong, 1998).
All of these acts are acts of morbid self-help because they provide the individual with temporary yet rapid relief from anxiety, racing and sometimes inappropriate thoughts, depersonalization, and severely fluctuating feelings or emotions. Those who self-mutilate, especially young girls feel as if they are the only ones who behave in this manner and that no one understands what they are going through which adds to the stress of the situation. Self-mutilation in our society has been trivialized, misidentified as attempts of suicide, regarded as a symptom of a mental disorder and misreported by both the public and the media (Pipher, 1994).
Journalist Marilee Strong, author of A Bright Red Scream, sums up the reason for self-mutilation perfectly by stating, “These people hurt themselves not really to inflict pain but, astonishingly enough, to relieve themselves of pain-to soothe themselves and purge their inner demons through a kind of ritual mortification of the flesh. Rather than a suicidal gesture, cutting is a symbol of the fight to stay alive” (Strong, 1998. p.xvii). Self-mutilation is many times connected to Borderline Personality Disorder and Post Traumatic Stress Disorder. Many studies have shown that another common reason for such internal pain that leads to self-mutilation is early childhood abuse, usually sexual. Child abuse is very commonly found within patients of self-injury. For those people, self-mutilation allows them to reclaim control over themselves and their body. In a case study regarding a 30 year old woman who constantly cut an 8-inch wound on her abdomen, she had stated in a therapy session that, “It was like I was trying to cut myself open. I might as well have been the father who was beating me.” (Strong, 1998. p.159). In 1989, Armando Favazza conducted a study consisting of 240 females who self mutilated. Of those 240 females, 62 percent reported experiencing child abuse and 61 percent announced that they had, at some point in their life, suffered from an eating disorder (Turner, 2002).
It is very common that sometimes self-injury exists in correlation with other addictive behaviors such as problems with drugs and alcohol or eating disorders. Some studies have implied that about 35 percent of anorexics and 41 percent of bulimics are also involved with the act of self mutilating. In the year 2000, it was found that there was a high frequency of Self-mutilation among 236 patients from a hospital’s unit for eating disorders. Any form of Self-mutilation was reported in approximately 60 to 75 percent of the patients. Nearly 13 to 17 percent of the patients were reported to have cut themselves or burned themselves. Hair-pulling existed in 31 to 44 percent of the patients and extreme nail-biting occurred in 31 to 50 percent of the patients (Turner, 2002).
Self injury and eating disorders are connected in many ways. Both problems usually exist within adolescent girls. Also, the symptoms of both Self-mutilation and eating disorders have a self-cleansing and mentally cathartic function that regulates the person’s tension and anxiety. It fills the emptiness that people feel and truly numbs their pain. Sufferers of both problems also have severe control issues. They have an intense need to control their bodies by any means necessary and they both have the potential to become highly addictive behaviors (Turner, 2002).
Those who self-mutilate by cutting themselves are known as cutters. They cut their skin to change their moods. Cutters use knives, razor blades, glass, needles, and other sharp objects cut themselves, usually on their arms. Sometimes they cut daily, sometimes weekly, or less often. Self-mutilators are very attached to the feelings they exhibit through their skin. For them, skin is how they feel, communicate, and it also signals reactions. Skin ultimately tells a story; it is their personal private diary or journal (Strong, 1998). Mutilators keep their habits to themselves in fear that they will be ridiculed or labeled crazy or psychotic. This is why most times self-mutilators harm themselves in places that can be covered or hidden with clothing such as the upper arms, thighs, or their stomach. Many cutters resort to wearing long-sleeved shirts because arms are the most common part of the body that is cut or burned during acts of self-mutilators. Those who self-mutilate are many times intelligent, creative, talented perfectionists who push themselves too hard and hide their pain behind a simple smile (American Academy of Child and Adolescent Psychiatry, 1999).
Self-mutilators can be found in prisons, foster home, hospitals, the best most wealthy of neighborhoods, and in the workplace, private schools, and prestigious colleges. Many reported self-mutilators are doctors, lawyers, teachers, nurses, singers, artists, poets, teenagers and even grandparents. In a study of junior high school girls in a prestigious private school, each girl that was surveyed claimed they knew another girl who self-mutilated. This serious problem is more common among females than males and is becoming a major issue among adolescent girls throughout the country (Levenkron, 1998).
One well known cutter was Princess Diana. She admitted in 1995 that self-mutilation was a problem, along with eating disorders, that were difficult issues that she struggled to deal with. In regards to cutting, Princess Diana, in a television interview, stated “You have so much pain inside yourself that you try and hurt yourself on the outside because you want help” (Strong, 1998. p.19). The fact that Princess Diana had the courage to admit that this was a serious problem that she constantly struggled with really was what shed public light on this problem within society. It showed other mutilators, especially girls, that they were not alone and that it is okay to admit that they have a problem.
The scars from self-injury are also extremely important to self-mutilators. Scars are extremely symbolic. They are permanent reminders not of pain and pure injury, but of healing. Self-mutilation serves many purposes for those who exhibit the behavior. It is a cry for help, an outlet for built-up anger, a way to self-punish, a method for reducing trauma emotionally, a way to stimulate the body, a way to feel anything other than emotional despairs, and a way to remind them that they are indeed alive.
Adolescence is one of the most difficult times in any girl’s life. They must learn to accept and acknowledge their changing bodies and new gain new anxieties regarding the responsibilities of becoming an adult. Since girls cannot control their bodies any longer and cannot control their menstrual bleeding so many girls cut themselves because the bleeding that they cause, they also can control. Adolescent self-mutilators are also usually having conflicts over their sexual identity. Self-mutilation, while not proven to be one, is often described as an addiction. This explains why many times self-mutilation in adolescent girls exists along with eating disorders (Favazza & Conterior, 1989).
Many psychiatrists refer to Self-mutilation as deliberate self-harm or DSH (Klonsky, Oltmanns, & Turkheimer, 2003). What is known about DSH has come from research conducted within patient populations. The most common type of DSH is cutting, which occurs in about 70% of those persons who deliberately self harm. Between 21% and 44% of individuals who harm them do so by banging or hitting, and 15% – 35% intentionally burn their skin. The majority of individuals who harm themselves employ more than one type of self-injurious behavior. The typical age that self-injurious behavior begins is usually between 14 and 24 years old. Studies have honestly been unclear as to whether self injurious behavior is more common in men or women, but many researchers believe women are far more likely to partake in this behavior than men (Klonsky et al, 2003).
Much of the research that has been conducted on DSH has mainly focused on forensic and clinical populations. By studying only those individuals who have serious psychopathology, the estimates of the correlation between self harm and psychiatric disorders may be inflated. A study was conducted by the University of Virginia’s Psychology Department which examined the correlates and prevalence of DSH in a group of subjects who were non-clinical. The participants used within this study were 1,986 Air Force recruits. The results showed that approximately 1 out of every 25 participants reported some type of self-harm in their history. Those who reported self harm exhibited more symptoms of various personality disorders than those who were non self harmers. Their performance on tests also suggested high levels of anxiety which plays a major factor in their psychopathology (Klonsky et al. 2003).
The participants of this study had a mean age of 20, with a standard deviation of 5 years. The mean of their IQ was 104. Ninety-nine percent were high school graduates. The racial makeup of the participants was as follows: 65% Caucasian, 17% African American, 4% Hispanic, 3% Asian, and 1% Native American and 10% reported their race as ‘other. The schedule for Non-adaptive and Adaptive Personality Tests was administered to all participants. This questionnaire is made up of 375 true/false statements and was created to assess various trait dimensions in the area of personality pathology (Klonsky et al. 2003).
Two specific statements from this questionnaire were used to assess and measure DSH. These statements were, “When I get tense, hurting myself physically calms me down” and “I have hurt myself on purpose several times”. Participants who answered true to either of these statements were considered to have a past history of DSH. It is important to note that participants who answered true to “I have tried to commit suicide” were excluded from this study because self-mutilation is separate from suicide or any suicide attempts. Participants of this study were also administered the Peer Inventory of Personality Disorders (assesses personality traits and pathology), the Beck Depression Inventory and Beck Anxiety Inventory (measures depression and anxiety respectively). The results of these tests showed 2.5% of the men and 2.4% of the women answered true to the statement, “When I get very tense, hurting myself physically somehow calms me down”. Furthermore, 2.5% of the men and 1.7% of the women answered true to “I have hurt myself on purpose several times”. Less than 1% of the participants answered true to both statements, but 4% answered true to at least one of those statements (Klonsky et al. 2003).
Participants who had admitted to having a history of DSH scored much higher in areas such as negative temperament, dependency, mistrust, self-derogation, aggression, manipulative-ness, dis-inhibition, eccentric perceptions, as well as all of the DSM-IV personality disorder diagnostic scales with the exception of Obsessive Compulsive Disorder. Pathological personality characteristics were the same for both women and men. The self harm group scored higher on the Beck Depression Inventory and the Beck Anxiety Inventory. The Peer Inventory of Personality Disorders showed those who are self-harmers were perceived by their peers as having characteristics of borderline, schizotypical, avoidant and dependent personality disorders compared to individuals that were not self harmers. Self harmers were also viewed by their peers as having odd and intense emotions and a great sensitivity to interpersonal rejection (Klonsky et al. 2003).
Individuals who harm themselves reported that they felt a sense of relief after an episode of self-harm. There is evidence that after harming themselves, there is a reduction in tension. From this study, as well as past research, it appears individuals who harm themselves have a heightened sense of anxiety that is reduced after an episode of self harm. The data from this study also suggests that self harmers are more anxious than depressed. Among college students, approximately 14% of students and 4% of the general population have reported a history which includes some type of self harm. Recent studies have shown evidence that DSH is becoming more prevalent. For more than thirty years, efforts have been made to develop a classification for DSH, but the only reference to DSH in the DSM-IV-TR is as a symptom of Borderline Personality Disorder. To devise effective management plans for individuals suffering from self-harm behaviors there must be a better understanding of DSH. There are currently no specific treatments that have been proven effective. Dialectical behavior therapy has been somewhat effective in reducing DSH behaviors in women who have borderline personality disorder (Klonsky et al, 2003).
In a study led by Armando Favazza in the 1980’s, it is estimated that 2 million Americans cut and burn themselves each year. According to psychiatrists, this number is actually too low. That number however is 30 times the number of yearly suicide attempts and is 140 times the number of successful suicides per year. Other research from Armando Favazza proved that out of a survey of 500 college students who were all taking a required psychology course, 1 in every 8 students or 12% of them at some point in their life had self-injured themselves. Self-mutilators usually describe themselves as feeling empty, alone, afraid of close relationships, and not able to properly express their emotions through use of words. In the 1960’s, a typical profile of self-mutilators was created and described as a young woman who is prone to drug and alcohol use and abuse yet is highly intelligent and has a difficult time getting close to people within personal relationships. In fact, one female self-mutilator described cutting by stating, “It’s like vomiting. You feel sick and spit out the badness” (Strong, 1998. p.33).
In order to better understand how such an extreme coping mechanism develops, well-known author Barent Walsh conducted a survey of 104 adolescents, 52 of which were self-mutilators, 52 of which were not and were therefore the control group. It was found that numerous childhood and adolescent factors contributed to self-mutilation. The mutilators, compared to the control group, were more likely to have lost someone close to them such as a parent, been in foster homes, suffered from illness or injury and had surgery, been a target of physical or sexual abuse, and witnessed alcoholism or domestic violence within their home or their family. Adolescent conflicts included loss, isolation from surrounding peers, and other conflicts (Strong, 1998).
The Royal College of Psychiatrics conducted a study in 2001 to explore the prevalence of both personality and psychiatric disorders in individuals who deliberately harm themselves. The study involved 150 deliberate self harm patients. They were first assessed by clinical interviews and a standardized test. The participants were followed up on for 12-16 months. The conclusion of this study was that it is common for DSH patients to have comorbid personality and psychiatric disorders (Haw et al, 2001).
In order to treat such a habit, ideally our culture should be and ultimately needs to be willing to change so that girls have less stress to deal with. But for now, the best way to deal with the problem is to learn better ways to deal with stress by thinking and talking about problems in particular. Various types of therapy are great resources that can help girls develop such skills. Most teenage girls respond very quickly and well to therapy and stop injuring themselves over time once they learn better ways to deal or cope with their emotional pain (Pipher, 1994).
Unfortunately there is no specific treatment for Self-mutilation. There are many different approaches but no single approach is superior in effectiveness than all of the others. Behavioral therapy is an option that has been extensively used and has had positive results among self mutilators. Many experts, such as Armando Favazza, believe that medications are the best option. Usually the medications that are used are typical anti-depressants or anti-anxiety treatments. An example of a medication that is sometimes used is Natrexone which is a drug that is used to treat addictions to various drugs and alcohol. This medication has been found to have helped many people in instances of cutting because it removes the physiological benefit of the euphoric high that those people receive when they self mutilate. Some medications however may increase instances of Self-mutilation. The National Institute of Mental Health found that the anti-anxiety drug Xanax actually increased Self-mutilation among people who were studied, even among those participants who had never self mutilated before. This is why doctors and therapists need to be careful of the treatment options that they offer. Many of the people who were involved in that study also had Borderline Personality Disorder which may have affected the results (Turner, 2002).
New and healthy coping strategies however are truly the most essential and necessary for mutilators to learn. Physical exercise is a great way for people to manage their tensions and stress. Treatment options can be combined or used individually in order to help self mutilators toward recovery. Of course, the potential and speed of recovery depends on how long the problem has existed and whether or not other disorders or addictions are evident in conjunction with that of Self-mutilation (Levenkron, 1998).
Some people who take part in Self-mutilation, however, may easily have the strength to stop the behavior on their own. It is possible that self mutilators can grow out of such extreme behavior because it may have simply served its purpose throughout a stressful stage in the individual’s life and eventually the behavior is no longer needed or necessary. It is difficult to pinpoint an exact therapy for individual self mutilators because the roots of the onset are so completely varied. If the underlying problem is not resolved or treated, relapse into Self-mutilation is likely to occur or the injurious behavior will be replaced with another destructive coping mechanism. These other mechanisms include the use and abuse of drugs and alcohol, sexual addictions as well as other relationship addictions, and common eating disorders. The best option for treatment in general would probably be a combination of medication, cognitive behavioral methods, and psychotherapy that is created to meet the individual needs of the patients (Turner, 2002).
Unfortunately however, many psychiatrists do no respect and understand the issue of Self-mutilation and would still, to this day, label self mutilators as simply psychotic and would order them into restraints. Fortunately for those who self mutilate, there are programs such as the Masters and Johnson treatment programs which views self injury as a type of reenactment of trauma that is truly unmetabolized. The basis of the Masters and Johnson treatment programs is that the symptom has a purpose and function which served as a form of communication for sufferers. The Masters and Johnson treatment program uses the symptom as a window into the real problem. In regards to adolescent girls in particular, many programs include art, drama, dance, writing, and other creative means for expression in order to help adolescent girls communicate their emotions that they cannot quite express through use of words (Turner, 2002).
From a cognitive behavioral standpoint, self-mutilation is a behavior that is learned and is a behavior that is maintained through positive reinforcement such as nurturance and attention and negative reinforcement such as relief from stress. Through cognitive behavioral therapy, many believe that the behavior of Self-mutilation can be unlearned through way of modifying negative thought patterns, by teaching self-mutilators healthy coping skills, counter-conditioning, and also by offering patients rewards for withdrawing from self mutilating (Strong, 1998).
Among all treatment options however, there is much disagreement among therapists regarding whether Self-mutilation treatment should focus on changing negative thought processes and behaviors that cause self-mutilation to continually occur, that strictly focus on the here and now, or that try and recall as well as resolve past traumas. Some people believe that dealing with past traumas actually increases acts of self-mutilation among the patient because it is traumatic to think about painful past experiences. Focusing on the here and now is also criticized because it deals only with the symptoms rather than the disorder and problem in general (Strong, 1998).
In conclusion, it is clear that self-mutilation is a serious issue. It is unfortunate and terrifying that so many adolescent girls take part in such self destructive behavior. Society needs to come to realize that this is a very serious issue that needs to be dealt with by means of reducing the stress and pressure that is put on adolescent girls nowadays. There is no reason adolescent girls should feel so depressed, stressed, and anxiety ridden. Parents need to become informed as to what problems to look for considering self-mutilation is a very secretive problem and is an incredibly difficult thing to notice. Society in general needs to also be more aware of the problem at hand and it needs to be made clear that Self-mutilation is not suicidal behavior. Those who self mutilate do so as a reminder to themselves that they are in fact alive. It releases those feelings of immense tension for people and is truly a mechanism that is used as a stress reliever (Strong, 1998).
Self-mutilation is a problem that needs to be discussed among teenagers more often. They need to be aware that there are many adolescents who behave in this manner and that they are not alone. Treatment options are indeed available although it may be difficult to find one that truly works for each individual and suits their needs. This is why many times a combination treatment program is the best option. Overall, Self-mutilation is becoming a major problem among adolescent girls in particular and is an issue that truly needs to be addressed (Turner, 2002).
References:
American Academy of Child and Adolescent Psychiatry: Self-injury in adolescence. December 1999. No.73.
Favazza, A. & Conterior, K. (1989). Female habitual self mutilators. Acta Psychiatrica Scandanavica.79, 283-289.
Haw, C., Hawton, K., Houston, K. & Townsend, E. (2001). Psychiatric and personality
disorders in deliberate self-harm patients. British Journal of Psychiatry.178, 48-54.
Klonsky, D., Oltmanns, T. & Turkheimer, E. (2003). Deliberate self-harm in a non-
clinical population: prevalence and psychological correlates. American Journal of Psychiatry. 160, 1501-1508.
Levenkron, S. (1998). Cutting: understanding and overcoming self-mutilation. New
York, NY: W.W. Norton & Company.
Pipher, M. (1994). Reviving ophelia. New York, N.Y: Random House.
Strong, M. (1998). A bright red scream. New York, N.Y: Penguin Books.
Turner, V. (2002). Secret scars: uncovering and understanding the addiction of self-
