Pages: 1 2  Next -- Posted by ManicDepressant at 5:11 pm on Oct. 18, 2005 Before I start I would like to note that this is not my own work, I compiled and edited this information written by Deb Martinson. The full document and website can be found at http://www.palace.net/~llama/psych/injury.html 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. ........................................ -- Posted by ManicDepressant at 5:11 pm on Oct. 18, 2005 The study strongly suggests, again, that self-injury and the serotonergic system are somehow related. For a wealth of information on OCD and trichotillomania, see the excellent pages at Fairlite.com.   Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder refers to a collection of symptoms that may occur as a delayed response to a serious trauma (or series of traumas) Herman (1992) suggests an expansion of the PTSD diagnosis for those who have been continually traumatized over a period of months or years. Based on patterns of history and symptomology in her clients, she created the concept of Complex Post-Traumatic Stress Disorder. CPTSD includes self-injury as a symptom of the disordered affect regulation severely traumatized patients often have (interestingly enough, one of the main reasons people who hurt themselves do so is in order to control seemingly uncontrollable and frightening emotions). This diagnosis, unlike BPD, centers on why patients who self-harm do so, referring to definite traumatic events in the client's past. Although CPTSD is not a one-size-fits-all diagnosis for self-injury any more than BPD is, Herman's book does help those who have a history of repeated severe trauma understand why they have so much trouble regulating and expressing emotion. For an incredible amount of information on trauma and its effects, including post-trauma stress syndromes, definitely visit David Baldwin's http://www.trauma-pages.com/ Dissociative Disorders The dissociative disorders involve problems of consciousness -- amnesia, fragmented consciousness (as seen in DID), and deformation or alteration of consciousness (as in Depersonalization Disorder or Dissociative Disorder Not Otherwise Specified ). Dissociation refers to a sort of turning off of consciousness. Even psychologically normal people do it all the time -- the classic example is a person who drives to a destination while "zoning out" and arrives not remembering much at all about the drive. Fauman (1994) defines it as "the splitting off of a group of mental processes from conscious awareness." In the dissociative disorders, this splitting off has become extreme and often beyond the patient's control. Depersonalization Disorder Depersonalization is a variety of dissociation in which one suddenly feels detached from one's own body, sometimes as if they were observing events from outside themselves. It can be a frightening feeling, and it may be accompanied by a lessening of sensory input -- sounds may be muffled, things may look strange, etc. It feels as if the body is not part of the self, although reality testing remains intact. Some describe depersonalization as feeling dreamlike or mechanical. A diagnosis of depersonalization disorder is made when a client suffers from frequent and severe episodes of depersonalization. Some people react to depersonalization episodes by inflicting physical harm on themselves in an attempt to stop the unreal feelings, hoping that pain will bring them back to awareness. This is a common reason for SI in people who dissociate frequently in other ways. DDNOS DDNOS is a diagnosis given to people who show some of the symptoms of other dissociative disorders but do not meet the diagnostic criteria for any of them. A person who felt she had alternate personalities but in whom those personalities were not fully developed or autonomous or who was always the personality in control might be diagnosed DDNOS, as might someone who suffered depersonalization episodes but not of the length and severity required for diagnosis. It can also be a diagnosis given to someone who dissociates frequently without feeling unreal or having alternate personalities. It's basically a way of saying "You have a problem with dissociation that affects your life negatively, but we don't have a name for exactly the sort of dissociation you do." Again, people who have DDNOS often self-injure in an attempt to cause themselves pain and thus end the dissociative episode. Dissociative Identity Disorder In DID, a person has at least two personalities who alternate taking full conscious control of the patients behavior, speech, etc. The DSM specifies that the two (or more) personalities must have distinctly different and relatively enduring ways of perceiving, thinking about, and relating to the outside world and to the self, and that at least two of these personalities must alternate control of the patient's actions. DID is somewhat controversial, and some people claim that it is over-diagnosed. Therapists must be extremely careful in diagnosing DID, probing without suggesting and taking care not to mistake undeveloped personality facets for fully-developed separate personalities. Also, some people who feel as if they have "bits" of them that sometimes take over but always while they're consciously aware and able to affect their own actions may run a risk of being misdiagnosed as DID if they also dissociate. When someone has DID, they may self-injure for any of the reasons other people do. They may have an angry alter who attempts to punish the group by damaging the body or who chooses self-injury as a way of venting his/her anger. It's extremely important that diagnoses of DID be made only by qualified professionals after lengthy interviews and examinations. For reliable information on all aspects of dissociation including DID, the International Society for the Study of Dissociation web site and The Sidran Foundation are good sources. Anxiety and/or Panic The DSM groups many disorders under the heading of "Anxiety Disorders." The symptoms and diagnoses of these vary greatly, and sometimes people with them use self-injury as a self-soothing coping mechanism. They've found that it brings fast temporary relief from the incredible tension and arousal that build up as they grow progressively more anxious. For a good selection of writings and links about anxiety, try tAPir (the Anxiety-Panic internet resource). Impulse-control Disorder Not Otherwise Specified I include this diagnosis simply because it is becoming a preferred diagnosis for self-injurers among some clinicians. This makes excellent sense when you consider that the defining criteria of any impulse-control disorder are (APA, 1995): •Failure to resist an impulse, drive, or temptation to perform some act that is harmful to the person or others. There may or may not be conscious resistance to the impulse. The act may or may not be planned. •An increasing sense of tension or [physiological or psychological] arousal before committing the act. •An experience of either pleasure, gratification, or release at the time of committing the act. The act . . . is consistent with the immediate conscious wish of the individual. Immediately following the act there may or may not be genuine regret, self-reproach, or guilt. This describes the cycle of self-injury for many of the people I've talked to. Self-injury as itself a diagnosis Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome. This would be an Axis I impulse-control syndrome (similar to OCD), not an Axis II personality disorder. Favazza (1996) pursues this idea further in Bodies Under Siege. Given that it often occurs without any apparent disease and sometimes persists after other symptoms of a particular psychological disorder have subsided, it makes sense to finally recognize that self-injury can and does become a disorder in its own right. Alderman (1997) also advocates recognizing self-inflicted violence as a disease rather than a symptom. Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome. Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles: the abuser (the one who harms), the victim, and the non-protecting bystander. Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in concert with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping.   Therapeutic approaches A group of activists and trainers in the U.K. is working on training A&E (emergency room) personnel on ways to make what is often the self-injurer's first contact with the medical system a productive encounter. This effort is spearheaded by nurses, former self-injurers, therapists, and others. Similar efforts in the US, Canada, and Australia would be worthwhile. Overall considerations In order to help those who self-injure, therapists must understand what role this powerful coping mechanism plays in their clients' lives. Is it primarily a means of releasing tension? Grounding? Communicating? Reliving painful experiences? Understanding why a particular person self-injures is key to helping that person stop using self-harm as a primary coping mechanism. "[H]aving [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive," warn Solomon and Farrand (1996); "techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress." Therapists need to examine their own motives for wanting a client to cease or stabilize his/her self-injurious behavior. Too often, care providers focus on stopping the SI as quickly as possible because they themselves are not comfortable with it -- it repulses them, makes them feel ineffective, frightens them, etc. Situations like this can easily deteriorate into a power struggle in which the therapist insists that the behavior stop and the client chooses to self-injure covertly and becomes reticent and distrustful, thus reducing the chance that a useful therapeutic alliance will be formed. On the other hand, it is legitimate for therapists to help clients devise some sort of plan for dealing with self-injurious impulses and getting their lives (including SIV) stabilized. When a client is engaging in uncontrolled self-injury, the SI and its concomitant crises take center stage in therapy, leaving no room for dealing with core issues. In order to have a minimum of stability in treatment, therapists must walk a fine line between attempting to repress/control all self-injurious behavior and allowing the SIV to dominate the therapy. An ideal approach would be one in which SIV is tolerated but has specific consequences. For example, a client might be invited to contact the therapist when an urge to self-harm occurs, but restricted from contact for 24 hours after an actual self-injurious act. In a system like this, the self-injurer has a chance to articulate what she is trying to communicate through her body without having to resort to self-injury, and she knows that carrying through an act of SIV will have tangible and immediate (but not permanent) negative effects. This kind of agreement between therapist and client can help stabilize the SIV and clear the road for dealing with the issues underlying the need to injure, allowing the therapist to follow Kehrberg's advice to treat self-harm within the context of underlying pathology. Therapists should ensure that self-injuring clients have access to non-judgmental, compassionate medical care for wounds they inflict on themselves (Dallam, 1997), care that does not rob them of their dignity or autonomy. Together, client and therapist can devise a plan for getting physical wounds treated without adding additional stress to the situation. This may involve educating physicians at local emergency rooms about the nature of SIV. Since successful treatment of SIV depends heavily on teaching the client new ways of coping with stressors so that underlying painful material can be dealt with, hospitalization should be used only as a last resort when the client is at risk for suicide or severe self-injury (Dallam, 1997). Hospitals are artificially safe environments, and the necessary tasks of learning to identify the feelings behind the act and of choosing a less-destructive method of coping need to be practiced and reinforced in the real world. Favazza (1998) advocates the use of high-dose SSRIs and mood stabilizers to get self-injury under control quickly, then suggests that care be managed under a team concept, with an overseeing psychiatrist who manages meds and coordinates care, a psychotherapist, and a group therapist. He also recommends that hospitalizations be kept brief. Several SI units have been started in U.K. hospitals, however, where self-injury is tolerated and clients are encouraged to examine their behavior after an incident. The staff accept some SI as inevitable and try to use these occasions as ways to teach about coping without SI. In cases like these, longer hospitalization may have more value. Hypnosis and relaxation Hypnotic relaxation techniques have apparently been used, with some success, as an adjunct to therapy. Malon and Berardi (1987) state that treating those who self-injure requires that the therapist realize the conflicting needs of the therapist to be in charge of the relationship and of the patient to be treated like an equal; if the patient's need for being seen as an equal isn't met, no progress can be made with or without hypnosis. The study in question reports success with three types of hypnosis: •Breath counting: the patient is led into a trance and instructed to notice her breathing, counting each deep slow breath.   •Positive imagery: the patient is put into a trance state and instructed to visualize herself in a calm, pleasant, relaxing place doing something she enjoys. This image is held for a while.   •Affect bridge: after trance is achieved, the patient is asked to use the current unpleasant feelings to remember other times in his life when he's felt this way. Memories that are too distressing to talk about in a normal state are sometimes speakable in a trance state.   It's important to note that in all of these techniques, the therapist must remain seated close to the patient, offering encouraging words and/or touches when appropriate. Malon and Berardi go so far as to say that "simple hypnotic techniques...offered the most immediate relief when delivered with a strong communicative focus and close here-and-now contact." Hospital-based treatment SAFE Alternatives (1-800-DONTCUT) is an inpatient program specifically for self-injurers located at MacNeal Hospital in a Chicago suburb (this program was formerly located at Rock Creek Hospital and at Hartgrove Hospital). The program combines milieu therapy, cognitive-behavioral therapies, and group and individual exercises to help patients gain an awareness of why they hurt themselves and how to stop. They claim to be the only inpatient unit for self-injurers in the U.S., though Rock Creek continues to have a program specifically for SI, as do a few other hospitals. Although their zero-tolerance policy toward SI is controversial, they claim to have lost very few clients because of it. There is no empirical evidence of the success of their approach, and I personally am uncomfortable with their overly aggressive marketing style. The hospital is quite expensive, and if you haven't insurance, you probably can't afford it. The Sanctuary at Friends' Hospital in Philadelphia is an inpatient unit for trauma survivors that is aware of the special needs of self-injurers and takes them into account in its treatment program. Butler Hospital in Rhode Island offers a partial hospitalization program that uses dialectical behavioral therapy to treat a diverse patient population of self-injurers. In a recent assessment of their program, they conclude, "Two years of operation of the women's partial program provides promising anecdotal evidence that DBT, which is an outpatient approach, can be effectively modified for hospital settings. . . . Our experience with more than 500 women certainly suggests that such treatment may be a feasible alternative to inpatient hospitalization" (Simpson, et al. 1998). Butler can be contacted at (401) 455-6200. The Rock Creek center still offers an inpatient self-injury management program and can be reached at 1-800-669-2426. Treatment efficacy In a 1998 review, Hawton et al. evaluated the effectiveness of ten different approaches to treating self-harm: problem-solving therapy, a special emergency room card getting the patient faster treatment in the ER, intensive education and outreach, and dialectical behavior therapy were compared to standard aftercare; inpatient behavior therapy was compared to inpatient insight-oriented therapy; admission to the hospital was compared to discharge after the ER visit; flupenthixol (fluanxol, an anti-psychotic drug not available in the US with severe potential side-effects) and antidepressants were each compared to placebo; followup by the initial treating therapist was contrasted to followup by a different therapist; and long-term therapy was compared with short-term therapy. They found no significant difference in % of repeaters who were in the long-term vs short-term therapy trials, the antidepressant vs placebo trials (which used mianserin, a drug that increases serotonin in the brain, and nomifensine, a dopaminergic drug that has serious side effects and is no longer available), the intensive intervention/outreach vs standard aftercare trials, the emergency card trials, and the hospital admission vs discharge trials and the (possibly too small to yield a significant effect) inpatient behavior vs insight-oriented therapy studies. The problem solving studies showed a distinct reduction in SI among those who got problem-solving therapy, but the results of combined studies did not reach statistical significance. The flupenthixol study showed significant reduction in repeat self-harm, but it was a very small study and there is some concern that the possible side effects of fluanxol outweighed any benefit. The two trials showing a significant decrease in repeat self-harm among the experimental group were the DBT studies (the DBT group has fewer repeaters) and the same vs different therapist doing followup (the % of repeaters was higher in the group that saw the same therapist).   Self-Help: Organized and otherwise This section contains a variety of ways that you can stop yourself from making that cut or burn or bruise right now. Am I ready to stop? How do I start stopping? What to do RIGHT NOW instead of SI What if I do all this and I still want to harm? "Fake" pain -- Understanding the urge DBT skills More suggestions BCSW S.A.F.E. First Aid Dealing with intrusive thoughts after stopping How do I know if I'm ready to stop? Deciding to stop self-injury is a very personal decision. You may have to consider it for a long time before you decide that you're ready to commit to a life without scars and bruises. Don't be discouraged if you conclude the time isn't right for you to stop yet; you can still exert more control over your self-injury by choosing when and how much you harm yourself, by setting limits for your self-harm, and by taking responsibility for it. If you choose to do this, you should take care to remain safe when harming yourself: don't share cutting implements and know basic first aid for treating your injuries. Alderman (1997) suggests this useful checklist of things to ask yourself before you begin walking away from self-harm. It isn't necessary that you be able to answer all of the questions "yes," but the more of these things you can set up for yourself, the easier it will be to stop hurting yourself. While it is not necessary that you meet all of these criteria before stopping SIV, the more of these statements that are true for you before you decide to stop this behavior, the better.   •I have a solid emotional support system of friends, family, and/or professionals that I can use if I feel like hurting myself.   •There are at least two people in my life that I can call if I want to hurt myself.   •I feel at least somewhat comfortable talking about SIV with three different people.   •I have a list of at least ten things I can do instead of hurting myself.   •I have a place to go if I need to leave my house so as not to hurt myself.   •I feel confident that I could get rid of all the things that I might be likely to use to hurt myself.   •I have told at least two other people that I am going to stop hurting myself.   •I am willing to feel uncomfortable, scared, and frustrated.   •I feel confident that I can endure thinking about hurting myself without having to actually do so.   •I want to stop hurting myself. [Alderman (1997) p. 132]   How do I stop? And anyway, aren't some of these techniques just as "bad" as SI? There are several different flat-out-crisis-in-the-moment strategies typically suggested. My favorite is doing anything that isn't SI and produces intense sensation: squeezing ice, taking a cold bath or hot or cold shower, biting into something strongly flavored (hot peppers, ginger root, unpeeled lemon/lime/grapefruit), rubbing Ben-Gay® or Icy-Hot® or Vap-O-Rub® under your nose, sex, etc. Matching reactions and feelings is extremely useful. These strategies work because the intense emotions that provoke SI are transient; they come and go like waves, and if you can stay upright through one, you get some breathing room before the next (and you strengthen your muscles). The more waves you tolerate without falling over, the stronger you become.   But, the question arises, aren't these things equivalent to punishing yourself by cutting or burning or hitting or whatever? The key difference is that they don't produce lasting results. If you squeeze a handful of ice until it melts or stick a couple of fingers into some ice cream for a few minutes, it'll hurt like (to quote someone I respect) "a cast-iron bitch" but it won't leave scars. It won't leave anything you'll have to explain away later. You most likely won't feel guilty after -- a little foolish, maybe, and kinda proud that you weathered a crisis without SI, but not guilty.   This kind of distraction isn't intended to cure the roots of your self-injury; you can't run a marathon when you're too tired to cross the room. These techniques serve, rather, to help you get through an intense moment of badness without making things worse for yourself in the long run. They're training wheels, and they teach you that you can get through a crisis without hurting yourself. You will refine them, even devise more productive coping mechanisms, later, as the urge to self-injure lessens and loses the hold it has on your life. Use these interim methods to demonstrate to yourself that you can cope with distress without permanently injuring your body. Every time you do you score another point and you make SI that much less likely next time you're in crisis.   Your first task when you've decided to stop is to break the cycle, to force yourself to try new coping mechanisms. And you do have to force yourself to do this; it doesn't just come. You can't theorize about new coping techniques until one day they're all in place and your life is changed. You have to work, to struggle, to make yourself do different things. When you pick up that knife or that lighter or get ready to hit that wall, you have to make a conscious decision to do something else. At first, the something else will be a gut-level primitive, maybe even punishing thing, and that's okay -- the important thing is that you made the decision, you chose to do something else. Even if you don't make that decision the next time, nothing can take away that moment of mastery, of having decided that you were not going to do it that time. If you choose to hurt yourself in the next crisis time, you will know that it is a choice, which implies the existence of alternative choices. It takes the helplessness out of the equation.   So what do I do instead? Many people try substitute activities as described above and report that sometimes they work, sometimes not. One way to increase the chances of a distraction/substitution helping calm the urge to harm is to match what you do to how you are feeling at the moment. First, take a few moments and look behind the urge. What are you feeling? Are you angry? Frustrated? Restless? Sad? Craving the feeling of SI? Depersonalized and unreal or numb? Unfocused?   Next, match the activity to the feeling. A few examples:   angry, frustrated, restless Try something physical and violent, something not directed at a living thing: Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or sock.   Make a soft cloth doll to represent the things you are angry at. Cut and tear it instead of yourself.   Flatten aluminum cans for recycling, seeing how fast you can go.   Hit a punching bag.   Use a pillow to hit a wall, pillow-fight style.   Rip up an old newspaper or phone book.   On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear the picture.   Make Play-Doh or Sculpey or other clay models and cut or smash them.   Throw ice into the bathtub or against a brick wall hard enough to shatter it.   Break sticks.   I've found that these things work even better if I rant at the thing I am cutting/tearing/hitting. I start out slowly, explaining why I am hurt and angry, but sometimes end up swearing and crying and yelling. It helps a lot to vent like that. Crank up the music and dance.   Clean your room (or your whole house).   Go for a walk/jog/run.   Stomp around in heavy shoes.   Play handball or tennis.   sad, soft, melancholy, depressed, unhappy Do something slow and soothing, like taking a hot bath with bath oil or bubbles, curling up under a comforter with hot cocoa and a good book, babying yourself somehow. Do whatever makes you feel taken care of and comforted. Light sweet-smelling incense. Listen to soothing music. Smooth nice body lotion into the parts or yourself you want to hurt. Call a friend and just talk about things that you like. Make a tray of special treats and tuck yourself into bed with it and watch TV or read. Visit a friend. craving sensation, feeling depersonalized, dissociating, feeling unreal Do something that creates a sharp physical sensation:   Squeeze ice hard (this really hurts). (Note: putting ice on a spot you want to burn gives you a strong painful sensation and leaves a red mark afterward, kind of like burning would.)   Put a finger into a frozen food (like ice cream) for a minute.   Bite into a hot pepper or chew a piece of ginger root.   Rub liniment under your nose.   Slap a tabletop hard.   Snap your wrist with a rubber band.   Take a cold bath.   Stomp your feet on the ground.   Focus on how it feels to breathe. Notice the way your chest and stomach move with each breath.   [NOTE: Some people report that being online while dissociating increases their sense of unreality; be cautious about logging on in a dissociative state until you know how it affects you.] wanting focus Do a task (a computer game like tetris or minesweeper, writing a computer program, needlework, etc) that is exacting and requires focus and concentration.   Eat a raisin mindfully. Pick it up, noticing how it feels in your hand. Look at it carefully; see the asymmetries and think about the changes the grape went through. Roll the raisin in your fingers and notice the texture; try to describe it. Bring the raisin up to your mouth, paying attention to how it feels to move your hand that way. Smell the raisin; what does it remind you of? How does a raisin smell? Notice that you're beginning to salivate, and see how that feels. Open your mouth and put the raisin in, taking time to think about how the raisin feels to your tongue. Chew slowly, noticing how the texture and even the taste of the raisin change as you chew it. Are there little seeds or stems? How is the inside different from the outside? Finally, swallow.   Choose an object in the room. Examine it carefully and then write as detailed a description of it as you can. Include everything: size, weight, texture, shape, color, possible uses, feel, etc.   Choose a random object, like a paper clip, and try to list 30 different uses for it.   Pick a subject and research it on the web.   wanting to see blood Draw on yourself with a red felt-tip pen.   Take a small bottle of liquid red food coloring and warm it slightly by dropping it into a cup of hot water for a few minutes. Uncap the bottle and press its tip against the place you want to cut. Draw the bottle in a cutting motion while squeezing it slightly to let the food color trickle out.   Draw on the areas you want to cut using ice that you've made by dropping six or seven drops of red food color into each of the ice-cube tray wells.   Paint yourself with red tempera paint.   wanting to see scars or pick scabs Get a henna tattoo kit. You put the henna on as a paste and leave it overnight; the next day you can pick it off as you would a scab and it leaves an orange-red mark behind. Another thing that helps sometimes is the fifteen-minute game. Tell yourself that if you still want to harm yourself in 15 minutes, you can. When the time is up, see if you can go another 15. I've been able to get through a whole night that way before.     I tried all of that. I still want to hurt myself. Sometimes you will make a good-faith effort to keep from harming yourself but nothing seems to work. You've slashed a bottle, your hand is numb from the ice, and the urge is still twisting you into knots. You feel that if you don't harm yourself, you'll explode. What now? Get out the questions Kharre asks. It's a good idea to have several copies of these printed out and ready to use; you can also answer them online; your responses will be mailed privately to you and no one will see them except you. Answer these as honestly and in as much detail as you are able to right now. No one is going to see the answers except you, and lying to yourself is pretty pointless. If, in all honesty, you see no other answer to #8 but yes, then give yourself permission, but set definite limits. Do not allow the urge to control you; if you choose to give in to it, then choose it. Decide beforehand exactly what you will allow yourself to do and how much is enough, and stick to those limits. Keep yourself as safe as you can while injuring yourself, and take responsibility for the injury. The questions (for more explanation, see kharre's post on the subject): 1.Why do I feel I need to hurt myself? What has brought me to this point?   2.Have I been here before? What did I do to deal with it? How did I feel then?   3.What I have done to ease this discomfort so far? What else can I do that won't hurt me?   4.How do I feel right now?   5.How will I feel when I am hurting myself?   6.How will I feel after hurting myself? How will I feel tomorrow morning?   7.Can I avoid this stressor, or deal with it better in the future?   8.Do I need to hurt myself? Staying safe while hurting yourself A few things to keep in mind should you decide that you do need to hurt yourself:   •Don't share cutting implements with anyone; you can get the same diseases (hepatitis, AIDS, etc) addicts get from sharing needles.   •Try to keep cuts shallow. Keep first aid supplies on hand and know what to do in the case of emergencies.   •Do only the minimum required to ease your distress. Set limits. Decide how much you are going to allow yourself to do (how many cuts/burns/bruises, how deep/severe, how long you will allow yourself to engage in SI), keep within those boundaries, and clean up and bandage yourself later. If you can manage that much, then at least you will be exerting some control over your SI.   What is "fake pain" and why does it matter? The concept of "fake pain" helps to explain why distress-tolerance skills are so crucial. Observation of myself and interviews with others have convinced me that one of the reasons people self-injure is to deflect unknown, frightening pain into understandable, sort-of-controllable "pseudo" or "fake" pain. Calling this phenomenon "fake pain" is in no way intended to suggest that it doesn't hurt; it hurts like hell. When memories or thoughts or beliefs or events are excessively painful, instead of facing them directly and feeling "genuine" pain, we sometimes deflect distress into pain that seems understandable and controllable, like that of self-injury. The real feelings associated with the event you're avoiding get overridden by those of the situation you create to distract yourself. It still hurts like hell, but it's a controllable familiar hell, whereas the real pain you're avoiding seems scary and poised to take over your world like the monster who ate Detroit. It's easy to revert to "fake" pain. Trying to find the source of your distress can be scary as hell, because you often don't know what you're going to unleash. Fake pain, although very painful and traumatic, is something that you understand and can control and can handle. It's familiar, not mysterious and scary like the real pain behind it. You might feel that if you ever exposed yourself to the real pain you'd lose control: "If I ever start crying, I'll never stop" or "If I let myself get mad about that, I'll never stop screaming." Instead, you unconsciously deflect the distress away from the memories or feelings that generated it and into self-injury. SI is seductive: you control it. You know the boundaries, even when you feel out of control. It makes sense and it makes the distress go away, at least for a while. It's a clever mechanism -- it takes what seems unbearable and transforms it into something you can control. The only problem is that when you deflect pain, you never face up directly to what it is that has caused this much tumult in your life. So long as you channel distress into fake pain, you never deal with the real pain and it never lessens in intensity. It keeps coming back and you have to keep cutting. You have to deal with the unbearable if you ever want to make it lose its power over you. Every time you can meet the real pain head-on and feel it and tolerate the distress, it loses a little of its ability to wipe you out and eventually it becomes just a memory. The process is like building tolerance to a drug. Narcotics users take a little bit more of their drug every day as tolerance builds, until eventually they're routinely taking amounts of drug that would kill an ordinary person. The poisonous events in your past work in a similar way. Exposure (with the help of a trained therapist) over time will build your tolerance to these events and enable you to lay them to rest. The key is learning to tolerate distress. DBT-related skills Marsha Linehan's Skills Training Manual has several helpful worksheets for getting through crisis situations. Though they are best used as part of a DBT program with a trained therapist, you might find some of them helpful.   Accepting Reality This concept focuses on learning to accept reality as it is. Accepting it doesn't mean you like it or are willing to allow it to continue unchanged; it means realizing that the basic facts of the situation are even if they aren't what you'd like them to be. Without this kind of radical acceptance, change isn't possible. Letting Go of Emotional Suffering In this worksheet, you learn ways to observe and describe your emotion, separate yourself from it, and let go of it. One of Linehan's basic principles is that emotion loves emotion, and this worksheet is designed to help you experience your emotions with amplifying them or get caught in a feedback loop. Distraction Distraction is simply doing other things to keep yourself from self-harming. Most of the techniques mentioned above are distraction techniques; you bring something else in to change the feeling. Using ice, rubber bands, etc, is substituting other intense feelings for the self-injury. Other things Linehan suggest substituting include experiences that change your current feelings, tasks (like counting the colors you can see in your immediate environment) that don't require much effort but do take a great deal of concentration, and volunteer work. Improve the Moment This worksheet focuses on ways to make the present moment more bearable. It differs from distraction in that it's not just a diverting of the mind but a complete change of attitude in the moment. Evaluating the Pros and Cons of Tolerating Distress As the name implies, this worksheet leads you through an evaluation: what are the benefits of doing this self-harming thing? What are the benefits of not doing it? What are the bad things about doing it? About not doing it? Sometimes writing this down can help you make a decision not to harm. Self-Soothing This, like improving the moment and distracting, is a distress tolerance technique. It's pretty straightforward: use things that are pleasing to your senses to soothe yourself. Some people find that active distraction works better for violent angry feelings and soothing is more effective for soft, sad ones. Reducing Vulnerability to Negative Emotion Prevention of states in which you are likely to self-harm is covered in this worksheet, which suggests ways of taking care of yourself in order to minimize the times when you feel the urge to hurt yourself. If you're balancing eating, sleeping, and self-care, you're less likely to be overwhelmed by emotion. Interpersonal Effectiveness Being clear about what you want and about your priorities in an interaction are crucial to good communication, and this worksheet offers a series of questions and steps to follow to help you determine how to approach a difficult interpersonal interaction. It is truly amazing how much going through these steps can help. Bristol Crisis Service for Women Bristol Crisis Service for Women is the leading UK (and as far as I know, European) support organization for women who self-harm. They offer a confidential help line, publications for self-harmers and for professionals, and other services. They're empathetic, dedicated and a valuable resource for women in the UK and Europe.   S.A.F.E. In 1984 Karen Conterio (then of Hartgrove) established a support group for self-injurers called SAFE (Self-Abuse Finally Ends). SAFE groups were not like 12-step groups or most self-help groups; they were short-term groups run by a professional facilitator. SAFE no longer offers these groups, but they do have a 30-day inpatient program. SAFE operates on the belief that the underlying emotional conflict is the primary problem, not the self-injury. More information about SAFE can be obtained at 1-800-DONTCUT. I stopped a few weeks ago, but I keep obsessing about hurting myself. Help? It's not uncommon for people to continue thinking obsessively about self-injury for a while after they've made the decision to stop. Hurting yourself has been a huge part of your life up until recently, and you're used to dwelling on it. You might think that you're supposed to be "cured" now and that all thoughts of SI should magically vanish from your head, so when you catch yourself thinking about that blade or lighter or whatever, you get angry and frustrated and shove the thought away. Foa and Wilson (1991) deal with intrusive thoughts by a combination of giving yourself permission to think about it and exposure/habituation techniques combined with ritual prevention. Exposure refers to repeatedly presenting someone with the situation about which they obsess, and habituation happens when, after much exposure without resulting to usual actions, the person gets used to the situation and it no longer distresses them. To adapt these techniques, first make yourself safe. If you're in a mind-set in which self-injury seems very very likely, it might be better to use distraction techniques to get past that place. Line up a support person whom you can call if you get overwhelmed by this technique. Try to tolerate it for as long as you can, even if you're uncomfortable. First, designate two 10- or 15-minute time periods daily. Choose times when you will be alone and able to think without being interrupted. To begin, set a timer for the designated amount of time. Then obsess about hurting yourself. Think about what it would feel like, how you would feel afterwards, how much you want to do this -- all those thoughts you've been trying to suppress. Get as distressed as you can, and stay focused on the topic of injuring yourself. You may find, especially after the first few times, that you get really bored toward the end of your time period. That's a good sign -- you're becoming habituated. When the time is up, stop thinking about SI. If thoughts of wanting to harm come into your mind at other times during the day, acknowledge them and remind yourself that you will think about them later, when it's time. Then let them go. If they come back, repeat the process. Don't shove them away or try to ignore them; just acknowledge, remind yourself they have their time soon, and let go. After a week or so you will notice an improvement (maybe even after just a few days). One crucial thing: no matter what, do not act on the thoughts of SI. They are just thoughts, and you can use the skills that you used to stop harming to get through these times. In order for habituation to occur, you have to get through the exposure without resorting to the old behavior. Use distraction and substitution for SI (ritual) prevention.   First Aid for Self-Injury NOTE: These first-aid tips are taken from the Red Cross guide to first aid and from personal experience. I am not a doctor and, although this page was checked over by a registered nurse, I am not liable for any damage claimed to result from this information. In all cases of serious injury, seek medical attention. This information is provided as a service only. The most important thing, and the hardest to remember when dealing with the consequences of self-injury, is to refrain from judging yourself. Do NOT invalidate yourself. You're a human being who made a mistake and did something you'd rather not have done, just like thousands of other human beings. The fact that most people don't understand self-injury does not make you bad or evil or hopeless or stupid; it makes you misunderstood. Accept this and move on. Don't deny yourself medical attention you may vitally need. Sometimes the results of self-injury can be safely treated at home. However, if you show symptoms of infection or your self-care doesn't seem to be adequately healing the wound, do NOT hesitate to seek professional medical attention. It can be annoying trying to explain what's happened to a doctor, but it's not worth dying to avoid embarrassment. What to expect in the emergency room and this ER/A&E checklist can help you get effective emergency treatment. Shock Severe cuts and burns can cause your body to go into physiological shock. Fluid loss causes the body to reduce blood flow to the extremities in order to protect vital organ systems. Basically, your body starts shutting down -- untreated shock can kill you. Symptoms of shock •restlessness/irritability   •altered consciousness (dizziness, feeling faint, nausea)   •pale, clammy, moist skin   •rapid breathing   •rapid pulse   Treating shock •Call 911. Shock is a serious condition requiring immediate medical treatment. It can kill. •Have the victim lie down   •Control external bleeding   •Keep victim comfortable to reduce the stress on body systems   •Help maintain body temperature; if victim seems cold, cover him/her with a blanket   •Reassure victim   •Unless head, neck, or back injuries or broken bones are suspected, elevate victim's legs about 12 inches   •Don't raise victim's head   •Give victim no food or drink, even though s/he is likely to be thirsty   Specific Wound Treatments Burns Critical burns that need immediate medical attention include those where breathing difficulty is present, where more than one body part is affected, or where the head, neck, hands, feet, or genitals are involved. All chemical, explosion, electrical, and third-degree burns, especially if they cover more area than the palm of your hand, should be evaluated by a medical professional.   Immediate treatment of burns •Run cold water over burned area for 15 minutes, if possible   •Do NOT put any creams or greases on the burned area   •Do not pop any blisters. Cover the burn with a light gauze dressing   •If blisters pop, apply a light antibiotic ointment and dress as above   First-degree burns, those that merely redden the skin, can usually be treated successfully at home. Keep the area moist and covered. Second-degree burns cause reddening and blistering of the skin. If they are moderately large, they require medical attention. Third-degree and worse burns involve charring or whitening of the skin. The burn has penetrated through the entire thickness of skin layers. These burns should always be treated professionally; they often require grafting or become infected. The layer of dead skin and nerves is called "eschar," and the process of removing it is known as "debridement." Having burns debrided hurts like hell, even with drugs, but it can be necessary to prevent infection. Let your doctor make the call on whether grafts or debridement are needed. Burns are nasty, disfiguring, painful, and far more trouble than they're worth. If you burn yourself severely enough to require grafting, the surgeons will put you under general anesthesia, take an instrument that's kind of like a carpenter's plane or a cheese slicer, and peel a section of skin from an unburned part of your body to graft onto the damaged site. It hurts, it's boring, and if it gets infected you have to do it all again. And few things in life have hurt me as much as a healing donor site did. You don't wanna deal with it. Once more, with emphasis, if you have a bad second or a third-degree burn, get your ass to an emergency room. Immediately. Cuts and lacerations Most cuts, even ones a doctor might suggest stitching, can be dealt with at home. There are two exceptions to this: If you can't stop the bleeding, or If you're going into shock.   If you can't stop the bleeding If a cut won't stop bleeding, first try pressing cloths or paper towels (maxipads and Depends make good bandages, too) directly on top of the wound. On top of that, place a large object (like a balled-up sock), and wrap the entire thing tightly in an Ace bandage. Keep the wound above the level of your heart and check it in ten minutes; if it's still bleeding, re-wrap it and go to an emergency room. If you're feeling the symptoms of shock, call 911. It's important to maintain direct pressure for ten minutes without peeking. If you're pressing a cloth or bandage against the wound and the blood soaks through before ten minutes are up, just put another one on top of it. After you stop the bleeding, place a cold pack on the wound for ten minutes. Then wash with Betadine and apply an antibiotic ointment or spray (to keep the wound moist and minimize chances of infection) and a bandage. Change the bandage twice daily, and rotate the direction of the bandage tape to keep the skin around the cut from becoming too irritated. Bandages should be large enough that they extend an inch beyond all edges of the wound. Watch for redness or heat spreading outward from the wound; these are signs of an infection and should be treated by a doctor. Other signs of infection include swollen lymph glands, increased pain, and fever. If you start running a fever, go to the doctor immediately. Why bother about bandaging? Well, properly bandaged cuts heal faster and are less likely to scar. If the wound is small enough, the new Advanced Care Band-Aid is a good idea. You apply it and leave it on for several days as the wound heals underneath; it's made from a special material that turns fluids from the wound into cushioning or lets them evaporate. The tight seal means no bacteria can get in. If you choose to use a product like this, be sure to read the package directions. Closing the wound with Steri-Strips is also a good way to minimize scarring; the closer the wound edges are as they heal, the less scar tissue the body has to produce to join them. Drink lots of fluid to make up for any blood you've lost. If you do this and you're still dizzy on standing (postural hypotension -- your blood pressure is dropping when you stand), see your doctor. Also, if you lost a lot of blood or are extremely fatigued, have your blood hematocrit (iron levels) checked -- you might have made yourself anemic. Stitches When do you need stitches? The criteria most doctors use:   •Cuts that will not stop bleeding;   •Cuts that are more than 1/4 inch long and on the hands, face, feet, or genitals;   •Cuts in the mouth that are more than 1/2 inch long;   •Cuts elsewhere on the body that are gaping (you can see tissue/fat).   If it's been more than 8-12 hours since the wound, most doctors won't stitch it. If you absolutely refuse to go to a doctor, at least get some Steri-Strips (or similar product; you can find them in pharmacies) to close the wound yourself. Wounds are stitched mainly to stop bleeding and to reduce scarring.   From a plastic surgeon: Wound/infection treatment 1.Get some Betadine ointment and Betadine solution (OTC povidone-iodine solution).   2.Put the Betadine solution on the wound when fresh. Wait until the Betadine dries, then butterfly it closed (you can get Steri-strips in a pharmacy) and cover it with gauze -- this is the only time you put on the liquid Betadine.   3.DON'T put anything in the fresh wound you wouldn't put in your own eye (no alcohol, peroxide, soap, etc.). [He says this is standard advice for 1st-year plastic surgery residents.]   4.If the wound seems deep or gaping, if you see fat, or you don't stop bleeding soon try to go to an emergency room. It's worth the [possible] humiliation to know you're safe.   5.The next day start changing the dressing 2 times a day:   owash it when you shower   opat it dry   osmear on some Betadine ointment and cover with gauze (the Betadine ointment stains). 6.If the Betadine ointment irritates you, substitute Silvadine (silver sulfadiazine)[prescription required in some places].   7.If you develop a fever, or the redness around the wound starts to spread away from the wound or the wound gets full of pus or becomes very tender and red you have an infection. The treatment involves oral antibiotic with a culture of the germ responsible for the infection and possibly reopening the wound if an abscess is formed. If you have access to antibiotics it is possible to treat yourself, but a visit to the doctor is safer. The proper antibiotic to use is a guessing game since there are different organisms on different parts of the body. Putting medicine on the surface of the wound is off once the skin has closed. If the wound is still open and you are not feverish and the redness is within an inch of the edge, you can try Dakin's solution: mix 1 tablespoon of liquid Clorox in a quart of water: it kills staph (the most common bug). Soak gauze in it and put on wound, cover with dry gauze, and change 3 times a day. If successful in two days (redness going away, wound with much less pus and less pain) then continue it until it heals. If it gets worse on this, stop it and see an MD. Remember this advice is general and may not fit every person or every wound--when in doubt invest in the medical visit.   Dr. Fischman also had this to say: Silvadine is first choice for burns. The real trouble in recommending Rx's for infections is that the person has to decide if it is "serious" and requires MD attention. The patient usually doesn't have the experience to make this decision safely (e.g., all diabetics' wounds are "serious"). Bruises and sprains If a bruise or sprain has caused significant swelling and pain, if you can't move the affected body part, or if a joint/bone looks misplaced, have it evaluated by a medical professional to be sure there's no break. Treat bruises and sprains with the RICE formula used for sports injuries: Rest, Ice, Compression (an Ace bandage), Elevation.   Pain For pain caused by self-injury it's best to use Tylenol; it doesn't thin the blood the way aspirin and NSAIDs (Advil, Aleve, etc) can. Be careful not to take so much that you mask any possible fever, and if you have severe pain persisting over many days, see your doctor.   Living with self-injury "to be nobody-but-myself in a world which is doing its best, night and day, to make me everybody else means to fight the hardest battle which any human being can fight, and never stop fighting" -- ee cummings As much as we'd like it to be, self-injury isn't something that can be tucked away in a little corner of your life where it doesn't touch anything else. Even after you've stopped, it continues to affect who you are and how you interact with people. Scars fade but never disappear entirely. Feelings of alienation may subside but still lurk in the background. If you're still actively hurting yourself, life gets even more complicated. This page is meant to offer some answers for the unique dilemmas self-injury brings into your life: telling others, answering intrusive questions, hiding and healing scars, and a few medical issues. I am not a medical professional and these pages are presented for informational purposes only. No diagnosis or treatment is intended.   Coming out Admitting to the people in your life that you self-injure is analogous in many ways to the process of coming out as gay or bi. This list of things to consider when deciding to tell those you love about your way of coping with stress is adapted from a coming-out list in Bass and Kaufman 1996.   The assumption here is that you'll tell people about your SI in a conversation, but that's not the only way to come out. Some people have found that writing down everything they want to say and presenting it to someone has worked for them. If you choose this approach, follow the general guidelines below and be sure you remain available for discussion after the person has read what you've told them. If you want to come out to someone via email, I'd suggest you follow up immediately with a chat session or a telephone call.   Be willing to give the other person some time to digest, though -- if you follow up with them and they say "I'd like to think about this for a while," give them space. Ask them to let you know when they're ready to talk, and let it go.   •Be sensitive to the other person's feelings It can be nearly as hard for them to hear it as it is for you to tell them. Realize that they're probably wondering what they did wrong or how they could have prevented you from feeling so much pain or why you turned out "sick." You don't have to accept their value judgments about your SI, but be open to hearing what they have to say about it. You might learn something, and you can teach them a great deal.   •Explain that coming out is an act of love   Let them know that your deciding to tell them about self-injury is a sign of your love for and trust in them. Usually, a person decides to tell someone about his/her SI because s/he loves them, wants or needs their loving support, and is tired of keeping a whole part of her/himself from them. The desire to be open and to trust outweighs the fear of rejection or hatred or disgust. Let the person you're telling about your self-harm know you're not trying to punish. manipulate, or guilt-trip them.   •Pick a place that is private and a time that is unhurried   This is serious stuff. Find a time when everyone involved is available for a long conversation. Do it in a place where everyone's comfortable and there's no need to worry about being overheard. If you're rushed or hurried or afraid other people nearby will hear and react, you're not going to be able to give your full attention to the conversation and neither will anyone else.   •Don't tell others in anger   Don't use your SI as a weapon: "Oh, yeah, well look, you made me cut/burn/scratch/hit!" To get the love and understanding you're seeking, you may have to give some in return. Whether or not the person you have decided to share your secret with has contributed to the problems that led to your SI is irrelevant to the coming-out conversation. If you start getting angry and blaming, you're going to put the other person on the defensive and they'll get angry. The whole process will bog down and be hideously unpleasant and unproductive. Using SI as a weapon also increases the likelihood that the person you're coming out to will react in exactly the ways you're hoping they won't.   •Consider enlisting an ally   If you have a friend or therapist who understands your SI you might want to ask them to sit in on the conversation. A neutral third person can help keep things calm.   •Provide as much information as you can   This is crucial.The more someone knows about something, the less they fear it. Many people have never heard of self-injury or have heard weird sensationalized tabloid reports. Be prepared to give the person books or names of books, articles, photocopies, printouts, addresses of web sites, etc. Gather as much information as you can so you can answer their questions accurately and honestly.   •Be willing (and prepared) to answer their questions   You may have to educate them about SI. Encourage them to ask whatever questions they may have. If they ask a question you don't have an answer to,say "I don't know" or "I can't say" or even "I prefer not to get into that right now." Be as open as you can. You might want to anticipate questions they'll ask and get an idea of how you want to answer those before you come out. You can ask other people who've come out what they were asked to get some ideas. You should also have a good idea in your mind of what you want to do about the self-injury -- they're going to ask. Do you want treatment? What sort? If not, what's the rationale for not treating it? Do you want them to help you stop or control it? How can they help? What's too intrusive and what isn't? Now is a good time to start setting boundaries.   •It's not necessary to bring up the most disturbing topics in the first conversation   Don't start by describing in technicolor detail the time you needed 43 stitches and a transfusion. It's probably best to avoid graphic descriptions of what you do; if asked, just say "I cut myself on the wrist" or "I hit the walls until I get bruises" or whatever. Try not to freak them out; you can give details (if necessary) in some other conversation.   •Trust your own judgment   Do what feels natural to you. You know yourself and your family and friends far better than I ever will.   •Communicate   Be willing to talk to the people you're coming out to about your reactions, and ask them to let you know what they're thinking. Communication goes both ways.   Scars For some people, scars aren't an issue -- they self-injure in ways that don't leave permanent marks or they only injure in places that are normally covered by clothing (the torso, shoulders, etc). For most people who cut or burn, though, scars happen. Some people like their scars and look on them as battle wounds or even life-maps. Many others hate their scars and want to find ways to get rid of them. Both attitudes are equally valid.   The two most common scar questions I hear are "How do I explain them?" and "How do I make them go away?"   Dealing with unpleasant questions It happens sooner or later - you're at school or work, on the bus, in a shop, and someone notices. "What happened to your {arm, leg, face, whatever}?" People aren't usually trying to make you uncomfortable. Quite often, they're just making conversation; they don't really want to know why you have scars, but it's something to say. Nevertheless, you're stuck coming up with an answer. Quite often, the easiest solution is to half-laugh or make a rueful face and say "It's a long story." Then change the topic. This deflects most people; if they persist, you can say, "I would really rather not discuss this." You can be a bit icy here -- after all, they're being a bit rude by asking you personal questions and not letting you gracefully avoid answering. On the other hand, you could try some of the suggestions that came up during a discussion of excuses on the bus email list. You prolly won't use most of them, but read them for the laughs:   •I had unprotected sex with a porcupine.   •I took my lizards for a walk and they held on for dear life.   •The neighborhood cat and I had a disagreement about the paw prints on my truck.   •The police didn't comply with the terrorists' demands fast enough, so they took it out on us hostages.   •This first one is kind of lame, but it's what I use most often: "Um, uh...I, uh....you see....I...uh...Well,...." At which they usually try to help me out by replying, "Did you fall?" And I say, "Yes, thanks."   •Well, let me just tell you this: You should NEVER EVER, under ANY circumstances, go out with a guy/girl that you met on the internet.   •I hurt myself.   •I keep falling off of cliffs trying to catch that damned roadrunner.   •"I was oyster hunting." They give me a blank stare. Then I say, with a wink, "You've obviously never been oyster hunting before."   •"It's a long story." They usually leave me alone, but this one guy said, "I've got time." Then I said, "I fell. [long pause] Ok, so it's obviously not THAT long."   •I was at this party with Marilyn Manson and everyone was giving out hugs.   •I lost a fight with a can of tuna fish.   •I slipped while making a salad. ............................. -- Posted by ManicDepressant at 5:15 pm on Oct. 18, 2005 •I'll just put it this way: when they tell you not to feed the bears, it's for a damned good reason.   •I thought those security tags on pants just sprayed ink, but apparently they spray shards of broken glass, too. •Those aren't cuts, they're mehendi.   •Don't worry about it. Because of me, they now have a warning label!   •What are you talking about?? (as I quickly pull my sleeves up.)   •Damn Cat.   •Well, when I was younger, I had this dream that a dog was following me...he ran, and I ran, but the faster I ran, the more he sped up. I wanted to get to safety, to my house...I was almost there...but right when I got to the front porch, he bit me. Everywhere. Lots of times. Making marks that don't look like bites at all. And when I woke up... ::wide eyes:: and I had THESE.   •"What scars?" They usually reply "those ones," to which I reply, "I don't see anything."   •The voices told me to do it.   •I wrestle Tigers...   •I got them climbing a fence to escape this hell-hole. (said at school)   •(said to a guy who thinks I worship the devil) I did this as a sacramental offering to my dark lord, you prick. ::Smile::   •(about scars on my stomach) "Oh, those are from having my baby." "You don't have a baby!" "No, but I could."   •None of your business, you stupid (insert appropriate curse word here)   •I did it. (Hey, honesty works sometimes)   Dealing with scars themselves If you hate your scars and want to do something about them, you have two options: You can find ways to conceal your scars, or you can try to heal/minimize them.   Hiding scars Sometimes it's possible to hide scars.   •Wrist scars can be covered by long sleeves, bracelets, or watches.   •In summer, wear long-sleeved shirts of light material (silk, gauzy cotton, and the like).   •Another summer idea is to wear a long-sleeved shirt open over a tank top or t-shirt. If anyone questions it, you can tell them you're worried about sun exposure.   •Some leg scars in women can be hidden by pantyhose or tights.   •Concealer makeup (like Dermablend) can be used to hide some scars. You can get more info at dermablend.com. People have reported getting very good results with Dermablend, which was formulated for covering port-wine birthmarks and skin conditions like vitiligo. It's waterproof and can be blended to match skin color very closely.   Healing scars The first step in healing scars is probably good wound care. Wash with Betadine if appropriate, and use a good antibiotic ointment (like Neosporin) on the wound daily. Johnson & Johnson make a new bandage, Band-Aid Advanced Healing, that seals the wound completely. Fluids from the wound are absorbed by special particles in the bandage that turn them into a gel to cushion the wound. This keeps the wound moist, which reduces itching and helps it heal faster. It also can reduce the urge to pick at the wound, because you are meant to keep the bandage on continuously until the wound has healed, or about a week. For some types of scarring, special creams or bandages may help. Mederma is a cream designed to minimize scarring, but it must be used when the scar is very new. Reports on its efficacy are mixed.   Syprex also makes a cream, a topical gel, and a special cleansing wipe. A new product, ScarGuard, combines liquid silicone, mild cortisone, and vitamin E. You paint the liquid over the scars to form something similar to a silicone sheet, and use it in the same way you use the sheets.   Silicone sheets are taped tightly (a few now are self-adhesive) over the scars for several hours each day. Treatment continues for varying lengths of time (days to weeks). The manufacturers claim that these sheet can soften and fade most raised or red scars, even keloids. Some burn centers do use them to help diminish scarring after grafts, and unlike Mederma, they are meant for old scars as well as new. None of these products will make scars disappear but they can help make them less obvious (and cut down on intrusive questions. I've seen Rejuveness and Cicacare at Walgreen's in the US. Curad recently introduced ScarTherapy, a new product for reducing scar tissue. It uses polyurethane instead of silicone, which allows air to get through; instead of wearing the sheet a few hours every day, you wear it continually; each day you take off the old sheet and put on a new self-adhesive one. Like the silicone sheets, it claims to be able to flatten and lighten scars (in other words, none of these will do much for flat scars that are paler than surrounding skin Plastic surgery might be effective for some sorts of scarring, but it is very expensive and leaves scars of its own. Dermabrasion might work for very light scarring, but I've heard from several people who found it useless, expensive, and painful. The same holds for laser resurfacing.   Cortisone injections combined with laser therapy can flatten large keloids, but you'll still have a remnant of a scar. The treatment can be painful, and results aren't guaranteed.   Skin grafts can be done to reduce a network of scars to one big scar which can be more easily explained, but they still leave you with a big ugly scar. Someone reported having wedge surgery in which the scarred areas were cut out in a wedge and skin edges sewn back together, leaving one long scar. I've also heard about a procedure in which balloons are slipped under the skin and slowly inflated to stretch the skin out. The loose skin is then sewn over the scarred area. If you know anything about this, I'd love to hear details.   If you decide to have plastic surgery done, you will have to convince your surgeon that you are through self-injuring; most doctors will not help you cover scars if they think you're going to go out and get new ones right away. Some may require that you be SI-free for a set period of time before they'll consider doing the surgery.   Tattooing over scars may be an option for some people, but scarred skin is very difficult to work with and may not hold ink well. If you want to try this route, ask around and check references until you find a very good, very experienced tattoo artist and set up a meeting to discuss the possibilities. If the artist thinks tattoos wouldn't work well on your scar, it might be best to drop the idea. Again, this is something to do only if you're pretty sure you're not going to scar the area afterward.   A good source for information about scars and plastic surgery is http://www.scarcare.org. Remember that nothing can make the scar go away completely; treatments can only change the shape, appearance, or location of it.   Medical concerns for people who cut If you are still using self-injury as a way to cope with overwhelming situations, you need to pay attention to your health and monitor yourself for symptoms of anemia or dehydration.   If you cut, you're losing two important things: fluid (plasma) and red blood cells. Your body can replace the plasma in about 48 hours if you drink enough liquid. The red cells will take about two months to be replenished.   Dehydration can send you into shock. The most common symptom is dizziness, especially when changing positions (for example, standing up after having been lying down for a while). You may also have a very rapid pulse. If the dehydration is severe (you're very dizzy, your eyes look sunken, you can't keep fluids down, your skin is clammy and you feel weak), go to the doctor immediately -- they'll give you IV fluids and you'll be fine in a few hours. To avoid getting to that point, be sure to drink 8 glasses of water daily (more on days you've lost blood). If you feel dizzy after SI, drink as much water or juice as you can and monitor yourself for symptoms of shock.   Anemia happens when you lose too much iron by losing too many red cells. If you are anemic, you will be pale and feel very weak. You might be irritable and short of breath and just feel bad. If you have these symptoms, you can see a doctor and have the anemia confirmed; the doctor will then give you iron supplements and vitamin C and tell you that you'll feel better in a couple of months. If you want to avoid becoming anemic, but you're not ready to stop cutting, you should take a multivitamin with iron and vitamin C daily and stop the bleeding on your cuts as quickly as possible.     Help for families and friends Now what? Perhaps someone you care about has honored you by trusting you with information about their self-injury, or maybe you've inadvertently discovered it. Regardless of how you found out, you know about it now, and you can't pretend it away -- you have to respond in some way. Here are some guidelines for dealing with SI in a friend or family member. You might also find it helpful to post to and read the family and friends section of the bus web board. Some good conversations happen there.   Don't take it personally. Self-injurious behavior is more about the person who does it than about the people around him/her. The person you're concerned about is not cutting, burning, hitting, or whatever just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn't intended as one. People generally do not SI to be dramatic, to annoy others, or to make a point.   Educate yourself. Get as much information as you can about self-injury in general. This page is a good start; there are also some very informative books out there (in particular, Bodies Under Siege by Favazza, The Scarred Soul by Alderman, and A Bright Red Scream by Strong). The Favazza book is more scholarly in tone, the Alderman book is oriented toward self-help, and Strong's book presents the voice of self-injurers talking about what they do and why -- it lets you inside the mind of people who SI. All contain much valuable information and advice. Understand your feelings. Be honest with yourself about how this self-injury makes you feel. Don't pretend to yourself that it's okay if it's not -- many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, find a good therapist. Be careful, though, that you not try to get "surrogate therapy" for your family member/friend -- what goes on in your therapy sessions should remain between you and your therapist. Don't ask your therapist to try to diagnose or treat the person you're concerned about, and if the self-injurer seeks treatment, be sure that s/he is seeing a different therapist than you are. Don't discuss the content of your therapy sessions in any but the most general terms, and never say anything like "My therapist says you should..." Therapy is a tool for self-understanding, not for getting others to change. Be supportive without reinforcing the behavior. It's important that your friend, lover, child, sibling know that you can separate who they are from what they do, and that you love them independently of whether they self-injure. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what's going on with the person. Some good ways of showing support include: •Don't avoid the subject of self-injury. Let it be known that you're willing to talk, and then follow the other person's lead. Tell the person that if you don't bring the subject up, it's because you're respecting their space, not because of aversion.   •Make the initial approach. "I know that sometimes you hurt yourself and I'd like to understand it. People do it for so many reasons; if you could help me understand yours, I'd be grateful." Don't push it after that; if the person says they'd rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you're willing to listen if they ever do want to talk about it.   •Be available. You can't be supportive of someone if you can't be reached.   •Set reasonable limits. "I cannot handle talking to you while you are actually cutting yourself because I care about you greatly and it hurts too much to see you doing that" is a reasonable statement, for example. "I will stop loving you if you cut yourself" isn't reasonable if your goal is to keep the relationship intact.   •Make it clear from your behavior that the person doesn't need to self-injure in order to get displays of love and caring from you. Be free with loving, caring gestures, even if they aren't returned always (or even often). Don't withdraw your love from the person. The way to avoid reinforcing SIV is to be consistently caring, so that taking care of the person after they injure is nothing special or extraordinary.   •Provide distractions if necessary. Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you care about is feeling depressed, you can sometimes help by bringing something pleasant and diverting into their lives. This doesn't mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it -- it's an attempt to break a negative cycle by injecting something positive. It could be as simple as bringing the person a flower. Don't expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)   •If you live apart from the person you're concerned about, offer physical safe space: "I'm worried about you; would you come sleep over at my house tonight?" Even if the offer is declined, just knowing it's there can be comforting.   •Don't ask "Is there anything I can do?" Find things that you can do and ask "Can I ?" People who feel really bad often can't think of anything that might make them feel better; asking if you can take them to a movie or wash those (month-old) dishes (if done nonjudgmentally) can be really helpful. Spontaneous acts of kindness ("I saw this flower at the store and knew you'd love to have it") work wonders. Take care of yourself. It sounds like hard work, and it is. And if you try to be completely supportive to someone else 24/7, you're going to burn out (and they won't have any incentive to change). You have to find ways to be sure your needs are being met. Take a break from it when you need to. When setting limits, remember that as much as you love someone, sometimes you're going to need to get away from them for a while. Tell the person that sometimes you need to recharge and that it doesn't affect your love for him/her. Only break into this personal time in cases of absolute life-or-death crisis. The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don't have to be about to die to get love and attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn't going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response. Ultimatums do NOT work. Ever. Loving someone who injures him/herself is an exercise in knowing your limitations. No matter how much you care about someone, you cannot force them to behave as you'd prefer them to. In nearly two years of running the bodies under siege mailing list, I have yet to hear of a single case in which an ultimatum worked. Sometimes SI is suppressed for a while, but when it inevitably surfaces it's often more destructive and intense than it had been before. Sometimes the behavior is just driven underground. One person I know responded to periodic strip searches by simply finding more and more hidden places to cut. Confiscating tools used for SIV is worse than useless -- it just encourages the person to be creative in finding implements. People have managed to cut themselves with plastic eating utensils. Punishments just feed the cycle of self-hatred and unpleasantness that leads to SIV. Guilt-tripping does the same. Both of these are incredibly common and both make things infinitely worse. The major fallacy here is in believing that SIV is about you; it almost invariably isn't (except in the most casual ways). Accept your limitations.   Acknowledge the pain of your loved one. Accepting and acknowledging that someone is in pain doesn't make the pain go away, but it can make it more bearable. Let them know you understand that SIV isn't an attempt to be willful or to make life hard for you or to be unpleasant; acknowledge that it's caused by genuine pain they can find no other way to handle. Be hopeful about the possibility of learning other ways to cope with pain. If they're open to it, discuss possibilities for treatment with them.   Don't force things. If you make overtures and they're rejected, back off for a few days or weeks. Don't push it. Some people need time to decide to trust someone else, particularly if they've received a lot of negative feedback about their SI before. Be patient.   Other resources Bristol Crisis Service for Women publishes a "Responses to Self-injury" sheet Ashley Unwin also has written a great guide on self harm that can be found on the Livewire Peer Support Networks website at http://www.golivewire.com/forums/topic.cgi?topic=118969 Accreditations Ashley Unwin (Editor and Livewire Formater) (Member ManicDepressant on the Livewire Peer Support Networks website) Deb Martinson (Author and copyright holder) Copyright 1996-2002, Deb Martinson. All rights reserved. Noncommericial reproduction is encouraged; please credit author. Edited: Formatting (Edited by ManicDepressant at 8:24 pm on Oct. 19, 2005) -- Posted by imbi gtovrit at 5:17 pm on Oct. 18, 2005   ...Is this supposed to make me feel better? (Edited by mi q in at 5:18 pm on Oct. 18, 2005) -- Posted by ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005   ...Is this supposed to make me feel better? (Edited by mi q in at 5:18 pm on Oct. 18, 2005) No, so go away. ManicD -- Posted by imbi gtovrit at 5:24 pm on Oct. 18, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005      ...Is this supposed to make me feel better? (Edited by mi q in at 5:18 pm on Oct. 18, 2005) No, so go away. ManicD Im not saying it to sound like a bitch -- Posted by ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005       ...Is this supposed to make me feel better?    (Edited by mi q in at 5:18 pm on Oct. 18, 2005)    No, so go away.    ManicD Im not saying it to sound like a bitch Then why say it at all? Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.? ManicD -- Posted by bobegods at 5:33 pm on Oct. 18, 2005 Maybe someday this site will go away to and then we won't have all that important information... What's the point of it anyway...to learn how to hurt yourself in a "good" way? -- Posted by imbi gtovrit at 5:41 pm on Oct. 18, 2005 Quote: from ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005          ...Is this supposed to make me feel better?     (Edited by mi q in at 5:18 pm on Oct. 18, 2005)     No, so go away.     ManicD    Im not saying it to sound like a bitch Then why say it at all?   Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.? ManicD why do you have to be such an ass? I wasn't tring to be a bitch and I wasnt insinuating anything by my previous statement. -- Posted by ManicDepressant at 5:42 pm on Oct. 18, 2005 Quote: from bobegods at 1:33 am on Oct. 19, 2005 Maybe someday this site will go away to and then we won't have all that important information... What's the point of it anyway...to learn how to hurt yourself in a "good" way? No, to clarify hat self harm is, why people do it, how people do it, how they can help themselves, how they can be helped. and answer any other question about self harm they may have. The point of view that it is written from also provides a no shame enviroment about the subject. ManicD -- Posted by imbi gtovrit at 5:54 pm on Oct. 18, 2005 Well... I think you did a well enough job -- Posted by shattered dreams at 6:14 pm on Oct. 18, 2005 Ive read that before... its good. Thanks for posting it:) -- Posted by TKDgoneveggie at 6:54 pm on Oct. 18, 2005 so is annorexia a SI??? when you do it to punish yourself and then get addicted to it??? -- Posted by Junja at 3:15 am on Oct. 19, 2005 Thanks for posting that, ManicD. I await your next informative masterpiece. -- Posted by ManicDepressant at 11:35 am on Oct. 19, 2005 Quote: from TKDgoneveggie at 2:54 am on Oct. 19, 2005 so is annorexia a SI??? when you do it to punish yourself and then get addicted to it??? 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. Not as such, anorexia is a condition where as the person sees themselves as overweight and therefore wishes to lose more weight and no matter how thin they become it is not good enough, this is not done to delibratly harm the body, though harm is a side effect of the condition. If a person was to stop eating in order to stop there body functioning normally and cause themselves pain through stomach cramps etc. this would be a form of self harm, they are doing it TO CAUSE HARM to themselves. What is being said in the quote above is that many people who suffer from anorexia also self harm. The two commonly coinside with each other but are not the same condition I hope this helps you understand, if you need anymore help them feel free to PM me. ManicD THIS REPLY HAS ALSO BEEN PM'ED TO THE USER -- Posted by miTdgKet at 1:00 pm on Oct. 22, 2005 i never knew that about burns... as far as second degree burns go, what would you call moderately large? i mean, like, lighter burns or what?   -- Posted by imbi gtovrit at 5:22 pm on Oct. 23, 2005 Quote: from ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005     Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.? ManicD Dont give me that shit, I know because I do it!!! -- Posted by ManicDepressant at 3:50 pm on Oct. 24, 2005 Quote: from mi q in at 1:22 am on Oct. 24, 2005 Quote: from ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005        Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.?    ManicD Dont give me that shit, I know because I do it!!! So did I, But that didnt make me Know much about it, I did it, but i didnt understand why i did. i didnt know why it felt so good, i didnt know what drove me to it again and agian, i didnt know how it helped. But i did it. ManicD -- Posted by The Pimp at 5:13 pm on Oct. 24, 2005 not bad man -- Posted by Snakx at 12:35 pm on Oct. 29, 2005 Quote: from ManicDepressant at 3:50 pm on Oct. 24, 2005 Quote: from mi q in at 1:22 am on Oct. 24, 2005 Quote: from ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005             Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.?     ManicD    Dont give me that shit, I know because I do it!!!   So did I, But that didnt make me Know much about it, I did it, but i didnt understand why i did. i didnt know why it felt so good, i didnt know what drove me to it again and agian, i didnt know how it helped. But i did it. ManicD Maniac u sound emo...they always hurt themselves....but they just keep coming back for more they always seem depressed we had pple who cut themselves at my school it kinda screwed them up pple saw cut marks on their wrists and they got teased for it...Its dumb that pple teased them... I just thought id bring this up...btw i didnt read your whole thing that u wrote at the start...if u already brought this up.. -- Posted by ManicDepressant at 8:02 pm on Oct. 29, 2005 Quote: from Snakx at 8:35 pm on Oct. 29, 2005 Quote: from ManicDepressant at 3:50 pm on Oct. 24, 2005 Quote: from mi q in at 1:22 am on Oct. 24, 2005 Quote: from ManicDepressant at 5:26 pm on Oct. 18, 2005 Quote: from mi q in at 1:24 am on Oct. 19, 2005 Quote: from ManicDepressant at 5:20 pm on Oct. 18, 2005 Quote: from mi q in at 1:17 am on Oct. 19, 2005                Read the title, does it sound like i'm trying to make people feel better or give them facts about something so many people dont understand.?        ManicD       Dont give me that shit, I know because I do it!!!        So did I, But that didnt make me Know much about it, I did it, but i didnt understand why i did. i didnt know why it felt so good, i didnt know what drove me to it again and agian, i didnt know how it helped. But i did it.    ManicD Maniac u sound emo...they always hurt themselves....but they just keep coming back for more   they always seem depressed   we had pple who cut themselves at my school it kinda screwed them up pple saw cut marks on their wrists and they got teased for it...Its dumb that pple teased them... I just thought id bring this up...btw i didnt read your whole thing that u wrote at the start...if u already brought this up..   holy shit, no way am i emo, in any way. It is a dum thing to do, i agree entirely. i also agree that many people do it as a trend or for attention. Meh. ManicD -- Posted by xdark angelx at 1:20 am on Nov. 4, 2005 er arguing don't help guys -- Posted by satanlover666 at 2:53 pm on Nov. 5, 2005 I'm seriously considering suicide, and I seriously need some1 2 talk 2.   -- Posted by Radagst91 at 2:03 pm on Nov. 9, 2005 Lol thanks for posting that very informative... the comical responses to the ever awkward questions made me laugh.... and that is an achievement... Thanks again for posting that :) -- Posted by MSN Babe1 at 8:21 pm on Nov. 9, 2005 I hope you no u are responciable for many ppl self harming themselfvs!! OK! Malia -- Posted by ManicDepressant at 4:59 am on Nov. 10, 2005 Quote: from MSN Babe1 at 4:21 am on Nov. 10, 2005 I hope you no u are responciable for many ppl self harming themselfvs!! OK! Malia NO, i'm not, and i never  will be, this documant contains spoilers for the sensitive parts and is here to provide information. This in no way, shape or form encourages the use of self harm as a method of dealing with problems, it only seeks to inform the people of what self harm is. If you have a problem with it feel free to PM me and we can talk further as to the content of the document. ManicD -- Posted by SwiftPainfulSparrow at 7:12 am on Nov. 12, 2005 Hmmmm...talk about mixed reviews eh?  Granted I see the point in trying to help people, but with a five hour disertation on SI in writing....I don't know about the healing effects of that on too many people.  Not to mention we don't like being criticized, so if you could leave the fact that you think cutting is stupid out of your responses we'd greatly appreciate it.  Funny how the former cutters go back to the outside world and leave us still struggling to feel r*t*rd*d.  But hey, what do I know, I'm a stupid cutter... -- Posted by Tayerr at 1:29 pm on Nov. 12, 2005 Yeah, I used to self harm, but it really gets you nowhere, in a twisted viscious circle. Cause the pain is nice after a while, turns into adiction. Someone you love, will help you out. That's how I did it. For my friends, they left nasty scars too. I have a few left. It's not good, but who's to say I won't do it again. -- Posted by ManicDepressant at 4:10 pm on Nov. 12, 2005 Quote: from SwiftPainfulSparrow at 3:12 pm on Nov. 12, 2005 Hmmmm...talk about mixed reviews eh?  Granted I see the point in trying to help people, but with a five hour disertation on SI in writing....I don't know about the healing effects of that on too many people.  Not to mention we don't like being criticized, so if you could leave the fact that you think cutting is stupid out of your responses we'd greatly appreciate it.  Funny how the former cutters go back to the outside world and leave us still struggling to feel r*t*rd*d.  But hey, what do I know, I'm a stupid cutter... If this is refering to me kindly reread the very first lines i wrote. Then reply again. ManicD -- Posted by Luke at 10:47 pm on Nov. 17, 2005 dont ever self harm and if you fell the need to or do self harm seek help or talk to me :D im a good guy :P lol Pages: 1 2  Next