Self-harm
Introduction
Self-harm is when somebody damages or injures their body on purpose. The National Institute for Clinical Excellence (NICE) describes it as ‘self-poisoning, or injury, irrespective of the apparent purpose of the act’.
Self-harm is not usually an attempt at committing suicide, but a way of expressing deep emotional feelings such as low self-esteem. It is also a way to cope with traumatic events, or situations, such as the death of a loved one, or an abusive relationship. Self-harm is not an illness, it is an expression of personal distress.
Types of self-harm may include:
- cutting the skin,
- burning the skin, and
- destructive, or dangerous, behaviour, such as misusing alcohol or drugs.
How common is self-harm?
Shame and fear of discovery mean that people often keep self-harm a secret. Unless medical treatment is required, self-harm is not usually reported. This makes it difficult to know how common it is. Some research has suggested that around six per cent of children who are 15 years of age have self-harmed at least once.
Self-harm is much more common among girls and teenagers. Research shows that the most common age group for self-harm is 15-19 year olds, although some children may start to self-harm as young as 11 years of age.
Self-harm can also be linked to other mental health conditions, such as depression. As depression can occur at any time, self-harm may affect people of all ages.
Outlook
The physical effects of self-harm can usually be treated with dressings or stitches. The emotional causes may need a psychological (mental health) assessment and counselling (talking therapy) to deal with the underlying issues.
Some people self-harm only once or a few times while others do it on a regular basis, sometimes throughout their life. While self-harm is not usually an attempt at suicide, research has suggested that there is a strong relationship between self-harm and suicide.
If someone is self-harming, they should seek medical help or advice immediately. Those who self-harm have a higher risk of committing suicide, either deliberately or accidently.
There are a number of websites and telephone help lines that can provide support and advice for anyone who would like to talk about their self-harming. See the ‘useful links’ section for more information.
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Symptoms
Cutting
The most common form of self-harm is cutting your skin, using a knife, razor blade, or a piece of glass. The cuts are not usually deep but, in some cases, medical attention is needed to clean, dress, and stitch the wounds.
The most common areas to cut on the body are:
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the wrists,
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upper arms,
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inner thighs, and
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upper chest.
Less common areas to cut include:
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the face,
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breasts,
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abdomen, and
- genitals.
Other types of self-harm
Other types of self-harm include:
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burning your skin (usually with cigarettes),
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scratching, or picking at, your skin,
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hitting or punching either yourself or an object,
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deliberately breaking your bones,
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pulling out your hair,
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swallowing poisonous substances, such as glue, or bleach, and
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taking an overdose of drugs, including prescription medication.
Several other forms of behaviour are also sometimes regarded as types of self-harm. For example:
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smoking too much,
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binge-eating - an eating disorder where you feel compelled to overeat, and
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bulimia nervosa - an eating disorder where you binge-eat and then purge your body of the food by making yourself sick, or taking laxatives.
These types of behaviour can be very dangerous. For example, in 2007, alcohol misuse was responsible for over 6,000 deaths. Illegal drug misuse kills around 2,000 people every year.
The more someone self-harms, the more dangerous it becomes. Research has shown that repetitive self-harm is more closely associated with suicidal behaviour (thinking about or attempting suicide), than occasional self-harm.
Self-harm in others
People who self-harm will usually try to keep it a secret from their friends and family. They will often injure themselves in places that can be easily hidden by clothing, and will be very careful to hide the damage and scars.
It may be up to their family and friends to notice that there is a problem. Signs that somebody may be self-harming include:
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unexplained cuts, bruises or cigarette burns, usually on the wrists, arms, thighs and chest,
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insisting on keeping fully covered at all times, even in hot weather,
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signs of
depression, such as low mood, tearfulness, a lack of motivation, or interest in anything, or a lack of energy,
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changes in eating habits, or being secretive about eating, and any unusual weight loss, or weight gain, and
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signs of low self-esteem, such as blaming themselves for any problems, or not thinking that they are good enough for something.
The person who is self-harming may feel deep shame and guilt, or they may feel confused and worried by their own behaviour. If you find out that someone close to you is self-harming, you should approach them with care and understanding.
They may not wish to discuss their self-harm with you, but may be happy to speak to an anonymous help line or use an internet chat room. See the ‘useful links’ for some possibilities.
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Causes
There are many reasons why someone could self-harm, and if they self-harm more than once, it may be for a different reason every time. The causes usually stem from unhappy emotions.
Self-harming has been described as a ‘physical expression of emotional distress’. If someone is feeling overwhelmed with unhappy emotions, they may find that the physical act of hurting themselves makes them feel better.
If you are feeling like this, you can call the Samaritans on 08457 909090 for support, or see the ‘selected links’ to find further advice.
Social factors and trauma
Research has shown that social factors are most often the cause of emotional distress in people who self-harm. The most common reason is difficult relationships with family members. Other possibilities include:
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difficult relationships with friends or partners,
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difficulties at school such as not doing well academically,
- difficulties at work,
- being bullied, either at home, school, or at work,
- worries about money,
- alcohol or drug use,
- coming to terms with your sexuality if you think that you might be gay or bisexual, and
- coping with cultural expectations - for example, an arranged marriage.
Self-harm could also sometimes be a way of coping with a traumatic experience - for example:
Emotional distress
The distress from a traumatic experience, or an unhappy situation, can lead to feelings of low self-esteem or self-hatred. You could also have feelings of:
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guilt,
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anxiety,
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loneliness,
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grief,
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anger, and
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numbness or emptiness,
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feeling unconnected to the world, or
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if you have been abused, you can feel unclean, unworthy, trapped, or silenced.
The emotions can gradually build up inside you, and you may not know who to turn to for help. Self-harm may be a way of releasing these pent-up feelings and finding a way to cope with your problems. It is not usually an attempt to seek attention, but a sign of emotional distress.
Some research has suggested that the emotional distress is a result of an inability to regulate emotions. People who self-harm may have difficulty understanding, or coping, with their emotions, and use self-harm as a way to avoid their feelings. The research showed that people who self-harm:
- have lower emotional awareness and understanding,
- have lower acceptance of emotions,
- try to avoid unpleasant emotions, and
- have difficulty controlling their behaviour when faced with difficult emotions.
It is possible that this inability to regulate emotions can cause self-harm in some people.
Other research has shown that self-harm is linked to both anxiety and depression. These mental health conditions can affect you at any age. Self-harm is also linked to antisocial behaviour, such as misbehaving at school, or getting into trouble with the police. However, it is not clear whether these problems and mental health conditions are a result of the self-harming, or if they were the cause of the self-harming initially.
Research into self-harm is limited because it tends to be ‘self-reporting’. This means that it is based on asking the people who self-harm questions about their feelings. As this process relies on people being truthful, and remembering their feelings accurately, it is open to possible errors.
Psychological causes
In some cases, there may be a psychological reason for the self-harming (where the cause is related to an issue with your mind). For example:
- you may hear voices telling you to self-harm,
- you may have repeated thoughts about self-harming, and feel like you have to do it,
- you may disassociate (lose touch with yourself and your surroundings) and self-harm unconsciously (without realising that you are doing it), or
- it can be a symptom of borderline personality disorder (a condition that affects how a person thinks, feels, and behaves).
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Diagnosis
If you are self-harming, you are probably doing it in secret, and you may not want to talk to anyone about it. However self-harm is very dangerous. You could seriously hurt yourself, either accidentally or on purpose, and your feelings are unlikely to get better without help.
In the first instance, you should speak to your GP. They should be able to diagnose the cause of your self-harm and arrange suitable treatment. For more general advice and support, there are a number of websites and help lines (see ‘selected links’). However, your GP is the best person to turn to.
Visiting your GP
Your GP will treat anything that you tell them as confidential, which means that they will not tell anyone else about it. If you are not registered with a GP, you can use the local service finder to find your local GP practices.
Your GP will discuss your history of self-harm with you, and try to find out whether there is an underlying cause that can be treated. You will not be made to feel ashamed of your actions; your GP is there to support you, not judge you. You will be treated with respect and your self-harm will be taken seriously.
You GP is likely to ask you about your feelings in some detail. They will want to establish why you self-harm, what triggers it, and how you feel afterwards. For example, you may be asked:
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whether you have an obsession with, or addiction to self-injury (if you think about it all the time, or if you feel you have to self-harm),
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whether you feel increasing tension before self-harming and a sense of relief afterwards, and
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whether you have any intention of committing suicide.
Underlying conditions
If you have any other symptoms, your GP will also ask you about them. For example, you may have:
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impulsive behaviour,
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mood swings,
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tearfulness,
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irritability,
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physical symptoms, such as disturbed sleep patterns, or a change in your appetite, or weight, or
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psychotic symptoms, such as delusions (where you believe things that are untrue), or hallucinations (where you see or hear things that are not there).
Your GP may be able to use a questionnaire to match your symptoms to a particular condition - for example, depression, anxiety, or borderline personality disorder.
If you are self-harming through a particular pattern of behaviour, such as an eating disorder (anorexia nervosa, bulimia, or binge-eating) you may be asked additional questions about this. Your height, weight, and blood pressure may also be checked.
If you are misusing alcohol and/or drugs, you will be asked about how much and how often you drink, how it affects your ability to perform everyday tasks, and what drugs you are taking.
It is important that you are honest with your GP about your symptoms and your feelings. If you do not know why you self-harm, you should tell your GP this as well. The more you discuss your situation with your GP, the more likely it is that the right diagnosis can be made for you.
Referral
Sometimes, if you self-harm, simply talking to your GP can help but, in most cases, your GP will want to refer you to the mental health services. This is because self-harming is caused by emotional distress, which is a mental health issue. A medical professional who is specially trained in the area of mental health will be able to provide better treatment for you.
You will only be referred if you wish to and it will be done confidentially. You may be referred to one of the following:
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a nurse who is specially trained in mental health,
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a counsellor (someone who is trained in talking therapies), or
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a psychotherapist (someone with extensive training in talking therapies, and possibly a psychology, or psychiatry, qualification as well).
They will assess your mental health and decide what treatment will work best for you. See the treatment section for more information about assessments and treatments.
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Treatment
If you self-harm, both the physical injuries of self-harm and the underlying emotional causes will need to be treated. Whether treatment is from your GP, a mental health professional, or emergency department staff, you will be treated with respect.
Do not let your concerns about judgement from healthcare professionals put you off seeking treatment if you have self-harmed. You will be shown understanding and given support from trained staff who will take into account the emotional distress that you are feeling.
Treatment for the injuries
The treatment that you need will depend on the severity of your injuries. If it is only a very minor injury, you may be able to clean the wound yourself and apply a plaster. However, you should still go to see your GP so that they can diagnose and treat the underlying cause of your self-harming.
Where to seek treatment
Some injuries will require admission to an accident and emergency (A&E) department. For example, you may need to call 999 to request an ambulance if:
- you, or someone else, has self-poisoned (taken an overdose of drugs, alcohol, or prescription medication, or swallowed a poisonous substance),
- someone is unconscious,
- you, or someone else, is in a lot of pain,
- you, or someone else, is having difficulty breathing,
- you, or someone else, is losing a lot of blood from a cut, or wound, or
- you, or someone else, is in shock after a serious cut, or burn.
If your injury is not serious, you could be treated at a minor injury unit (MIU). MIUs are healthcare services that are run by doctors, or nurses, which provide assessment and treatment for minor injuries such as:
- minor burns and scalds,
- infected wounds, and
- broken bones.
To find your nearest A&E or MIU, you can use the Local Services Search.
Types of treatment
Depending on the type of injury that you have, you may have your wounds cleaned and a dressing applied. Some cuts may need stitches to help close the wound.
If you have self-poisoned, you may be given activated charcoal. This is a fine, black powder which has been processed in a certain way to make it very absorbent. It can be mixed with water to form a liquid and swallowed. If it is taken 1-2 hours after self-poisoning, it can absorb any poison in your stomach and intestines.
The specific treatment that you will receive will depend on your physical injuries. The healthcare professional treating you will explain everything they are doing. Whenever possible, they will ask for your consent (permission) before giving you any treatment, and will offer you alternatives if there are any. If possible, they will ask you whether you would prefer treatment from a male or female healthcare professional, and will make arrangements to suit you.
Treatment of the emotional distress
Your GP, or a healthcare professional who has treated your physical injuries may refer you to mental health services.
The National Institute for Clinical Excellence (NICE) recommends that if you report to an accident and emergency (A&E) department after self-harming, you should have a mental health assessment within 48 hours.
Psychosocial assessment
A psychosocial assessment is an assessment of your mental health capacity. In particular, you will have:
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an assessment of your mental health needs, and
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an assessment of the risk of future self-harm or suicide.
The psychosocial assessment will be carried out be a specialist mental health professional. If possible, you will be asked whether you would prefer this to be with a male or female. Your initial assessment will be carried out alone, although for future assessments and treatment, you may wish to have a friend or family member with you.
Your assessment will include a complete evaluation of all the factors that contributed to you self-harming including:
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social factors - for example, your relationships with others,
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psychological factors - your feelings and emotions, and
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motivational factors - what made you want to do it.
You will also be asked about your current feelings, particularly if you are feeling hopeless, or considering suicide. If you have any other symptoms, either physical or emotional, you will also be asked about these.
After the assessment, you will be allowed to read through what has been written to make sure that you agree with it. Any further treatment will, if possible, be decided jointly between you and your mental healthcare professional. It will be a specific programme for you according to your needs and what is likely to be effective. You will be asked for your consent before any treatment begins.
Specialist referral
If a specific trauma, or a particular pattern of behaviour, has been identified as a cause of your self-harming, you may be referred to a mental health professional that specialises in this area. This could be:
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a counsellor - someone who is trained in talking therapies,
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a psychiatrist - a qualified medical doctor with further training in treating mental health conditions, or
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a psychologist - a health professional who specialises in the assessment and treatment of mental health conditions.
For example, if you have lost a close relative, you may be referred to a specialist grief counsellor. If you are self-harming after an incident of rape, or physical and/or mental abuse, you may be referred to someone who is trained in dealing with victims of sexual assault or domestic abuse.
If you have another condition which is linked to your self harming, such as anorexia nervosa, or bulimia, you may be referred to a specialist in eating disorders, as well as a dietitian or nutritionist (someone who specialises in nutrition).
It might also be recommended that you attend a self-help group - for example, Alcoholics Anonymous, if you are misusing alcohol, or Narcotics Anonymous - if you are misusing drugs. These groups will be able to offer you support as you try to stop your self-harming behaviour.
Regulating your emotions
The links between regulating your emotions and self-harming (see the causes section) means that treatment tends to focus on counselling to address how you deal with your emotions. This can be with either:
Psychotherapy
Psychotherapy is a type of talking therapy that can often prove useful in treating emotional problems and mental health conditions, such as self-harming. As well as listening and discussing important issues with you, the psychotherapist will be able to suggest strategies for resolving your problems and, if necessary, help you to change your attitudes and behaviour.
Cognitive behavioural therapy
Cognitive Behavioural Therapy (CBT) works on the premise that your problems are often created by you. It is not the situation itself that is making you unhappy, but how you think about it, and how you react to it.
CBT can be used to explore your feelings and find other ways to express the build up of emotions and tensions. It can develop your emotion regulation skills and modify any behaviour that interferes with this.
Hospitalisation is only used as a last resort if the individual is at a risk of severe self-harm or suicide. In most cases, this can be avoided with frequent therapy sessions, including home visits if necessary. You may also be provided with a telephone contact number to use if you are considering self-harming again.
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Complications
If you are self-harming and your wound is not treated properly, you are at risk of getting an infection. Cuts can become infected you use a non-sterile or dirty, cutting instrument.
If you think that your wound may be infected, or you are not sure how to look after it, you should seek medical attention. You should get your wounds checked even if you do not want further treatment for your self-harming.
It is also important not to share cutting implements with other people. Diseases such as HIV/AIDS and some types of hepatitis can be caught this way.
There is also at risk of permanent scarring from the cuts and wounds.
Suicide
Most acts of self-harm are not done with the intention of committing suicide. However, if you self-harm, your risk of committing suicide is increased.
Some suicides may be accidents, where the person did not mean to kill themselves. For others, it may be due to emotional distress that finally becomes too much.
If you are self-harming, you should seek medical help immediately. Treatment can teach you how to deal with your emotions and prevent them overwhelming you.
If you do not wish to speak to your GP about your self-harming, it is possible to find someone else who you can talk to, such as the Samaritans. See the ‘selected links’ section for details.
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References
Brunner R et al. Prevalence and Psychological Correlates of Occasional and Repetitive Deliberate Self-harm in Adolescents. Archives of Pediatrics and Adolescent Medicine. July 2007. Vol 161.
Hawton K and Harriss L. How Often Does Deliberate Self-Harm Occur Relative to Each Suicide? A Study of Variations by Gender and Age. Suicide and Life-Threatening Behavior. December 2008. Vol./is 38/6.
Palmer L et al. Helping people who self-harm. Emergency Nurse. June 2008. Vol./is. 16/3.
Slee N et al. Emotion Regulation as Mediator of Treatment Outcome in Therapy for
Deliberate Self-Harm. Clinical Psychology and Psychotherapy. January 2008. Vol./is. 15/4.
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