Self-harm

as evidence of self-mutilation's longstanding use in healing rituals. Pao differentiated between delicate (low lethality) and coarse (high lethality) self-mutilators who cut. The "delicate" cutters were young, multiple episodic of superficial cuts and generally had borderline personality disorder diagnosis. The "coarse" cutters were older and generally psychotic. Ross and McKay (1979) categorized self-mutilators into nine groups: cutting, biting, abrading, severing, inserting, burning, ingesting or inhaling, hitting, and constricting. After the 1970s the focus of self-harm shifted from Freudian psycho-sexual drives of the patients. Walsh and Rosen created four categories numbered by Roman numerals I–IV, defining Self-mutilation as rows II, III and IV. Favazza and Rosenthal reviewed hundreds of studies and divided self-mutilation into two categories: culturally sanctioned self-mutilation and deviant self-mutilation. Favazza also created two subcategories of sanctioned self-mutilations; rituals and practices. The rituals are mutilations repeated generationally and "reflect the traditions, symbolism, and beliefs of a society" (p. 226). Practices "imply activities that may be faddish and that often hold little underlying significance" such as piercing of earlobes, nose, eyebrows as well as male circumcision while deviant self-mutilation is equivalent to self-harm. ==Terminology==

Self-harm (SH), self-injury (SI), nonsuicidal self-injury (NSSI) and self-injurious behavior (SIB) are different terms to describe tissue damage that is performed intentionally and usually without suicidal intent. The adjective "deliberate" is sometimes used, although this has become less common, as some view it as presumptuous or judgmental. Less common or more dated terms include parasuicidal behavior, self-mutilation, self-destructive behavior, self-inflicted violence, self-injurious behavior, and self-abuse. Others use the phrase self-soothing as intentionally positive terminology to counter more negative associations. Self-inflicted wound or self-inflicted injury refers to a broader range of circumstances, including wounds that result from organic brain syndromes, substance abuse, and autoeroticism. Different sources draw various distinctions between some of these terms. Some sources define self-harm more broadly than self-injury, such as to include drug overdose, eating disorders, and other acts that do not directly lead to visible injuries. Others explicitly exclude these. Some sources, particularly in the United Kingdom, define deliberate self-harm or self-harm in general to include suicidal acts. (This article principally discusses non-suicidal acts of self-inflicted skin damage or self-poisoning.) The inconsistent definitions used for self-harm have made research more difficult. Nonsuicidal self-injury (NSSI) is listed in Section II (Diagnostic criteria and codes) of the latest, , edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) under the category "other conditions that may be a focus of clinical attention". While NSSI is not a separate mental disorder, the DSM-5-TR adds a diagnostic code for the condition in-line with the ICD. The disorder is defined as intentional self-inflicted injury without the intent of dying by suicide. Section III (Emerging measures and models) of the previous edition of the DSM (DSM-5) contains the proposed diagnosis along with criteria and description of Nonsuicidal Self-injury. Criteria for NSSI include five or more days of self-inflicted harm over the course of one year without suicidal intent, and the individual must have been motivated by seeking relief from a negative state, resolving an interpersonal difficulty, or achieving a positive state. == Concealment ==

A common practice in those who self-harm is that of concealment. Concealment is the process of hiding ones self-harm scars or wounds via methods such as wearing concealing attire, harming in less perceived places, such as thighs, makeup, plastic surgery or tattoos. in cases like these, people may not wish to conceal their scars or wounds either from themselves or others, believing they will gain approval, cause disgust or instill fear in others. ==Signs and symptoms==

The most common form of self-harm for adolescents, according to studies conducted in six countries, is stabbing or cutting the skin with a sharp object. For adults ages 60 and over, self-poisoning (including intentional drug overdose) is by far the most common form. Other self-harm methods include burning, head-banging, biting, scratching, hitting, preventing wounds from healing, self-embedding of objects, and hair-pulling. The locations of self-harm are often areas of the body that are easily hidden and concealed from the sight of others, most commonly being the forearms, thighs or torso. ==Causes==

Mental disorder Although some people who self-harm do not have any form of recognized mental disorder, self-harm often co-occurs with psychiatric conditions. Self-harm is, for example, associated with eating disorders, autism, borderline personality disorder, body dysmorphic disorder, dissociative disorders, bipolar disorder, depression, phobias, As many as 70% of individuals with borderline personality disorder engage in self-harm. An estimated 30% of autistic individuals engage in self-harm at some point, including eye-poking, skin-picking, hand-biting, and head-banging. There may be a common ground of inner distress culminating in self-directed harm in patients with this condition. However, a desire to deceive medical personnel in order to gain treatment and attention is more important in factitious disorder than in self-harm. Abuse during childhood is accepted as a primary social factor increasing the incidence of self-harm, as is bereavement, Other predictors of self-harm and suicidal behavior include feelings of entrapment, defeat, lack of belonging, and perceiving oneself as a burden along with having an impulsive personality and/or less effective social problem-solving skills. Transgender adolescents are significantly more likely to engage in self-harm than their cisgender peers. This can be attributed to distress caused by gender dysphoria as well as increased likelihoods of experiencing bullying, abuse, and mental illness. Genetics The most distinctive characteristic of the rare genetic condition Lesch–Nyhan syndrome is uncontrollable self-harm and self-mutilation, and may include biting (particularly of the skin, nails, and lips) and head-banging. Genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behavior. However, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive. Alcohol is a major risk factor for self-harm. A study which analyzed self-harm presentations to emergency rooms in Northern Ireland found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations. A 2009 study in the relation between cannabis use and deliberate self-harm (DSH) in Norway and England found that, in general, cannabis use may not be a specific risk factor for DSH in young adolescents. Smoking has also been associated with both non-suicidal self injury and suicide attempts in adolescents, although the nature of the relationship is unclear. A 2021 meta-analysis on literature concerning the association between cannabis use and self-injurious behaviors has defined the extent of this association, which is significant both at the cross-sectional (odds ratio = 1.569, 95% confidence interval [1.167-2.108]) and longitudinal (odds ratio = 2.569, 95% confidence interval [2.207-3.256]) levels, and highlighting the role of the chronic use of the substance, and the presence of depressive symptoms or of mental disorders as factors that might increase the risk of self-injury among cannabis users. ==Pathophysiology==

Self-injury may result in serious injury and scarring. While non-suicidal self-injury by definition lacks suicidal intent, it may nonetheless result in accidental death. While the motivations for self harm vary, the most commonly endorsed reason for self harm given by adolescents is to get relief from a terrible state of mind. Young people with a history of repeated episodes of self harm are more likely to self-harm into adulthood, and are at higher risk of suicide. In older adults, influenced by a combination of interconnected individual, societal, and healthcare factors, including financial and interpersonal problems and comorbid physical conditions and pain, with increased loneliness, perceived burdensomeness of ageing, and loss of control reported as particular motivations. There is a positive statistical correlation between self-harm and physical, sexual, and emotional abuse. Self-harm may become a means of managing and controlling pain, in contrast to the pain experienced earlier in the person's life over which they had no control (e.g., through abuse). A UK Office for National Statistics study reported only two motives: "to draw attention" and "because of anger". It may also be an attempt to affect others and to manipulate them in some way emotionally. Many people who self-harm state that it allows them to "go away" or dissociate, separating the mind from feelings that are causing anguish. Alternatively, self-harm may be a means of feeling something, even if the sensation is unpleasant and painful. Those who self-harm sometimes describe feelings of emptiness or numbness (anhedonia), and physical pain may be a relief from these feelings. Endorphins are endogenous opioids that are released in response to physical injury, acting as natural painkillers and inducing pleasant feelings, and in response to self-harm would act to reduce tension and emotional distress. Autonomic nervous system Emotional pain activates the same regions of the brain as physical pain, so emotional stress can be a significantly intolerable state for some people. Some of this is environmental and some of this is due to physiological differences in responding. The autonomic nervous system is composed of two components: the sympathetic nervous system controls arousal and physical activation (e.g., the fight-or-flight response) and the parasympathetic nervous system controls physical processes that are automatic (e.g., saliva production). The sympathetic nervous system innervates (e.g., is physically connected to and regulates) many parts of the body involved in stress responses. Studies of adolescents have shown that adolescents who self-injure have greater physiological reactivity (e.g., skin conductance) to stress than adolescents who do not self-injure. ==Treatment==

Several forms of psychosocial treatments can be used in self-harm including dialectical behavior therapy. Psychiatric and personality disorders are common in individuals who self-harm and as a result self-harm may be an indicator of depression and/or other psychological problems. , there is little or no evidence that antidepressants, mood stabilizers, or dietary supplements reduce repetition of self-harm. In limited research into antipsychotics, one small trial of flupentixol found a possible reduction in repetition, while one small trial of fluphenazine found no difference between low and ultra-low doses. , no clinical trials have evaluated the effects of pharmacotherapy on adolescents who self-harm. Emergency departments are often the first point of contact with healthcare for people who self-harm. As such they are crucial in supporting them and can play a role in preventing suicide. At the same time, according to a study conducted in England, people who self-harm often experience that they do not receive meaningful care at the emergency department. Both people who self-harm and staff in the study highlighted the failure of the healthcare system to support, the lack of specialist care. People who self-harm in the study often felt shame or being judged due to their condition, and said that being listened to and validated gave them hope. At the same time staff experienced frustration from being powerless to help and were afraid of being blamed if someone died by suicide. There are also difficulties in meeting the need of patients that self-harm in mental healthcare. Studies have shown that staff found the care for people who self-harm emotionally challenging and they experienced an overwhelming responsibility in preventing the patients from self-harming and the care focuses mainly on maintaining the safety for the patients, for example by removing dangerous items or physical restraint, even if it is believed to be ineffective. A French ethnographic study has found out that regular staff meeting for caregivers but also for parents dealing with adolescents who self-harm were especially efficient to diminish guilt and powerless feelings, as well as violent reactions denounced by those who self-harm. Therapy A meta-analysis from Cochrane in 2016 found low-quality evidence suggesting that CBT-based psychotherapy can reduce the number of adults repeating self-harm. For those with repeated self-harm or probable personality disorder, group-based emotion-regulation psychotherapy, mentalization, and DBT showed promise in reducing repetition or frequency of self-harm, though the evidence quality varied from low to moderate. This meta-analysis was repeated again in 2021, and found uncertain evidence for many psychosocial interventions in reducing self-harm repetition in adults, noting significant methodological limitations across studies. While CBT-based therapies might reduce repetition at longer follow-ups (however with low certainty of evidence), MBT and group-based emotion regulation therapy showed promise in single or related trials, warranting further research. Dialectical behavior therapy for adolescents (DBT-A) is a well-established treatment for self-injurious behavior in youth and is probably useful for decreasing the risk of non-suicidal self-injury. Several other treatments including integrated CBT (I-CBT), attachment-based family therapy (ABFT), resourceful adolescent parent program (RAP-P), intensive interpersonal psychotherapy for adolescents (IPT-A-IN), mentalization-based treatment for adolescents (MBT-A), and integrated family therapy are probably efficacious. Cognitive behavioral therapy may also be used to assist those with Axis I diagnoses, such as depression, schizophrenia, and bipolar disorder. Dialectical behavior therapy (DBT) can be successful for those individuals exhibiting a personality disorder, and could potentially be used for those with other mental disorders who exhibit self-harming behavior. According to the classification of Walsh and Rosen A meta-analysis found that psychological therapy is effective in reducing self-harm. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%). Psychological therapies with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). Avoidance techniques Generating alternative behaviors that the person can engage in instead of self-harm is one successful behavioral method that is employed to avoid self-harm. Techniques, aimed at keeping busy, may include journaling, taking a walk, participating in sports or exercise or being around friends when the person has the urge to harm themselves. Some providers may recommend harm-reduction techniques such as snapping of a rubber band on the wrist, but there is no consensus as to the efficacy of this approach. ==Epidemiology==

, which is a measure of each country's disease burden, for self-inflicted injuries per 100,000 inhabitants in 2004 It is difficult to gain an accurate picture of incidence and prevalence of self-harm. Even with sufficient monitoring resources, self-harm is usually unreported, with instances taking place in private and wounds being treated by the self-harming individual. Recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys. A 2015 meta-analysis of reported self-harm among 600,000 adolescents found a lifetime prevalence of 11.4% for suicidal or non-suicidal self-harm (i.e. excluding self-poisoning) and 22.9% for non-suicidal self-injury (i.e. excluding suicidal acts), for an overall prevalence of 16.9%. The difference in SH and NSSI rates, compared to figures of 16.1% and 18.0% found in a 2012 review, may be attributable to differences in methodology among the studies analyzed. The World Health Organization estimates that, as of 2010, 880,000 deaths occur as a result of self-harm (including suicides). About 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses. However, studies based only on hospital admissions may hide the larger group of self-harmers who do not need or seek hospital treatment for their injuries, The onset of self-harm tends to occur around puberty, although scholarship is divided as to whether this is usually before puberty or later in adolescence. Meta-analyses have not supported some studies' conclusion that self-harm rates are increasing among adolescents. It is generally thought that self-harm rates increase over the course of adolescence, although this has not been studied thoroughly. The earliest reported incidents of self-harm are in children between 5 and 7 years old. In addition there appears to be an increased risk of self-harm in college students than among the general population. At least one in ten Chinese college students experience self-harm; in 2019, intentional self-harm and sequelae were the third and second leading causes of death among adolescents aged 15 to 19 years and 20 to 24 years in the country. In Ireland, a study found that instances of hospital-treated self-harm were much higher in city and urban districts, than in rural settings. The CASE (Child & Adolescent Self-harm in Europe) study suggests that the life-time risk of self-injury is ~1:7 for women and ~1:25 for men. Gender differences Aggregated research has found no difference in the prevalence of self-harm between men and women. Such problems have sometimes been the focus of criticism in the context of broader psychosocial interpretation. For example, feminist author Barbara Brickman has speculated that reported gender differences in rates of self-harm are due to deliberate socially biased methodological and sampling errors, directly blaming medical discourse for pathologising the female. Analyzing 70 most-cited articles in the psychiatrists and psychoanalytics journals in 2020, the psychologist Adrien Cascarino found out that one of the reason for this bias was the belief that most of the people self-harm because they have been sexually abused during their childhood (and were therefore mostly women), This gender discrepancy is often distorted in specific populations where rates of self-harm are inordinately high, which may have implications on the significance and interpretation of psychosocial factors other than gender. A study in 2003 found an extremely high prevalence of self-harm among 428 homeless and runaway youths (aged 16–19) with 72% of males and 66% of females reporting a history of self-harm. However, in 2008, a study of young people and self-harm saw the gender gap widen in the opposite direction, with 32% of young females, and 22% of young males admitting to self-harm. Studies also indicate that males who self-harm may also be at a greater risk of completing suicide. However, females who self-cut are more likely than males to explain their self-harm episode by saying that they had wanted to punish themselves. In New Zealand, more females are hospitalized for intentional self-harm than males. Females more commonly choose methods such as self-poisoning that generally are not fatal, but still serious enough to require hospitalization. Elderly In a study of a district general hospital in the UK, 5.4% of all the hospital's self-harm cases were aged over 65. The male to female ratio was 2:3, although the self-harm rates for males and females over 65 in the local population were identical. Over 90% had depressive conditions, and 63% had significant physical illness. Under 10% of the patients gave a prior history of earlier self-harm, while both the repetition and suicide rates were very low, which could be explained by the absence of factors known to be associated with repetition, such as personality disorder and alcohol abuse. Deliberate self-harm is common in the developing world. Research into self-harm in these areas is however, still very limited. Though an important case study is that of Sri Lanka, which is a country exhibiting a high incidence of suicide and self-poisoning with agricultural pesticides or natural poisons. Prisoners are sometimes placed in solitary confinement cells under protective custody to prevent them from harming themselves. Self-harm also occurs frequently in inmates who are placed in solitary confinement. ==Awareness==

There are many movements among the general self-harm community to make self-harm itself and treatment better known to mental health professionals, as well as the general public. For example, March 1 is designated as Self-injury Awareness Day (SIAD) around the world. On this day, some people choose to be more open about their own self-harm, and awareness organizations make special efforts to raise awareness about self-harm. ==Other animals==

Self-harm in non-human mammals is a well-established but not widely known phenomenon. Its study under zoo or laboratory conditions could lead to a better understanding of self-harm in human patients. In dogs, canine compulsive disorder can lead to self-inflicted injuries, for example canine lick granuloma. Captive birds are sometimes known to engage in feather-plucking, causing damage to feathers that can range from feather shredding to the removal of most or all feathers within the bird's reach, or even the mutilation of skin or muscle tissue. Breeders of show mice have noticed similar behaviors. One known as "barbering" involves a mouse obsessively grooming the whiskers and facial fur off themselves and cage-mates. File:Moluccan Cockatoo (Cacatua moluccensis) -feather plucking.jpg|Feather-plucking in a Moluccan cockatoo File:Canine lick granuloma.jpg|Lick granuloma from excessive licking ==See also==