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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 75-78

Deliberate self-harm: A perspective

Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission13-Nov-2019
Date of Decision28-Nov-2019
Date of Acceptance06-Dec-2019
Date of Web Publication20-Jun-2020

Correspondence Address:
Dr. Sharol Lionel Fernandes
Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_154_19

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Recent years have seen an alarming increase in the incidence of deliberate self-harm (DSH). It has come to be a significant health issue and a pressing problem faced by clinicians in emergency settings as well as psychiatrists. However, it is often very difficult to ascertain the pathology underlying such behavior, thereby making it difficult to manage it. It significantly burdens an already ailing healthcare system as a large number of individuals try it at least once in their life, and a significant percentage of these are found to repeatedly engage in such behavior. A better understanding of DSH is essential for effective management of this behavior.

Keywords: Deliberate self-harm, para-suicide, psychiatry

How to cite this article:
Fernandes SL, Safeekh A T, Chandini S, Shetty S. Deliberate self-harm: A perspective. Arch Med Health Sci 2020;8:75-8

How to cite this URL:
Fernandes SL, Safeekh A T, Chandini S, Shetty S. Deliberate self-harm: A perspective. Arch Med Health Sci [serial online] 2020 [cited 2023 Feb 7];8:75-8. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/75/287351

  Introduction Top

”You have so much pain inside yourself that you try and hurt yourself on the outside because you want help.”

– Princess Diana

Deliberate self-harm (DSH) can be defined as the intentional injuring of one's body without apparent suicidal intent.[1] These acts are usually nonfatal and not intended to end life. DSH includes but is not restricted to acts such as self-cutting, burning, ingestion of a substance or medication in excess of its therapeutic/prescribed dosage, ingesting a recreational or illicit compound in a bid to harm self, and consuming a noningestible compound, self-battery, etc.[2] Several other terms have been used to refer to this behavior such as self-injurious behavior, para-suicide, and self-wounding.[3]

Although deliberately inflicting damage to one's own bodies is perceived as quite disturbing, patients who self-harm are commonly encountered in clinical practice. They are known to constitute around 9% of the patients in emergency departments and up to 20% in psychiatric hospital settings.[4] A lot of popular names and celebrities have also been known to have engaged in such behavior – some of whom are Megan Fox, Johnny Depp, Colin Farrell, Angelina Jolie, Lindsay Lohan, Drew Barrymore, and Princess Diana. Historically as well many famous artists and politicians have been known to have engaged in DSH – the most famous being Dutch painter Vincent van Gogh, after whom Van Gogh syndrome is named. Van Gogh syndrome refers to individuals (often suffering from a psychiatric illness) who engage in self-mutilation akin to Van Gogh severing his ear following a spat with a fellow painter during a psychotic episode and then presenting the same to his lover as a token of affection. In today's world, DSH in adolescents and young adults is an area of growing concern. Reports from both clinics and emergency settings indicate an increase in the incidence of DSH – in India and internationally.[5]

A lot of theories have been put forth to explain such behavior – none of them definite. Individuals engaging in such behavior often do it either to get relief from negative feelings, to induce a positive feeling, or at times even to resolve interpersonal difficulties. Several researchers have used learning theories to explain the maintenance of DSH in individuals. They postulate that a person might find positive reinforcement in the form of emotional relief obtained from the act or the attention and importance it generates. Negative reinforcement results from the decrease in unpleasant emotions or avoiding distressing thoughts. An interesting aspect the social learning theory puts forward is the explanation that increased highlighting of DSH in the media could explain the rising trend of self-injurious behavior among adolescents and the youth.[5] The self-punishment hypothesis states that individuals may engage in DSH as a means of affect regulation and as a vehicle for punishing oneself for wrong deeds. The social signaling hypothesis explains DSH to be “cries for help” or rather a “means of communication.” Another theory called the “altered pain hypothesis” states that these individuals have a higher threshold for pain, which makes them engage repeatedly in such acts, which ordinarily would be quite painful for others.[6]

Individuals who engage in DSH have also been found to have poor tolerance to distress, higher arousal in response to stressful events, poor verbal communication, and social problem-solving skills. However, DSH is deemed to be a complex phenomenon, and most times, a number of factors are at play when an individual engages in DSH.

Nonsuicidal self-injury (NSSI) is a diagnostic category proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as a “condition for further study” to encourage further research in this area. The proposed criteria require an individual to engage in intentional self-inflicted damage to the surface of his/her body, on 5 or more days in the last 1 year, with the expectation that the injury will lead to only mild or moderate physical harm.[7]

  Prevalence Top

DSH is encountered frequently not just in the hospital settings but in the general population. There is substantial evidence indicating that DSH has become more prevalent in recent years. A large number of studies have found higher rates of self-harm in individuals from younger generations.[3]

In a study done in Europe on DSH in adolescents, a prevalence rate of 27.6% was seen – ranging from 17.1% in Hungary to 38.7% in France.[8] Gandhi et al. in their review of Indian studies on self-injurious behavior reported a lifetime prevalence of 31% in a sample of emerging adults.[9] Another study carried out among 1571 male and female school and college students in India found the prevalence of NSSI to be 33.8%.[10] The prevalence rates of DSH on an average in adolescents fall between 7.5% and 46.5%, rising up to 38.9% among university students and 4%–23% among adults.[11] However, since different studies use different terminologies to refer to this behavior, it is difficult to ascertain the exact prevalence of DSH. In addition, a large number of these incidents go unreported – therefore, the actual prevalence of DSH is often underestimated. Age at onset typically is seen to be between 14 and 24 years.[12]

When it comes to individuals with psychiatric disorders, the rates are much higher – around 40%–70%.[13],[14] According to the WHO, DSH has increased by around 60% over the past 50 years, and around 90% of the ones engaging in DSH were found to have a psychiatric disorder.[15] DSH may be found in patients with a variety of psychiatric diagnoses, including substance abuse, eating disorders, posttraumatic stress disorder, depressive disorders, anxiety disorders, and schizophrenia, as well as each of the personality disorders and especially borderline personality disorder.[3]

DSH includes several types of behavior – skin cutting, burning, self-battery, consumption of substances, etc. Skin cutting appears to be the most common form of DSH, seen in as many as 70% of individuals engaging in DSH.[16] Around 21%–44% of those engaging in DSH bang or hit themselves, and around 15%–35% burn their skin.[12],[17],[18]

There are differences in the type of DSH method chosen: Self-cutting is seen to be the most common among women,[19] whereas hitting, burning, and banging are more commonly seen among men engaging in DSH.[20] Individuals with psychotic disorders are often found to self-mutilate in extremely bizarre ways – chopping-off fingers, tongue, ears, and even genital mutilation. Most individuals who engage in DSH often use more than one method.[12]

  Comorbidities Top

There is an abundance of research suggesting that DSH co-occurs frequently with primary psychiatric disorders.[14] In a study by Hawton et al., psychiatric disorders were identified in as many as 83.9% of adults and 81.2% of adolescents who engaged in DSH.[21] The most frequent disorders found to be comorbidly present with DSH include adjustment disorders, major depressive disorders, posttraumatic stress disorders, alcohol and other substance use disorders, schizophrenia and other psychotic disorders, and personality disorders, especially borderline personality disorder. The prevalence of personality disorders has been found to be around 30% in patients seeking emergency care following DSH.[21] However, there are reports of DSH in patients with eating disorders as well as body dysmorphic disorder. In younger patients, DSH may be comorbid with attention-deficit hyperactivity disorder and conduct disorder. Self-mutilation has also been associated with several genetic syndromes such as Lesch Nyhan syndrome and Riley Day syndrome (particularly oral mutilation is seen).

  Risk Factors Top

A large number of factors have been studied in relation to DSH. Sociodemographic variables such as gender and age, family dynamics, stressful life events are a few of the factors known to influence an individual engaging in DSH.[22]

Studies have shown higher rates of DSH in adolescents and young adults.[23] Among those who sought medical treatment for DSH, a greater number of females were seen than males.[24] In adolescents, several studies found higher DSH rates for females.[25] However, when it comes to adults, according to most available literature, the rates of DSH are comparable between men and women.[21] Studies have shown that DSH is also associated with a lower level of education – especially in adolescents and young adults.[22],[25] Unemployment has been seen to be predictive of the recurrence of self-harm within a year.[24]

Stressful and traumatic childhood experiences have been found to be associated with the risk of DSH in later life. Some of the following are the significant factors: psychiatric and psychological problems in a parent, parental neglect, physical/psychological/sexual abuse, substance abuse in parent(s), death of a parent(s), parental separation and divorce, and early or prolonged separation from a parent.

Maladaptive coping with life stressors is also an important risk factor for DSH. Studies have shown a correlation between a higher level of perceived stress and DSH behavior.[26] A study in adolescents found an association between the number of critical life events and DSH.[27] Association between lower personal coping resources and DSH has been seen. In several studies, DSH has been found to be associated with low self-esteem and low problem-solving abilities. The ones who engaged in DSH frequently had a lower belief in self-efficacy [28] and a higher tendency toward a self-blaming coping style [29] than the ones who did not. The presence of substance abuse and psychiatric disorder further increases the risk for DSH.

  Management Top

Managing DSH effectively is a team effort and requires an interdisciplinary approach. Since most of the patients with DSH initially present to the emergency settings, sensitization of emergency personnel is a key step in the management of DSH. Adequate medical and surgical management followed by a psychiatric consultation is essential as most of those with DSH have been found to have a comorbid psychiatric disorder. Furthermore, studies have found that a large number of those engaging in DSH go on to attempt suicide in the future. This makes it all the more important for such individuals to receive timely psychiatric and psychosocial care. Pharmacological management is symptomatic based on the psychiatric symptoms present along with DSH – including antidepressants, antipsychotics, mood stabilizers, and anti-anxiety medications including benzodiazepines. Psychotherapy plays an important role in the management of DSH. Sensitization of family members and family therapy is essential for managing DSH effectively. Several other therapies have been found to be helpful – such as supportive psychotherapy, cognitive behavior therapy, and dialectical behavior therapy.

  Conclusion Top

DSH places a significant burden on the healthcare system today. Therefore, it is essential that further research is done to understand DSH better which will subsequently aid clinicians in managing it more effectively. Furthermore, knowledge and awareness regarding the correlates and risk factors of DSH are important to better predict, understand, and treat such behavior. As most patients engaging in DSH are found to have psychiatric disorders, appropriate psychiatric evaluation and psychosocial assessment should be included in the aftercare of DSH patients, and wherever possible necessary, therapeutic interventions should be initiated.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: Self report survey in schools in England. BMJ 2002;325:1207-11.  Back to cited text no. 2
Klonsky ED, Oltmanns TF, Turkheimer E. Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. Am J Psychiatry 2003;160:1501-8.  Back to cited text no. 3
Gunderson JG, Choi-Kain LW. Working With Patients Who Self-injure. JAMA Psychiatry 2019;76:976-7.  Back to cited text no. 4
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