Understanding Self-Harm

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Acts of self-harm such as self-cutting may be carried out for a variety of reasons, most commonly to express and relieve bottled-up anger or tension, to feel more in control of a seemingly desperate life situation or to punish oneself for being a "bad" person.

For some people, the pain inflicted by self-harm is preferable to the numbness and emptiness that it replaces — it is something rather than nothing, and a salutatory reminder that one is still able to feel, that one is still alive. For others, the pain of self-harm merely replaces a different kind of pain that they can neither understand nor control. Acts of self-harm reflect deep distress, and are most often used as a desperate and reluctant last resort — a means of surviving rather than dying, and sometimes also a means of attracting much-needed attention.

In general, it appears that teenagers, particularly teenage girls, are at the highest risk of self-harm. Perhaps this is because older people are more adept at dealing with their emotions, or because they are better at hiding their self-harming activity. It may also be because older people may only self-harm indirectly, for instance, by misusing alcohol or drugs.

Self-harm is reaching epidemic proportions in the U.K. In a speech delivered to the Mental Health Conference in January 2015, the then Deputy Prime Minister Nick Clegg claimed that emergency departments see 300,000 cases of self-harm each year. This in itself is a gross underestimate of the true incidence of self-harm, as the vast majority of cases do not report to the hospital.

According to the British Psychological Association and The Guardian, the most recent Health Behaviour in School-Aged Children (HBSC) report is due to reveal that of 6,000 young people aged 11, 13, and 15 surveyed across England, about 20 percent of the 15-year-olds reported self-harming within the past 12 months.

The last similar survey of self-harm in England, published in the British Medical Journal in 2002, surveyed 6,020 pupils aged 15 and 16. At the time, "only" 6.9 percent of the pupils reported self-harming within the past 12 months, compared to about 20 percent in the 2013-14 HBSC study.

The vast majority of cases of self-harm that present to the hospital involve either a tablet overdose or self-cutting, although self-cutting is much more common in the community at large. Occasionally, other forms of self-harm are also seen, such as banging or hitting body parts, scratching, hair pulling, burning and strangulation. The drugs most commonly involved in tablet overdoses are painkillers, antidepressants and sedatives.

According to the most recent report on self-harm in Oxford, England, of those people who present themselves to the hospital, about 25 percent report high suicidal intent, and about 40 percent are assessed as suffering from a major psychiatric disorder excluding personality disorder and substance misuse. This suggests that many people who self-harm are not in fact mentally ill.

The problems most frequently cited at the time of presentation are problems with relationships, alcohol, employment or studies, finances, housing, social isolation, physical health, bereavement, and childhood emotional and sexual abuse.

For some people, self-harm is a one-off response to a severe emotional crisis. For others, it is a more long-term problem. People may keep on self-harming because they keep on suffering from the same problems, or they may stop self-harming for a time, sometimes several years, only to return to self-harm at the next major emotional crisis.

Self-harm is generally believed to be rare in many non-Western countries, suggesting that it is in fact a culture-bound syndrome. Foreign doctors often claim never to have seen a case of self-harm prior to working in the UK.

The testimony of Dr. Eric Avevor in The Psychiatrist is fairly representative:

The subject [of self-harm] was hardly mentioned, let alone taught, as a topic throughout my undergraduate medical training in Ghana. In my medical school clinical years and throughout my work as a house officer in the largest teaching hospital in Ghana, I never saw or heard of a single case of self-harm. I later worked as a medical officer (hospital-based general practice) in a busy district hospital for three years and here too I never encountered such a case…I had a cultural shock in my first psychiatric senior house officer post in the U.K. when I quickly realised that self-harm was the ‘bread and butter’ of emergency psychiatric practice.

Self-Harm Essential Reads

Hallucinations About Harm in Borderline Personality Disorder

Self-Injury: 4 Reasons People Cut and What to Do

As Dr. Avevor concedes, this stark difference could owe to the under-reporting of cases in Ghana. But even if very common, under-reporting seems unlikely to account for the full difference.

Neel Burton is author of The Meaning of Madness and other books.

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Source: Neel Burton