I compiled and posted this on this website as a definitive guide for self harmers, Everything you could ever want to know is contained at some point in the guide.  

Any questions PM me

ManicD

Self-injury: You are NOT the only one

Introduction
In spite of the title, there is no shame here. If you cause physical harm to your body in order to deal with overwhelming feelings, know that you have nothing to be ashamed of. It's likely that you're keeping yourself alive and maintaining psychological integrity with the only tool you have right now. It's a crude and ultimately self-destructive tool, but it works; you get relief from the overwhelming pain/fear/anxiety in your life. The prospect of giving it up may be unthinkable, which makes sense; you may not realize that self-harm isn't the only or even best coping method around.
For many people who self-injure, though, there comes a breakthrough moment when they realize that change is possible, that they can escape, that things can be different. They begin to believe that other tools do exist and begin figuring out which of these non-self-destructive ways of coping work for them. This site exists to help you come closer to that moment.  
How do you know if you self-injure? It may seem an odd question to some, but a few people aren't sure if what they do is "really" self-injury. Answer these questions:
1.Do you deliberately cause physical harm to yourself to the extent of causing tissue damage (breaking the skin, bruising, leaving marks that last for more than an hour)?  
2.Do you cause this harm to yourself as a way of dealing with unpleasant or overwhelming emotions, thoughts, or situations (including dissociation)?  
3.If your self-harm is not compulsive, do you often think about SI even when you're relatively calm and not doing it at the moment?
If you answer #1 and #2 yes, you are a self-injurer. If you answer #3 yes, you are most likely a repetitive self-injurer. The way you choose to hurt yourself could be cutting, hitting, burning, scratching, skin-picking, banging your head, breaking bones, not letting wounds heal, among others. You might do several of these. How you injure yourself isn't as important as recognizing that you do and what it means in your life.
Self-injurious behavior does not necessarily mean you were an abused child. It usually indicates that somewhere along the line, you didn't learn good ways of coping with overwhelming feelings. You're not a disgusting or sick; you just never learned positive ways to deal with your feelings.

Please try to make yourself safe before proceeding; some of these pages contain material that may temporarily intensify the urge to self-harm in some people. If you are struggling with the impulse to self-injure right now, you may want to skip directly to the self-help section.
 
What self-injury is

NOTE: This section contains potentially distressing material. If you self-injure now or have in the past, please make yourself safe before reading this section; it may intensify your urge to harm.

Classifying self-harm
We all do things that aren't good for us and that may harm us. We also do things that inflict injury but that are primarily intended for other purposes. Some self-harm is culturally sanctioned, while other types are seen as pathological. Where does one draw lines?
An easy line to draw is that of deliberate, immediate physical harm being done. For example, cutting your arm or hitting yourself with a hammer are clearly self-injurious acts. Things like overeating, smoking, not exercising, etc., are harmful to a person in the long run but immediate physical damage is not the desired effect of the behaviors. What, then, about things like tattooing and piercing, where physical modification of the body is deliberate and is the desired effect?
The first step in classifying self-harm, as demonstrated by Favazza (1996), is to sort out what makes a type of self-injury pathological, as opposed to culturally-sanctioned. Socially sanctioned self-harm, he found, falls into two groups: rituals and practices. Body modification (piercings, tattoos, etc) can fall into either class.
Rituals are distinguished from practices in that they reflect community tradition, usually have deep underlying symbolism, and represent a way for an individual to connect to the community. Rituals are done for purposes of healing (mostly in primitive cultures), expressions of spirituality and spiritual enlightenment, and to mark place in the social order. Practices, on the other hand, have little underlying meaning to the practitioners and are sometimes fads. Practices are done for purposes of ornamentation, showing identification with a particular cultural group, and in some cases, for perceived medical/hygienic reasons.
Non-socially sanctioned (pathological) self-harm can be classified as either suicidality, self-mutilation (which is further broken down into major, stereotypic, and superficial/moderate), or unhealthful behavior.  
Kahan and Pattison (1984; Pattison and Kahan, 1983) tackled these taxonomic problems. They began by identifying three components of self-harming acts: directness, lethality, and repetition.  

Directness
refers to how intentional the behavior is; if an act is completed in a brief period of time and done with full awareness of its harmful effects and there was conscious intent to produce those effects, it is considered direct. Otherwise, it is an indirect method of harm.

Lethality
refers to the likelihood of death resulting from the act in the immediate or near future. A lethal act is one that is highly likely to result in death, and death is usually the intent of the person doing it.

Repetition
refers to whether of not the act is done only once or is repeated frequently over a period of time It is defined simply by whether or not the act is done repeatedly.

Definitions of moderate/superficial self-injury
Perhaps the best definition of self-injury is found in Winchel and Stanley (1991), who define it as  
...the commission of deliberate harm to one's own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.
Mosby's Medical, Nursing, and Allied Health Dictionary (1994) contains the following definition:  
Self-mutilation, high risk for
A nursing diagnosis . . . defined as a state in which an individual is at high risk to injure but not kill himself or herself, and that produces tissue damage and tension relief. Risk factors include being a member of an at-risk group, inability to cope with increased psychological/physiological tension in a healthy manner, feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization, command hallucinations, need for sensory stimuli, parental emotional deprivation, and a dysfunctional family.
Groups at risk include clients with borderlines personality disorder (especially females 16 to 25 years of age), clients in a psychotic state (frequently males in young adulthood), emotionally disturbed and/or battered children, mentally retarded and autistic children, clients with a history of self-injury, and clients with a history of physical, emotional, or sexual abuse.
Malon and Berardi (1987) summarize the process they believe underlies self-injury:  
Investigators have discovered a common pattern in the cutting behavior. The stimulus...appears to be a threat of separation, rejection, or disappointment. A feeling of overwhelming tension and isolation deriving from fear of abandonment, self-hatred, and apprehension about being unable to control one's own aggression seems to take hold. The anxiety increases and culminates in a sense of unreality and emptiness that produces an emotional numbness or depersonalization. The cutting is a primitive means for combating the frightening depersonalization.
This seems to coincide with the definition given in Mosby's of someone susceptible to self-harm.
This site is concerned mainly with moderate/superficial self-harm, which is direct, repetitive, and of low lethality. Stereotypic self-mutilation tends also to be direct, repetitive, and of low lethality, whereas major self-mutilation (discussed below) is direct, not repetitive, and of low lethality. Moderate self-harm can be further divided into impulsive and compulsive.  

Varieties of Self-Harm
Self-injury is separated by Favazza (1986) into three types. Major self-mutilation (including such things as castration, amputation of limbs, enucleation of eyes, etc) is fairly rare and usually associated with psychotic states. Stereotypic self-injury comprises the sort of rhythmic head-banging, etc, seen in autistic, mentally retarded, and psychotic people. The most common form of self-mutilation, and the topic of this site, is called superficial or moderate. This can include cutting, burning, scratching, skin-picking, hair-pulling, bone-breaking, hitting, deliberate overuse injuries, interference with wound healing, and virtually any other method of inflicting damage on oneself. Both in clinical studies and in an informal Usenet survey, the most popular act was cutting, and the most popular sites were wrists, upper arms, and inner thighs. Many people have used more than one method, but even they tend to favor one or two preferred methods and sites of abuse.

Compulsive self-harm
Favazza (1996) further breaks down superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury differs in character from the other two types and is more closely associated with obsessive-compulsive disorder (OCD). Compulsive self-harm comprises hair-pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. These acts may be part of an OCD ritual involving obsessional thoughts; the person tries to relieve tension and prevent some bad thing from happening by engaging in these self-harm behaviors. Compulsive self-harm has a somewhat different nature and different roots from the impulsive (episodic and repetitive types).

Impulsive self-harm
Both episodic and repetitive self-harm are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-harm is self-injurious behavior engaged in every so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder.
What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners (Favazza and Rosenthal, 1993; Kahan and Pattison, 1984; Miller, 1994; among others) believe should be classified as a separate Axis I impulse-control disorder. Favazza (1997) suggests that until repetitive self-harm is recognized as a separate category in the DSM, practitioners should diagnose it on Axis I as 312.3, Impulse-Control Disorder Not Otherwise Specified.
Repetitive self-harm is marked by a shift toward ruminating on self-injury even when not actually doing it and self-identification as a self-injurer (Favazza, 1996). Episodic self-harm becomes repetitive when what was formerly a symptom becomes a disease in itself (as seen in the way many people who self-injure describe self-harm as being "addictive"). It is impulsive in nature, and often becomes a reflex response to any sort of stress, positive or negative. Just like smokers who reach for a cigarette when they're overwhelmed, repetitive self-injurers reach for a lighter or a blade or a belt when things get to be too much.
In a study of bulimics who self-harm, Favaro and Santonastaso (1998), used a statistical technique known as factor analysis to try to distinguish between which kinds of acts were compulsive in nature and which were impulsive. They report that vomiting, severe nail biting, and hair pulling loaded on the compulsive factor, whereas suicide attempts, substance abuse, laxative abuse, and skin cutting and burning loaded on the impulsive factor.

Should self-injurious acts be considered botched or manipulative suicide attempts?
Favazza (1998) states, quite definitively, that  
. . . self-mutilation is distinct from suicide. Major reviews have upheld this distinction. . . A basic understanding is that a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better. p. 262.
Although these behaviors are sometimes referred to "parasuicide," most researchers recognize that the self-injurer generally does not intend to die as a result of his/her acts. "Suicide attempts are reported not to provide relief, to be repeated less frequently, and to have less communicative value" (van der Kolk et al., 1991). "Patients with the [proposed Deliberate Self-Harm Syndrome] often suffer social ostracism and, in desperation, may attempt suicide (Favazza et al, 1989) [emphasis added]. Thus, although self-injurious behavior is not suicidal in intent, it can easily lead to suicidal ideation or even, when a self-harmer goes too far, suicide itself. Herpertz (1995) notes that self-injurers distinguish between self-injurious acts and suicidal ones, and Solomon and Farrand (1996) say "Although the [self-injurious and suicidal] acts themselves may blur, their meaning does not. What does emerge, though, is a link between the two acts in that one (self-injury) is an alternative to the other (suicide), and is preferable." In a review of the literature on self-injury, Favazza (1998) notes that only recently has it become generally recognized that self-harm is a morbid form of coping, one which is often turned to when suicide seems inescapable. He writes that "traditionally it has been trivialized ([delicate] wrist cutting), misidentified (suicide attempt) and regarding solely as a symptom [of borderline personality disorder.
Further support for the distinct nature of self-injury comes from a study of psychiatric diagnoses among self-injurers as opposed to attempted suicides (Ferreira de Castro et al., 1998). On Axis I, 14% of self-injurers (SI) were diagnosed with major depression, as opposed to 56% of the suicide-attempters (SA). Alcohol dependence was diagnosed in 16% of the SI group, but in 26% of the SA group. Only 2% of the SI group were considered schizophrenic; 9% of the SA group were. The SI group was more likely to be dysthymic (12% vs 7%) or to be diagnosed with adjustment disorder with depressed mood (24% vs 6%). Of course, the fact of a suicide attempt may have influenced the depression-related diagnoses.
This study also revealed similar disparities in Axis II diagnoses of those whose self-harm was directed toward suicide and those whose was not, although 9% of both groups were considered borderline and 0% of each were considered to have avoidant personality disorder. There were sharp differences among rates in the other personality disorders -- dependent: 13% SI, 7% of SA; schizoid: 2% SI, 5% SA; and histrionic: 22% SI, 4% SA. It seems clear, then, that those who self-injure in order to die and those who do it in order to cope present very different psychiatric profiles.
Informal surveys collected via the net reveal that many of those who injure themselves are strongly aware of the fine line they walk, but are also resentful of doctors and mental health professionals who mistake their incidents of self-harm as suicide attempts instead of seeing them as the desperate attempts to stave off suicide that they often are.

Is self-injury the same thing as Munchausen's or some other factitious disorder?
Again, NO. Little research has been done on whether there is a connection between SI and Munchausen's or similar syndromes, but uneducated medical professionals sometimes conflate the two. In SI, the person is injuring to escape unbearable emotional and physiological tension; in Munchausen's the injuries inflicted are deliberate and calculated to produce specific symptoms that will lead to a medical hospital admission. Although some people who self-injure desire hospitalization, it is almost always to a psychiatric ward and not to a general medical floor. Clients with Munchausen's, on the other hand, shy away from psychiatric care and seek to be admitted on the medical service.
 
Why do people deliberately injure themselves?
Drowning in the dark blood of would-be brothers who,
beyond the pressing of fingers, those for whom
the slice is only the beginning, and a different kind
of light comes in, begs recognition and peace of mind.
-- Judybats
This may be the aspect of self-harm that is most puzzling to those who do not do it. Why would anyone choose to inflict physical damage on him or herself? Because they cannot imagine themselves doing such a thing under any circumstances, many people dismiss self-injury as "senseless" or "irrational" behavior. And certainly it does seem that way at first glance.
But people generally do things for reasons that make sense to them. The reasons may not be apparent or may not fit into our frame of reference, but they exist and recognizing their existence is crucial to understanding self-harm. With understanding of the reasons behind a particular act of self-harm comes knowledge of the coping skills that are lacking. When you know what skills are missing, you can start trying to introduce them.
This page is in two sections. The first has to do with what people who engage in SIB say it does for them. The second deals with possible biological or psychoneurological reasons -- why some people find relief in self-harm while others don't. The message of both is simple: It's about coping.

The assumption is that the alternative to self-injury is "acting normally," but on the contrary . . . the alternative to self-injury is total loss of control and possibly suicide. It becomes a forced choice from among limited options.
Solomon and Farrand (1996)

Psychological motivations: What self-injurers say SI does for them
Many papers on self-harm (Miller, 1994; Favazza 1986, 1996; Connors, 1996a, 2000; Solomon & Farrand, 1996; Ousch et al., 1999; Suyemoto, 1998; and others), have uncovered possible motivations for self-injurious behavior:
•Escape from emptiness, depression, and feelings of unreality.  
•Easing tension.  
•Providing relief: when intense feelings build, self-injurers are overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.  
•Relieving anger: many self-injurers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings.  
•Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive.  
•Grounding in reality, as a way of dealing with feelings of depersonalization and dissociation  
•Maintaining a sense of security or feeling of uniqueness  
•Obtaining a feeling of euphoria  
•Preventing suicide
•Expressing emotional pain they feel they cannot bear
•Obtaining or maintaining influence over the behavior of others  
•Communicating to others the extent of their inner turmoil  
•Communicating a need for support  
•Expressing or repressing sexuality  
•Expressing or coping with feelings of alienation  
•Validating their emotional pain -- the wounds can serve as evidence that those feelings are real
•Continuing abusive patterns: self-injurers tend to have been abused as children.  
•Punishing oneself for being "bad"  
•Obtaining biochemical relief: there is some thought that adults who were repeatedly traumatized as children have a hard time returning to a "normal" baseline level of arousal and are, in some sense, addicted to crisis behavior. Self-harm can perpetuate this kind of crisis state  
•Diverting attention (inner or outer) from issues that are too painful to examine  
•Exerting a sense of control over one's body  
•Preventing something worse from happening  
These reasons can be broadly grouped into three categories:  
Affect regulation -- Trying to bring the body back to equilibrium in the face of turbulent or unsettling feelings. This includes reconnection with the body after a dissociative episode, calming of the body in times of high emotional and physiological arousal, validating the inner pain with an outer expression, and avoiding suicide because of unbearable feelings. In many ways, as Sutton says, self-harm is a "gift of survival." It can be the most integrative and self-preserving choice from a very limited field of options.  
Communication -- Some people use self-harm as a way to express things they cannot speak. When the communication is directed at others, the SIB is often seen as manipulative. However, manipulation is usually an indirect attempt to get a need met; if a person learns that direct requests will be listened to and addressed the need for indirect attempts to influence behavior decreases. Thus, understanding what an act of self-harm is trying to communicate can be crucial to dealing with it in an effective and constructive way.
Control/punishment -- This category includes trauma reenactment, bargaining and magical thinking (if I hurt myself, then the bad thing I am fearing will be prevented), protecting other people, and self-control. Self-control overlaps somewhat with affect regulation; in fact, most of the reasons for self-harm listed above have an element of affect control in them.
In an interesting theory that combines all three categories, Miller (1994) posits an explanation for why such a large majority of peep who self-harm are female. Women are not socialized to express violence externally and when confronted with the vast rage many self-injurers feel, women tend to vent on themselves. She quotes the feminist poet Adrienne Rich:  
"Most women have not even been able to touch  
this anger except to drive it inward like a  
rusted nail."
Miller says, "Men act out. Women act out by acting in." Another reason fewer men self-injure may be that men are socialized in a way that makes repressing feelings the norm. Linehan's (1993a) theory that self-harm results in part from chronic invalidation, from always being told that your feelings are bad or wrong or inappropriate, could explain the gender disparity in self-injury; men are generally brought up to hold emotion in.

Alexithymia
Alexithymia is a fairly recent psychological construct describing the state of not being able to describe the emotions one is feeling. Alexithymia was positively linked to self-injurious behavior in a 1996 study (Zlotnick, et el.) and is congruent with how people who self-injure often describe the emotional state before an injury; they frequently cannot pinpoint any particular feeling that was present. This is especially important in understanding the communicative function of self-injury: "Rather than use words to express feelings, an alexithymic's communication is an act aimed at making others feel [those same feelings]" (Zlotnick et al., 1996).

Self-capacities and Invalidation
A constructivist theory of self-injurious behavior (Deiter, Nicholls, & Pearlman, 2000) holds that people who self-injure usually have not developed three important self-capacities: the ability to tolerate strong affect, the ability to maintain a sense of self-worth, and the ability to maintain a sense of connection to others. The first of these speaks directly to the affect-regulation role of self-harm; the others are perhaps related to its communicative functions.  
Pearlman et al. (2000) note that "when children experience shaming and punitive rhetoric or physical blows rather than responsive words" they cannot internalize others are loving and cannot develop the capacity to maintain a sense of connection to others. They further state, "The ability to experience, tolerate, and integrate strong affect cannot develop fully when strong feelings are met with punishment or derision." Having a sense that some feelings are unacceptable and not allowed also impairs this ability. And the ability to maintain a sense of oneself as a person of worth cannot be developed when a child never feels she is good enough, when her "existence and accomplishments are met with silence or abusive words or actions."
Interestingly, all of these conditions are found in invalidating environments, which Linehan and others have tied to future self-injury.  
Finally, Haines and Williams (1997) found that self-mutilators reported more use of problem avoidance as a coping strategy and perceived themselves to have less control over problem-solving options. This feeling of disempowerment may in turn be related to the chronic invalidation many self-injurers have experienced.  

Physiological concerns: What the researchers have found
People who self-injure tend to be dysphoric -- experiencing a depressed mood with a high degree of irritability and sensitivity to rejection and some underlying tension -- even when not actively hurting themselves. The pattern found by Herpertz (1995) indicates that something, usually some sort of interpersonal stressor, increases the level of dysphoria and tension to an unbearable degree. The painful feelings become overwhelming: it's as if the usual underlying uncomfortable affect is escalated to a critical maximum point. "SIB has the function of bringing about a transient relief from these [high levels of irritability and sensitivity to rejection]," Herpertz said. This conclusion is supported by the work of Haines and her colleagues.  
In a fascinating study, Haines et al. (1995) led groups of self-injuring and non-self-injuring subjects through guided imagery sessions. Each subject experienced the same four scenarios in random order: a scene in which aggression was imagined, a neutral scene, a scene of accidental injury, and one in which self-injury was imagined. The scripts had four stages: scene-setting, approach, incident, and consequence. During the guided imagery sessions, physiological arousal and subjective arousal were measured.  
The results were striking. Subject reactions across groups didn't differ on the aggression, accident, and neutral scripts. In the self-injury script, though, the control groups went to a high level of arousal and stayed there throughout the script, in spite of relaxation instructions contained in the "consequences" stage. In contrast, self-injurers experienced increased arousal through the scene-setting and approach stages, until the the decision to self-injure was made. Their tension then dropped, dropping even more at the incident stage and remaining low.  
These results provide strong evidence that self-injury provides a quick, effective release of physiological tension, which would include the physiological arousal brought on by negative or overwhelming psychological states. As Haines et al. say  
Self-mutilators often are unable to provide explanations for their own self-mutilative behavior. . . . Participants reported continued negative feelings despite reduced psychophysiological arousal. This result suggests that it is the alteration of psychophysiological arousal that may operate to reinforce and maintain the behavior, not the psychological response. (1995, p. 481)
In other words, self-injury may be a preferred coping mechanism because it quickly and dramatically calms the body, even though people who self-injure may have very negative feelings after an episode. They feel bad, but the overwhelming psychophysiological pressure and tension is gone. Herpertz et al. (1995) explain this:  
We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70).
A recent case study (Sachsse et al., 2002) supports the idea that self-injury acts to reduce physiological and thus emotional stress. They tracked the nightly cortisol levels in a woman who self-harmed, then compared the results for days on which she did not engage in self-harm acts to those for days during which she did hurt herself. Cortisol excretion is increased under stress, which makes it an excellent marker for stress levels. An analysis of the results showed that on the days during which the woman had harmed herself, her cortisol levels were significantly lower than on other days.
Another stress-reduction theory, set forth by Herman (1992), says that most children who are abused discover that a serious jolt to the body, like that produced by self-injury, can make intolerable feelings go away temporarily. This may help explain how self-injury gets entrenched as a coping mechanism.

Brain chemistry and serotonin
Brain chemistry may play a role in determining who self-injures and who doesn't. Simeon et al. (1992) found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system. Favazza (1993) refers to this study and to work by Coccaro on irritability to posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts.  
Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to serotonin dysfunction. More recently, Steiger et al. (2000), in a study of bulimics, found that serotonin function in bulimic women was significantly lower in bulimics who also engaged in self-harm.  
 
Who self-injures?
Psychological characteristics common in self-injurers
The overall picture seems to be of people who:  
•strongly dislike/invalidate themselves  
•are hypersensitive to rejection  
•are chronically angry, usually at themselves  
•tend to suppress their anger  
•have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward  
•are more impulsive and more lacking in impulse control  
•tend to act in accordance with their mood of the moment  
•tend not to plan for the future  
•are depressed and suicidal/self-destructive  
•suffer chronic anxiety  
•tend toward irritability  
•do not see themselves as skilled at coping  
•do not have a flexible repertoire of coping skills  
•do not think they have much control over how/whether they cope with life  
•tend to be avoidant  
•do not see themselves as empowered  
People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (1995). Similar findings appear in Simeon et al. (1992); they found that two major emotional states most commonly present in self-injurers at the time of injury -- anger and anxiety -- also appeared as longstanding personality traits. Linehan (1993a) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals.
In another study, Herpertz et al. (1995) found, in addition to the poor affect regulation, impulsivity, and aggression noted earlier, disordered affect, a great deal of suppressed anger, high levels of self-directed hostility, and a lack of planning among self-injurers:  
We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70).
And Dulit et al. (1994) found several common characteristics in self-injuring subjects with borderline personality disorder (as opposed to non-SI BPD subjects):  
•more likely to be in psychotherapy or on medications
•more likely to have additional diagnoses of depression or bulimia  
•more acute and chronic suicidality  
•more lifetime suicide attempts  
•less sexual interest and activity  
In a study of bulimics who self-injure (Favaro and Santonastaso, 1998), subjects whose SIB was partially or mostly impulsive had higher scores on measures of obsession-compulsion, somatization, depression, anxiety, and hostility.
Simeon et al. (1992) found that the tendency to self-injure increased as levels of impulsivity, chronic anger, and somatic anxiety increased. The higher the level of chronic inappropriate anger, the more severe the degree of self-injury. They also found a combination of high aggression and poor impulse control. Haines and Williams (1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping. In addition, they had low self-esteem and low optimism about life.

Demographics
Conterio and Favazza estimate that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000, or 1%, of Americans self-injure). In their 1986 survey, they found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported.
Types of self-injurious behavior reported were as follows:  
Cutting: 72 percent  
Burning: 35 percent  
Self-hitting: 30 percent  
Interference w/wound healing: 22 percent  
Hair pulling: 10 percent  
Bone breaking: 8 percent  
Multiple methods: 78 percent (included in above)  
On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years.
Half the sample had been hospitalized for the problem (the median number of days was 105 and the mean 240). Only 14% said the hospitalization had helped a lot (44 percent said it helped a little and 42 percent not at all). Outpatient therapy (75 sessions was the median, 60 the mean) had been tried by 64 percent of the sample, with 29 percent of those saying it helped a lot, 47 percent a little, and 24 percent not at all. Thirty-eight percent had been to a hospital emergency room for treatment of self-inflicted injuries (the median number of visits was 3, the mean 9.5).

Why so many women?
Although the results of an informal net survey and the composition of an e-mail support mailing list for self-injurers don't show quite as strong a female bias as Conterio's numbers do (the survey population turned out to be about 85/15 percent female, and the list is closer to 67/34 percent), it is clear that women tend to resort to this behavior more often than men do. Miller (1994) is undoubtedly onto something with her theories about how women are socialized to internalize anger and men to externalize it. It is also possible that because men are socialized to repress emotion, they may have less trouble keeping things inside when overwhelmed by emotion or externalizing it in seemingly unrelated violence.
As early as 1985, Barnes recognized that gender role expectations played a significant role in how self-injurious patients were treated. Her study showed only two statistically significant diagnoses among self-harmers who were seen at a general hospital in Toronto: women were much more likely to receive a diagnosis of "transient situational disturbance" and men were more likely to be diagnosed as substance abusers. Overall, about a quarter of both men and women in this study were diagnosed with personality disorder.
Barnes suggests that men who self-injure get taken more "seriously" by physicians; only 3.4 percent of the men in the study were considered to have transient and situational problems, as compared to 11.8 percent of the women.
 
Etiology (history and causes)

Past trauma/invalidation as an antecedent
Van der Kolk, Perry, and Herman (1991) conducted a study of patients who exhibited cutting behavior and suicidality. They found that exposure to physical or sexual abuse, physical or emotional neglect, and chaotic family conditions during childhood, latency and adolescence were reliable predictors of the amount and severity of cutting. The earlier the abuse began, the more likely the subjects were to cut and the more severe their cutting was. Sexual abuse victims were most likely of all to cut. They summarize,  
...neglect [was] the most powerful predictor of self-destructive behavior. This implies that although childhood trauma contributes heavily to the initiation of self-destructive behavior, lack of secure attachments maintains it. Those ... who could not remember feeling special or loved by anyone as children were least able to ...control their self-destructive behavior.
In this same paper, van der Kolk et al. note that dissociation and frequency of dissociative experiences appear to be related to the presence of self-injurious behavior. Dissociation in adulthood has also been positively linked to abuse, neglect, or trauma as a child.
More support for the theory that physical or sexual abuse or trauma is an important antecedent to this behavior comes from a 1989 article in the American Journal of Psychiatry. Greenspan and Samuel present three cases in which women who seemed to have no prior psychopathology presented as self-cutters following a traumatic rape.

Invalidation independent of abuse
Although sexual and physical abuse and neglect can seemingly precipitate self-injurious behavior, the converse does not hold: many of those who hurt themselves have suffered no childhood abuse. A 1994 study by Zweig-Frank et al. showed no relationship at all between abuse, dissociation, and self-injury among patients diagnosed with borderline personality disorder. A followup study by Brodsky, et al. (1995) also showed that abuse as a child is not a marker for dissociation and self-injury as an adult. Because of these and other studies as well as personal observations, it's become obvious to me that there is some basic characteristic present in people who self-injure that is not present in those who don't, and that the factor is something more subtle than abuse as a child. Reading Linehan's work provides a good idea of what the factor is.
Linehan (1993a) talks about people who SI having grown up in "invalidating environments." While an abusive home certainly qualifies as invalidating, so do other, "normal," situations. She says:  
An invalidating environment is one in which communication of private experiences is met by erratic, inappropriate, or extreme responses. In other words, the expression of private experiences is not validated; instead it is often punished and/or trivialized. the experience of painful emotions [is] disregarded. The individual's interpretations of her own behavior, including the experience of the intents and motivations of the behavior, are dismissed...
Invalidation has two primary characteristics. First, it tells the individual that she is wrong in both her description and her analyses of her own experiences, particularly in her views of what is causing her own emotions, beliefs, and actions. Second, it attributes her experiences to socially unacceptable characteristics or personality traits.
This invalidation can take many forms:  
•"You're angry but you just won't admit it."  
•"You say no but you mean yes, i know."  
•"You really did do (something you in truth hadn't). Stop lying."  
•"You're being hypersensitive."  
•"You're just lazy."  
•"I won't let you manipulate me like that."  
•"Cheer up. Snap out of it. You can get over this."  
•"If you'd just look on the bright side and stop being a pessimist..."  
•"You're just not trying hard enough."  
•"I'll give you something to cry about!"  
Everyone experiences invalidations like these at some time or another, but for people brought up in invalidating environments, these messages are constantly received. Parents may mean well but be too uncomfortable with negative emotion to allow their children to express it, and the result is unintentional invalidation. Chronic invalidation can lead to almost subconscious self-invalidation and self-distrust, and to the "I never mattered" feelings van der Kolk et al. describe.  

Biological Considerations and Neurochemistry
It has been demonstrated (Carlson, 1986) that reduced levels of serotonin lead to increased aggressive behavior in mice. In this study, serotonin inhibitors produced increased aggression and serotonin exciters decreased aggression in mice. Since serotonin levels have also been linked to depression, and depression has been positively identified as one of the long-term consequences of childhood physical abuse (Malinosky-Rummell and Hansen, 1993), this could explain why self-injurious behaviors are seen more frequently among those abused as children than among the general population (Malinosky-Rummel and Hansen, 1993). Apparently, the most promising line of investigation in this area is the hypothesis that self-harm may result from decreases in necessary brain neurotransmitters.
This view is supported by evidence presented in Winchel and Stanley (1991) that although the opiate and dopaminergic systems don't seem to be implicated in self-harm, the serotonin system does. Drugs that are serotonin precursors or that block the reuptake of serotonin (thus making more available to the brain) seem to have some effect on self-harming behavior. Winchel and Staley hypothesize a relationship between this fact and the clinical similarities between obsessive- compulsive disorder (known to be helped by serotonin-enhancing drugs) and self-injuring behavior. They also note that some mood-stabilizing drugs (such as Tegretol, Depakote) can stabilize this sort of behavior.

Serotonin
Coccaro and colleagues have done much to advance the hypothesis that a deficit in the serotonin system is implicated in self-injurious behavior. They found (1997c) that irritability is the core behavioral correlate of serotonin function, and the exact type of aggressive behavior shown in response to irritation seems to be dependent on levels of serotonin -- if they are normal, irritability may be expressed by screaming, throwing things, etc. If serotonin levels are low, aggression increases and responses to irritation escalate into self-injury, suicide, and/or attacks on others.
Simeon et al. (1992) found that self-injurious behavior was significantly negatively correlated with number of platelet imipramine binding sites (self-injurers have fewer platelet imipramine binding sites, a level of serotonin activity) and note that this "may reflect central serotonergic dysfunction with reduced presynaptic serotonin release. . . . Serotonergic dysfunction may facilitate self-mutilation."
When these results are considered in light of work such as that by Stoff et al. (1987) and Birmaher et al. (1990), which links reduced numbers of platelet imipramine binding sites to impulsivity and aggression, it appears that the most appropriate classification for self-injurious behavior might be as an impulse-control disorder similar to trichotillomania, kleptomania, or compulsive gambling.
Herpertz (Herpertz et al, 1995; Herpertz and Favazza, 1997) has investigated how blood levels of prolactin respond to doses of d-fenfluramine in self-injuring and control subjects. The prolactin response in self-injuring subjects was blunted, which is "suggestive of a deficit in overall and primarily pre-synaptic central 5-HT (serotonin) function." Stein et al. (1996) found a similar blunting of prolactin response on fenfluramine challenge in subjects with compulsive personality disorder, and Coccaro et al. (1997c) found prolactin response varied inversely with scores on the Life History of Aggression scale.
It is not clear whether these abnormalities are caused by the trauma/abuse/invalidating experiences or whether some individuals with these kinds of brain abnormalities have traumatic life experiences that prevent their learning effective ways to cope with distress and that cause them to feel they have little control over what happens in their lives and subsequently resort to self-injury as a way of coping.

Knowing when to stop -- pain doesn't seem to be a factor
Most of those who self-mutilate can't quite explain it, but they know when to stop a session. After a certain amount of injury, the need is somehow satisfied and the abuser feels peaceful, calm, soothed. Only 10% of respondents to Conterio and Favazza's 1986 survey reported feeling "great pain"; 23 percent reported moderate pain and 67% reported feeling little or no pain at all. Naloxone, a drug that reverses the effects of opiods (including endorphins, the body's natural painkillers), was given to self-mutilators in one study but did not prove effective (see Richardson and Zaleski, 1986). These findings are intriguing in light of Haines et al. (1995), a study that found that reduction of psychophysiological tension may be the primary purpose of self-injury. It may be that when a certain level of physiological calm is reached, the self-injurer no longer feels an urgent need to inflict harm on his/her body. The lack of pain may be due to dissociation in some self-injurers, and to the way in which self-injury serves as a focusing behavior for others.

Behavioralist explanations
NOTE: most of this applies mainly to stereotypical self-injury, such as that seen in retarded and autistic clients.
Much work has been done in behavioral psychology in an attempt to explain the etiology of self-injurious behavior. In a 1990 review, Belfiore and Dattilio examine three possible explanations. They quote Phillips and Muzaffer (1961) in describing self-injury as "measures carried out by an individual upon him/herself which tend to 'cut off, to remove, to maim, to destroy, to render imperfect' some part of the body." This study also found that frequency of self-injury was higher in females but severity tended to be more extreme in males. Belfiore and Dattilio also point out that the terms "self-injury" and "self-mutilation" are deceiving; the description given above does not speak to the intent of the behavior.  

Operant Conditioning
It should be noted that explanations involving operant conditioning are generally more useful when dealing with stereotypic self-injury and less useful with episodic/repetitive behavior.
Two paradigms are put forth by those who wish to explain self-injury in terms of operant conditioning. One is that individuals who self-injure are positively reinforced by getting attention and thus tend to repeat the self-harming acts. Another implication of this theory is that the sensory stimulation associated with self-harm could serve as a positive reinforcer and thus a stimulus for further self-abuse.
The other posits that individuals self-injure in order to remove some aversive stimulus or unpleasant condition (emotional, physical, whatever). This negative reinforcement paradigm is supported by research showing that intensity of self-injury can be increased by increasing the "demand" of a situation. In effect, self-harm is a way to escape otherwise intolerable emotional pain.  

Sensory Contingencies
One hypothesis long held has been that self-injurers are attempting to mediate levels of sensory arousal. Self-injury can increase sensory arousal (many respondents to the internet survey said it made them feel more real) or decrease it by masking sensory input that is even more distressing than the self-harm. This seems related to what Haines and Williams (1997) found: self-injury provides a quick and dramatic release of physiological tension/arousal. Cataldo and Harris (1982) concluded that theories of arousal, though satisfying in their parsimony, need to take into consideration biological bases of these factors.
 
Diagnoses associated with self-injury
In the DSM-IV, the only diagnoses that mention self-injury as a symptom or criterion for diagnosis are borderline personality disorder, stereotypic movement disorder (associated with autism and mental retardation), and factitious (faked) disorders in which an attempt to fake physical illness is present (APA, 1995; Fauman, 1994). It also seems to be generally accepted that extreme forms of self-mutilation (amputations, castrations, etc) are possible in psychotic or delusional patients. Reading the DSM, one can easily get the impression that people who self-injure are doing it willfully, in order to fake illness or be dramatic. Another indication of how the therapeutic community views those who harm themselves is seen in the opening sentence of Malon and Berardi's 1987 paper "Hypnosis and Self-Cutters":
Since self-cutters were first reported on in 1960, they have continued to be a prevalent mental health problem. (emphasis added)
To these researchers, self-cutting is not the problem, the self-cutters are.
However, self-injurious behavior is seen in patients with many more diagnoses than the DSM suggests. In interviews, people who engage in repetitive self-injury have reported being diagnosed with depression, bipolar disorder, anorexia, bulimia, obsessive-compulsive disorder, post-traumatic stress disorder, many of the dissociative disorders (including depersonalization disorder, dissociative disorder not otherwise specified, and MPD/DID), anxiety and panic disorders, and impulse-control disorder not otherwise specified. In addition, the call for a separate diagnosis for self-injurers is being taken up by many practitioners.
It is beyond the scope of this page to provide definitive information about all of these conditions. I will try, instead, to give a basic description of the disorder, explain when I can how self-injury might fit into the pattern of the disease, and give references to pages where much more information is available. In the case of borderline personality disorder (BPD), I devote considerable space to discussion simply because the label BPD is sometimes automatically applied in cases where self-injury is present, and the negative effects of a BPD misdiagnosis can be extreme.

Conditions in which self-injurious behavior is seen
•Borderline Personality Disorder  
•Mood Disorders  
•Eating Disorders  
•Obsessive-Compulsive Disorder  
•Post-Traumatic Stress Disorder  
•Dissociative Disorders  
•Anxiety and/or Panic  
•Impulse-control Disorder Not Otherwise Specified  
•Self-injury as itself a diagnosis  
As mentioned, self-injury is often seen in those with autism or mental retardation; you can find a good discussion of self-harm behaviors in this group of disorders at the website of The Center for the Study of Autism.

Borderline Personality Disorder
"Every time I say something they find hard to hear, they chalk it up to my anger, and never to their own fear."
--Ani DiFranco
Unfortunately, the most popular diagnosis assigned to anyone who self-injures is borderline personality disorder. Patients with this diagnosis are frequently treated as outcasts by psychiatrists; Herman (1992) tells of a psychiatric resident who asked his supervising therapist how to treat borderlines was told, "You refer them." Miller (1994) notes that those diagnosed as borderline are often seen as being responsible for their own pain, more so than patients in any other diagnostic category. BPD diagnoses are sometimes used as a way to "flag" certain patients, to indicate to future care givers that someone is difficult or a troublemaker. I sometimes used to think of BPD as standing for "Bitch Pissed Doc."
This is not to say that BPD is a fictional illness; I have encountered people who meet the DSM criteria for BPD. They tend to be people in great pain who are struggling to survive however they can, and they often unintentionally cause great pain for those who love them. But I have met many more people who don't meet the criteria but have been given the label because of their self-injury.
Consider, however, the DSM-IV Handbook of Differential Diagnosis (First et al. 1995). In its decision tree for the symptom "self-mutilation," the first decision point is "Motivation is to decrease dysphoria, vent angry feelings, or to reduce feelings of numbness... in association with a pattern of impulsivity and identity disturbance." If this is true, then a practitioner following this manual would have to diagnose someone as BPD purely because they cope with overwhelming feelings by self-injuring.
This is particularly disturbing in light of recent findings (Herpertz, et al., 1997) that only 48% of their sample of self-injurers met the DSM criteria for BPD. When self-injury was excluded as a factor, only 28% of the sample met the criteria.
Similar results were seen in a 1992 study by Rusch, Guastello, and Mason. They examined 89 psychiatric inpatients who had been diagnosed as BPD, and summarized their results statistically.
Different raters examined the patients and the hospital records and indicated the degree to which each of the eight defining BPD symptoms were present. One fascinating note: only 36 of the 89 patients actually met the DSM-IIIR criteria (five of eight symptoms present) for being diagnosed with the disorder. Rusch and colleagues ran a statistical procedure called factor analysis in an effort to discover which symptoms tend to co-occur.
The results are interesting. They found three symptom complexes: the "volatility" factor, which consisted of inappropriate anger, unstable relationships, and impulsive behavior; the "self-destructive/unpredictable" factor, which consisted of self-harm and emotional instability; and the "identity disturbance" factor.
The SDU (self-destructive) factor was present in 82 of the patients, while the volatility was seen in only 25 and the identity disturbance in 21. The authors suggest that either self-mutilation is at the core of BPD or clinicians tend to use self-harm as a sufficient criterion to label a patient BPD. The latter seems more likely, given that fewer than half of the patients studied met the DSM criteria for BPD.  
One of the foremost researchers into Borderline Personality Disorder, Marsha Linehan, does believe that it is a valid diagnosis, but in a 1995 article notes: "No diagnosis should be made unless the DSM-IV criteria are strictly applied. . . . the diagnosis of a personality disorder requires the understanding of a person's long-term pattern of functioning." (Linehan, et al. 1995, emphasis added.) That this does not happen is evident in the increasing numbers of teenagers being diagnosed as borderline. Given that the DSM-IV refers to personality disorders as longstanding patterns of behavior usually beginning in early adulthood, one wonders what justification is used for giving a 14-year-old a negative psychiatric label that will stay with her all of her life? Reading Linehan's work has caused some therapists to wonder if perhaps the label "BPD" is too stigmatized and too over-used, and if it might be better to call it what it really is: a disorder of emotional regulation.
If a care giver diagnoses you as BPD and you're fairly certain the label is inaccurate and counterproductive, find another doctor. Wakefield and Underwager (1994) point out that mental health professionals are no less likely to err and no less prone to the cognitive shortcuts we all take than anyone else is:  
When many psychotherapists reach a conclusion about a person, not only do they ignore anything that questions or contradicts their conclusions, they actively fabricate and conjure up false statements or erroneous observations to support their conclusion [note that this process can be unconscious] (Arkes and Harkness 1980). When given information by a patient, therapists attend only to that which supports the conclusion they have already reached (Strohmer et al. 1990). . . . The frightening fact about conclusions reached by therapists with respect to patients is that they are made within 30 seconds to two or three minutes of the first contact (Ganton and Dickinson 1969; Meehl 1959; Weber et al. 1993). Once the conclusion is reached, mental health professionals are often impervious to any new information and persist in the label assigned very early in the process on the basis of minimal information, usually an idiosyncratic single cue (Rosenhan 1973) (emphasis added).
[NOTE: My inclusion of a quote from these authors does not constitute a full endorsement of their entire body of work.]

Mood Disorders
Self-injury is seen in patients who suffer from major depressive illness and from bipolar disorder. It is not exactly clear why this is so, although all three problems have been linked to deficiencies in the amount of serotonin available to the brain. It is important to separate the self-injury from the mood disorder; people who self-injure frequently come to learn that it is a quick and easy way of defusing great physical or psychological tension, and it is possible for the behavior to continue after the depression is resolved. Care should be taken to teach patients alternative ways to cope with distressing feelings and over-stimulation.

Eating Disorders
Self-inflicted violence is often seen in women and girls with anorexia (a disease in which a person has an obsession with losing weight, dieting, or fasting, and as a distorted body image -- seeing his/her skeletal body as "fat") or bulimia (an eating disorder marked by binges where large amounts of food are eaten followed by purges, during which the person attempts to remove the food from her/his body by forced vomiting, abuse of laxatives, excessive exercise, etc).
There are many theories as to why SI and eating disorders co-occur so frequently. Cross is quoted in Favazza (1996) as saying that the two sorts of behavior are  
attempts to own the body, to perceive it as self (not other), known (not uncharted and unpredictable), and impenetrable (not invaded or controlled from the outside. . . . [T]he metaphorical destruction between body and self collapses [ie, is no longer metaphorical]: thinness is self-sufficiency, bleeding emotional catharsis, bingeing is the assuaging of loneliness, and purging is the moral purification of self. (p.51)
Favazza himself favors the theory that young children identify with food, and thus during the early stages of life, eating could be seen as a consuming of something that is self and thus make the idea of self-mutilation easier to accept. He also notes that children can anger their parents by refusing to eat; this could be a prototype of self-mutilation done to retaliate against abusive adults. In addition, children can please their parents by eating what they are given, and in this Favazza sees the prototype for SI as manipulation.
He does note, though, that self-injury brings about a rapid release from tension, anxiety, racing thoughts, etc. This could be a motivation for an eating-disordered person to hurt him/herself -- shame or frustration at the eating behavior leads to increased tension and arousal and the person cuts or burns or hits to obtain quick relief from these uncomfortable feelings. Also, from having spoken to several people who both have an eating disorder and self-injure, I think it's quite possible that self-injury offers some an alternative to the disordered eating. Instead of fasting or purging, they cut.
There haven't been many laboratory studies probing the link between SI and eating disorders, so all of the above is speculation and conjecture.
Two eating-disorders web pages -- the ED section of Something Fishy and its associated site, Mirror, Mirror -- are probably the best sources for detailed information on eating disorders.

Obsessive-Compulsive Disorder
Self-injury among those diagnosed with OCD is considered by many to be limited to compulsive hair-pulling (known as trichotillomania and usually involving eyebrows, eyelashes, and other body hair in addition to head hair) and/or compulsive skin picking/scratching/excoriation. In the DSM-IV, though, trichotillomania is classified as an impulse-control disorder, and OCD as an anxiety disorder. Unless the self-injury is part of a compulsive ritual designed to ward off some bad thing that would otherwise happen, it should not be considered a symptom of OCD. The DSM-IV diagnosis of OCD requires:
1.the presence of obsessions (recurrent and persistent thoughts that are not simply worries about everyday matters) and/or compulsions (repetitive behaviors that a person feels a need to perform (counting, checking, washing, ordering, etc) in order to stave off anxiety or disaster);  
2.recognition at some point that the obsessions or compulsions are unreasonable;  
3.excessive time spent on obsessions or compulsions, reduction of quality of life due to them, or marked distress due to them;  
4.the content of the behaviors/thoughts is not confined to that associated with any other Axis I disorder currently present;  
5.the behavior/thoughts not being a direct result of medication or other drug use.
The current consensus seems to be that OCD is due to a serotonin imbalance in the brain; SSRI's are the drug of choice for this condition. A 1995 study of self-injury among female OCD patients (Yaryura-Tobias et al.) showed that clomipramine (a tricyclic antidepressant known as Anafranil) reduced the frequency of both compulsive behaviors and of SIB. It is possible that this reduction came about simply because the self-injury was a compulsive behavior with different roots than SIB in non-OCD patients, but the study subjects had much in common with them -- 70 percent of them had been sexually abused as children, they showed the presence of eating disorders, etc.
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