"When the body weeps tears of blood, we need to wonder what terrible sorrows cannot be spoken. When food that had tasted good suddenly feels like poison and has to be purged from the body, we should wonder what traumatic experiences exist that cannot be contained, metabolized, and integrated. . . The body speaks of that which cannot be said in words, of secrets, lies, and trust that has been broken (Farber 2003, p.188)."

When I was obtaining training in the treatment of people with eating disorders, I was shocked when my first patient was not the adolescent girl I expected to see but a 67 year old woman who had been anorexic since infancy, an unusual failure-to-thrive syndrome. From a devout Irish Catholic family, she was preoccupied with thoughts of good and evil and tried very hard to be perfect. Her models were the saints she read about in The Lives of the Saints and she even had an aunt, a nun who died of starvation in the convent.

When introduced to the confession and communion, both became a weekly practice. She was proud that she could fast more easily than the others before receiving the sacrament, but then felt guilty of the sin of pride. At times when she had no real sin to confess, she was afraid to say so for fear that the priest would say "Who do you think you are, perfect?", and then she would be guilty of the sin of pride  At other times she felt so guilty for angry thoughts that a million Hail Marys would not have been sufficient penance. Claudia wept for Jesus and became determined to suffer like him. She suffered from malnutrition, was frequently ill, prone to chronic headaches and nail biting so severe that her cuticles bled and became infected.

In the middle ages, Christian saints and mystics, wanting to suffer like Jesus, starved and hurt themselves as they went into trances.  Some, like Saint Catherine of Siena,  were even canonized as saints. Wanting to suffer and be good Christians, many people emulated them and performed the same acts of self-harm. These medieval mystics seemed to suffer the post-traumatic stress disorder (PTSD) that many today who harm themselves suffer. Someone hurting himself like this today is more likely to be regarded as being in need of treatment.

Self-harm is the result of self-inflicted pain and suffering. Just as addicts self-medicate and find a "drug of choice" to regulate difficult states of mind, we can understand self-harm behavior as the attempts of desperate people to alleviate their psychic suffering in much the same way that others may use drugs and alcohol. It occurs along a continuum, from the bodily self-harm of self-injury such as cutting, burning, or picking at one’s skin, to eating disorders, to substance abuse, and other high risk behavior, to the psychological harm to ones self-esteem.  Even compulsively getting one's body tattooed or pierced is a form of self-mutilation, albeit a passive one.

Having just one or two of these body modifications may be a sign of belonging to a group. The marks tell stories, personal history written on the body. But like many drug addicts, many self-mutilators who stick themselves or seek out others to do so repeatedly by means of tattooing or piercing may be “needle freaks”, addicted to the physical pain. These are the people who may have a “full-body suit” tattooed all over their bodies, or have multiple body piercings.

Drug or alcohol abuse, disordered eating, self‑mutilation,compulsive body modifications, suicide attempts, impulsive sexual behavior, compulsive shopping, spending, or shoplifting, other high risk behavior often comprise clusters of self-harm behavior. Those who self-mutilate and/or have eating disorders suffer from a marked inability to verbalize and process emotions and use their bodies instead of their minds to express emotion. Their thoughts are dissociated from their feelings, and their minds are dissociated from their bodies, usually because there are memories of traumatic experiences too painful to remember  or feel emotionally. In some people, the eating disorder coexists with some kind of self-mutilating behavior, usually an indication of a history of severe trauma, usually a past history of neglect and/or abuse, usually from childhood. As adolescents or adults, they may suffer from childhood relational trauma, such as parental indifference or unattunement.

These dissociative tendencies may well have begun in childhood. Along with dissociation comes an attachment disorder, in which they do not feel safe and secure with either or both parents. They may have a traumatic attachment to pain and suffering and to those who inflicted pain and suffering, which underlies the infliction of harm to the self.  A safe and secure attachment to another person can allow the person to begin to relinquish the attachment to self-harm.  This can happen in a long-term relationship or marriage or in the development of a safe and secure attachment to the therapist. The development of this kind of trusting relationship is what allows the individual to relinquish the attachment to self-harm.

Both eating disorders and self-mutilation seem to be far more prevalent among females but are increasing in males. The more severe forms of self-mutilation, eating disorders, and suicides are more common among men.

You may wonder just what they get out of mutilating themselves or the eating disordered behavior.  They get something that is missing from themselves  out of it, a way of calming themselves or boosting their mood, even if only temporarily. Consider this behavior to be their “drug of choice”, in much the same way alcohol or prescription pain relievers may be an addict’s drug of choice. Just as alcoholism is a progressive process in which over time there is a crucial loss of control over intake, the same is true of the eating disorders and self-mutilation.

This explains why what starts as just being a little bit too thin can become life-threatening self-starvation over time. This explains why what starts as non-suicidal self-injury can become suicidal self-injury. Without the proper treatment, the illness gets worse and worse until it no longer helps the person to feel better. This is when the risk of suicide is greatest, when thoughts that the only thing that can stop the emotional pain is ceasing to exist. Both kinds of problems are associated with suicidal behavior and suicide attempts.

The risk for suicide is great in those who harm themselves severely. Self-mutilation may begin as non-suicidal self-injury but through this addictive process, over time the wish to preserve life can be transformed into a wish for death, with mild, superficial, and controlled forms of self-mutilation escalating to deep, less inhibited, and more life-threatening self-mutilation. A mild eating disorder can similarly be transformed into one that is life-threatening. When people become accustomed to potentially lethal behavior and lose the sense of excitement that danger holds, the groundwork for disaster is established. Those who commit suicide do so during a transient period during which they seem to have tunnel vision, when perception of the alternatives is severely constricted. They do not have the ability to consider that they might feel somewhat better tomorrow or next week. In a fascinating book, Waking Up, Alive, Richard Heckler described his fascinating study of individuals who experienced this "suicidal  trance" and tried to kill themselves but failed found that they gradually recovered a will to live and gradually woke up to life and feeling alive.

Just as some people look for drinking buddies or eating buddies, someone who feels a need to harm himself will feel less deviant doing it with others. But there are some who may not feel the need to harm themselves but may feel the need to belong to a group, especially adolescents. If they do not fit into the athletic or jock group, or the heavy metal-heads or the computer geeks, then acts of self-harm can be an initiation rite, providing the sense of belonging to a group of others who harm themselves.

All of this is elaborated upon in my book, When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments.  

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