
Self-Harm
Self-Harm: What, why and how
Globally, one in seven 10-19 year-olds experiences a mental disorder, accounting for 15% of the global burden of disease in this age group1. While depression, anxiety, self-harm and behavioral disorders are among the leading causes of illness and disability among adolescents, suicide is the third leading cause of death among those aged 15-29 year-olds1.
Very closely related to suicide is Self-Harm which is also known as Non-Suicidal-Self-injury (NSSI) in scientific literatures. NSSI is highly prevalent in young adults and are strong predictor of suicide. Non-suicidal self-injury (NSSI) in adolescents is an ongoing public health concern and is defined as the deliberate, direct, and socially unacceptable destruction of body tissue, such as skin cutting, skin burning, and hitting oneself, but without an attempt at suicide2,3,4. Individuals typically engage in NSSIs to reduce or distract from negative emotions, punish oneself, and /or reduce feelings of numbness or dissociation5.
Non-suicidal self-injury (NSSIs) is used synonymously with self-harm (SH) in this article is a significant global health concern6. Many individuals, especially adolescents, engage in self-harm as a way to cope with overwhelming emotions, trauma, or mental health issues. “It takes away the emotional pain” remarked one client. “I feel a soothing sensation when I see the blood oozing out” was told by another. “The numbness that I constantly feel is so bizarre that I am confused whether the “me” is real or not, and when I cut and feel the pain and the blood, I know that I am actually alive” There are many such reasons and aspects presented by those who engage in self-harm.
Many feel that at least their own body is under their control whilst emotions are not. They mean that the body is immediately under their control and can be hurt to numb down emotional pain arising out of various experiences of trauma. Literatures point to disruption in emotional regulations as a causative factor for self-harm which will be discussed later in this article.
Association to Trauma
It has been found that those who self-harm often have a significant history of bullying, sexual and other forms of abuse, parental conflict including separation or divorce, feeling left out at school, and other forms of trauma. These factors contribute to feelings of significant distress, hopelessness, and emotional pain, which many find difficult to process.
It is consistently found that individuals who have suffered trauma in the past are more likely to self-harm and are not able to utilize healthier outlets to their traumatic experience, either by unavailability of someone to confide to, or by their own nature of shying away and not seeking social and interpersonal means to vent out the pain.
Prevalence of Self-Harm
Worldwide, self-harm is rising as a major public health concern, common among adolescents and young adults, with global studies showing 17-20% of teenagers and 24% of high school girls in the US reporting at least once in their lifetime 1. Even though the intention of self-harm is not to end one’s life5, self-harm is a significant predictor of suicide in adolescents7. In fact, the majority of adolescents who have engaged in NSSI have also attempted suicide and NSSI has emerged as a robust predictor of future suicidal attempt among youths with depressive disorders8,9.
Prevalence of self-harm is way higher in females than in males2. Many studies indicate a female to male ratio of more than 2:1 10,11,12. It is very easy to see that our society has a completely different sets of values and norms for females. Females are subjected to unrealistic beauty standards along with judgment and discrimination based on complexion, height, weight, and myriads of other body image issues created by the societal norms and values. Since early childhood, females start being exposed to comments and remarks regarding their look or beauty either positively or negatively. Peer pressure and social comparisons, especially with the influence of social media, leads to feelings of inadequacy, social rejection, and self-hatred. This then leads the person to self-isolate which makes them even more less likely to engage in healthy conversations with their loved ones creating a vicious cycle of loneliness and self-harm. Self-harm is strongly associated with complaints of low mood, emotional distress, suicidality, and other symptomatology’s of trauma.10.
Vulnerability to self-harm increases in individuals with histories of trauma, childhood abuse, neglect, or mental health issues such as depression, anxiety, and borderline personality disorder (BPD)3. Those identifying as LGBTQ+ and individuals facing family dysfunction or bullying are also at greater risk4,13. Since these groups are also vulnerable to being judged of being different and nonconforming to societal values and norms.
Self-Harm as dysfunction in Emotional Regulation
NSSIs have been found to be significantly associated with emotional regulation. Emotion regulation have intrapersonal and social functions domains14. A study has highlighted that individuals self-harm to cope with negative emotions15. Intrapersonal functions of emotion regulation aim to directly change how one is feeling, including alleviating distress, tension, dissociation, or suicidal thoughts. Social functions of emotional regulation aims to change one’s environment by influencing how others feel or behave, including encouraging emotional support, ameliorating distressing situations (e.g., deterring abuse), or fitting in with peers16. A 2018 meta-analysis estimates 74 % of people who self-injure report dysfunction in intrapersonal functions and 44 % report dysfunction in social functions which are most often aimed at communicating distress17.
Risk Factors to self-harm and suicide
Even though the prevalence of suicide has increased alarmingly in Nepal and other countries like US, and has been listed as the second leading cause of death among 10-24 year-olds18 by a survey cited in CDC, it is very difficult to predict suicide. Despite decades of research and attempts at suicide prevention in young age group, suicide rates among 10-19 years olds increased by 56% between 2007 and 2016. A 2017 survey found that 17.2% of high school students seriously considered making a suicidal attempt, 13.6% made a suicide plan, and 7.4% made one or more suicidal attempts19. Suicidal ideations have been found to be a strong predictor of actual suicidal attempt. In one study 86.1% of adolescents made a suicidal attempt within 12 months of having suicidal ideations20.
In November of 2016, the American Psychological Association (APA) released a statement titled, “After Decades of Research, Science Is No Better Able to Predict Suicidal Behaviors”21. This was based on a meta-analysis of 50 years of research on risk factors for suicidality in which the authors found that the ability of identified risk factors to predict suicidal thoughts and behaviors was only slightly better than chance22.
While it has generally been held that risk for suicidal behavior increases with the number of risk factors present23, it is not yet known what combinations of risk factors are most likely to lead to suicidal behavior and death by suicide24.
Even though self-harm and suicide both have a diverse predisposition, including genetic, biological, psychological and social and as stated above it is difficult to predict suicide, below are given a list of risk factors that may predispose an individual to self-harm and suicide.
Table 1. Risk factors for suicidal behavior and deaths by suicide7. Click to open in another window
Inclusion of NSSI in DSM 5
Moreover, Self-harm, as stated above is also a strong predictor of suicidality as found by many studies8,9. Taking the seriousness of Self harm as an important entity, DSM 5 has included NSSI and suicidal behavior as “other conditions that may be a focus of clinical attention” in its fifth revision25.
Self-Harm: as a means to handle difficult emotion
Self-harm is often misunderstood. Rather than a simple cry for help, it serves specific psychological functions. One major function is emotional regulation—self-harm provides temporary relief from emotional pain or intense negative feelings like sadness, anger, or emptiness28. This act is not always visible or intended to get attention; for some, it is a secret ritual, a way to express and cope with pain they find difficult to verbalize29. As Gillian Straker puts it, self-harm can be like “signing with a scar,” expressing emotional pain that words cannot convey30.
The Biological Mechanisms
From a biological perspective, self-harm activates the body’s natural pain-relief mechanisms. Cutting or injuring oneself can trigger the release of endorphins, the body’s natural painkillers, which can temporarily soothe emotional distress31. This physiological response reinforces the behavior, making it difficult to break the cycle of self-harm32.
Social and Psychological Factors
Childhood trauma, abuse, and emotional neglect are strongly linked to the development of self-harm behaviors. For example, individuals who experience invalidation in childhood or who feel misunderstood may resort to self-harm as a way of asserting control over their emotions and bodies33. Social media has also been shown to play a dual role, with certain online platforms both supporting recovery and, in some cases, promoting harmful behaviors by normalizing self-harm34.
A Case Study: “Skye”
The case of Skye, a young woman in custody, illustrates the complexity of self-harm and the potential for recovery. Skye had a traumatic past, including abuse and neglect, which led her to self-harm as a way to cope with emotional pain. Over time, she used therapy sessions to explore the origins of her behavior, finding new ways to express her emotions and reduce her self-harm urges35. Skye’s story shows that with support and persistence, it is possible to build resilience and move away from self-harm.
It has been found that Therapies such as Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) can be effective in reducing self-harm. These therapies help individuals regulate their emotions, improve distress tolerance, and express feelings in non-harmful ways36. Educating family into the intricacies of self-harm with the aim of strengthening bonding can be highly therapeutic in the recovery and relapse prevention37
References
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- Yu C, Xie Q, Lin S, Liang Y, Wang G, Nie Y, et al. Cyberbullying Victimization and Non-suicidal Self-Injurious Behavior Among Chinese Adolescents: School Engagement as a Mediator and Sensation Seeking as a Moderator. Front Psychol. 2020;11:572521.
- Esposito C, Bacchini D, Affuso G. Adolescent non-suicidal self-injury and its relationships with school bullying and peer rejection. Psychiatry Res. 2019 Apr;274:1–6.
- Klonsky ED, Victor SE, Saffer BY. Nonsuicidal Self-Injury: What We Know, and What We Need to Know. Can J Psychiatry. 2014 Nov 1;59(11):565–8.
- Ed K. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev [Internet]. 2007 Mar [cited 2024 Oct 14];27(2). Available from: https://pubmed.ncbi.nlm.nih.gov/17014942/
- Nock MK. Self-injury. Annu Rev Clin Psychol. 2010;6:339–63.
- Clarke S, Allerhand LA, Berk MS. Recent advances in understanding and managing self-harm in adolescents. F1000Research. 2019 Oct 24;8:F1000 Faculty Rev-1794.
- Asarnow JR, Porta G, Spirito A, Emslie G, Clarke G, Wagner KD, et al. Suicide Attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: Findings from the TORDIA Trial. J Am Acad Child Adolesc Psychiatry. 2011 Aug;50(8):772–81.
- Wilkinson P, Kelvin R, Roberts C, Dubicka B, Goodyer I. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011 May;168(5):495–501.
- Lutz NM, Chamberlain SR, Grant JE, Lochner C, Wilkinson PO, Ford TJ, et al. Similarities and differences in the functions of non-suicidal self-injury (NSSI) across gender non-conforming and cisgender young adults. J Affect Disord. 2024 Dec 15;367:496–506.
- Lutz NM, Chamberlain SR, Grant JE, Lochner C, Wilkinson PO, Ford TJ, et al. Similarities and differences in the functions of non-suicidal self-injury (NSSI) across gender non-conforming and cisgender young adults. J Affect Disord. 2024 Dec 15;367:496–506.
- Xiao Q, Song X, Huang L, Hou D, Huang X. Global prevalence and characteristics of non-suicidal self-injury between 2010 and 2021 among a non-clinical sample of adolescents: A meta-analysis. Front Psychiatry [Internet]. 2022 Aug 10 [cited 2024 Oct 17];13. Available from: https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2022.912441/full
- Lutz NM, Chamberlain SR, Grant JE, Lochner C, Wilkinson PO, Ford TJ, et al. Similarities and differences in the functions of non-suicidal self-injury (NSSI) across gender non-conforming and cisgender young adults. J Affect Disord. 2024 Dec 15;367:496–506.
- Hooley JM, Franklin JC. Why Do People Hurt Themselves? A New Conceptual Model of Nonsuicidal Self-Injury. Clin Psychol Sci. 2018 May 1;6(3):428–51.
- Lutz NM, Chamberlain SR, Grant JE, Lochner C, Wilkinson PO, Ford TJ, et al. Similarities and differences in the functions of non-suicidal self-injury (NSSI) across gender non-conforming and cisgender young adults. J Affect Disord. 2024 Dec 15;367:496–506.
- Edmondson AJ, Brennan CA, House AO. Non-suicidal reasons for self-harm: A systematic review of self-reported accounts. J Affect Disord. 2016 Feb 1;191:109–17.
- Taylor PJ, Jomar K, Dhingra K, Forrester R, Shahmalak U, Dickson JM. A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J Affect Disord. 2018 Feb 1;227:759–69.
- Garcia MC. Potentially Excess Deaths from the Five Leading Causes of Death in Metropolitan and Nonmetropolitan Counties — United States, 2010–2017. MMWR Surveill Summ [Internet]. 2019 [cited 2024 Oct 14];68. Available from: https://www.cdc.gov/mmwr/volumes/68/ss/ss6810a1.htm
- Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, et al. Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ. 2018 Jun 15;67(8):1–114.
- Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication – Adolescent Supplement (NCS-A). JAMA Psychiatry. 2013 Mar;70(3):10.1001/2013.jamapsychiatry.55.
- https://www.apa.org [Internet]. [cited 2024 Oct 14]. After decades of research, science is no better able to predict suicidal behaviors. Available from: https://www.apa.org/news/press/releases/2016/11/suicidal-behaviors
- Jc F, Jd R, Kr F, Kh B, Em K, X H, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull [Internet]. 2017 Feb [cited 2024 Oct 14];143(2). Available from: https://pubmed.ncbi.nlm.nih.gov/27841450/
- Lewinsohn PM, Rohde P, Seeley JR. Psychosocial risk factors for future adolescent suicide attempts. J Consult Clin Psychol. 1994 Apr;62(2):297–305.
- Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017 Feb;143(2):187–232.
- DSM Library [Internet]. [cited 2024 Oct 14]. Diagnostic and Statistical Manual of Mental Disorders | Psychiatry Online. Available from: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
- Nock MK. Why do People Hurt Themselves? New Insights Into the Nature and Functions of Self-Injury. Curr Dir Psychol Sci. 2009 Apr 1;18(2):78.
- Franklin JC, Hessel ET, Prinstein MJ. Clarifying the role of pain tolerance in suicidal capability. Psychiatry Res. 2011 Oct 30;189(3):362–7.
- Straker G. Signing with a Scar: Understanding Self-Harm. Psychoanal Dialogues. 2006 Feb 1;16:93–112.
- Klonsky ED, Glenn CR, Styer DM, Olino TM, Washburn JJ. The functions of nonsuicidal self-injury: converging evidence for a two-factor structure. Child Adolesc Psychiatry Ment Health. 2015 Sep 28;9(1):44.
- Bentley KH, Nock MK, Sauer-Zavala S, Gorman BS, Barlow DH. A functional analysis of two transdiagnostic, emotion-focused interventions on nonsuicidal self-injury. J Consult Clin Psychol. 2017 Jun;85(6):632–46.
- Gratz KL, Tull MT. The Relationship Between Emotion Dysregulation and Deliberate Self-Harm Among Inpatients with Substance Use Disorders. Cogn Ther Res. 2010 Dec 1;34(6):544.
- House A. Social media, self-harm and suicide. BJPsych Bull. 2020 Aug;44(4):131.
- Motz A, Motz. Self-harm as a sign of hope. Psychoanal Psychother. 2010 Jan 1;24(2):81–92.
- Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757–66.
- Wyman PA, Gaudieri PA, Schmeelk-Cone K, Cross W, Brown CH, Sworts L, et al. Emotional triggers and psychopathology associated with suicidal ideation in urban children with elevated aggressive-disruptive behavior. J Abnorm Child Psychol. 2009 Oct;37(7):917–28.