Self-Mutilation. ERIC Digest.
by Simpson, Chris
Suyemoto and MacDonald (1995) reported that the incidence of self-mutilation
occurred in adolescents and young adults between the ages of 15 and 35
at an estimated 1,800 individuals out of 100,000. The incidence among inpatient
adolescents was an estimated 40%. Self-mutilation has been most commonly
seen as a diagnostic indicator for Borderline Personality Disorder, a characteristic
of Stereotypic Movement Disorder (associated with autism and mental retardation)
and attributed to Factitious Disorders. However, practitioners have more
recently observed self-harming behavior among those individuals diagnosed
with bipolar disorder, obsessive-compulsive disorder, eating disorders,
multiple personality disorder, borderline personality disorder, schizophrenia,
and most recently, with adolescents and young adults. The increased observance
of these behaviors has left many mental health professionals calling for
self-mutilation to have its own diagnosis in the Diagnostic and Statistical
Manual of Mental Disorders (Zila & Kiselica, 2001). The phenomenon
is often difficult to define and easily misunderstood.
DEFINITION OF SELF-MUTILATION
Several definitions of this phenomenon exist. In fact, researchers and
mental health professionals have not agreed upon one term to identify the
behavior. Self-harm, self-injury, and self-mutilation are often used interchangeably.
Some researchers have categorized self-mutilation as a form of self-injury.
Self-injury is characterized as any sort of self-harm that involves inflicting
injury or pain on one's own body. In addition to self-mutilation, examples
of self-injury include: hair pulling, picking the skin, excessive or dangerous
use of mind-altering substances such as alcohol, and eating disorders.
Favazza and Rosenthal (1993) identify pathological self-mutilation as
the deliberate alteration or destruction of body tissue without conscious
suicidal intent. A common example of self-mutilating behavior is cutting
the skin with a knife or razor until pain is felt or blood has been drawn.
Burning the skin with an iron, or more commonly with the ignited end of
a cigarette, is also a form of self-mutilation.
Self-mutilating behavior does exist within a variety of populations.
For the purpose of accurate identification, three different types of self-mutilation
have been identified:
1) superficial or moderate; 2) stereotypic; and 3) major. Superficial
or moderate self-mutilation is seen in individuals diagnosed with personality
disorders (i.e. borderline personality disorder). Stereotypic self-mutilation
is often associated with mentally delayed individuals. Major self-mutilation,
more rarely documented than the two previously mentioned categories, involves
the amputation of the limbs or genitals. This category is most commonly
associated with pathology (Favazza & Rosenthal, 1993). The remaining
portion of this digest will focus on superficial or moderate self-mutilation.
Additionally, self-injurious behavior may be divided into two dimensions:
nondissociative and dissociative. Self-mutilative behavior often stems
from events that occur in the first six years of a child's development.
Nondissociative self-mutilators usually experience a childhood in which
they are required to provide nurturing and support for parents or caretakers.
If a child experiences this reversal of dependence during formative years,
that child perceives that she can only feel anger toward self, but never
toward others. This child experiences rage, but cannot express that rage
toward anyone but him or herself. Consequently, self-mutilation will later
be used as a means to express anger.
Dissociative self-mutilation occurs when a child feels a lack of warmth
or caring, or cruelty by parents or caretakers. A child in this situation
feels disconnected in his/her relationships with parents and significant
others. Disconnection leads to a sense of "mental disintegration." In this
case, self-mutilative behavior serves to center the person (Levenkron,
1998, p. 48).
REASONS FOR SELF-MUTILATING BEHAVIOR
Individuals who self-injure often have suffered sexual, emotional, or
physical abuse from someone with whom a significant connection has been
established such as a parent or sibling. This often results in the literal
or symbolic loss or disruption of the relationship. The behavior of superficial
self-mutilation has been described as an attempt to escape from intolerable
or painful feelings relating to the trauma of abuse.
The person who self-harms often has difficulty experiencing feelings
of anxiety, anger, or sadness. Consequently, cutting or disfiguring the
skin serves as a coping mechanism. The injury is intended to assist the
individual in dissociating from immediate tension (Stanley, Gameroff, Michaelson
& Mann, 2001).
CHARACTERISTICS OF INDIVIDUALS WHO SELF-MUTILATE
Self-mutilating behavior has been studied in a variety of racial, chronological,
ethnic, gender, and socioeconomic populations. However, the phenomenon
appears most commonly associated with middle to upper class adolescent
girls or young women.
People who participate in self-injurious behavior are usually likeable,
intelligent, and functional. At times of high stress, these individuals
often report an inability to think, the presence of unexpressable rage,
and a sense of powerlessness. An additional characteristic identified by
researchers and therapists is the inability to verbally express feelings.
Some behaviors found in other populations have been mistaken for self-mutilation.
Individuals who have tattoos or piercing's are often falsely accused of
being self-mutilators. Although these practices have varying degrees of
social acceptability, the behavior is not typical of self-mutilation. The
majority of these persons tolerate pain for the purpose of attaining a
finished product like a piercing or tattoo. This differs from the individual
who self-mutilates for whom pain experienced from cutting or damaging the
skin is sought as an escape from intolerable affect (Levenkron, 1998).
COMMON MISCONCEPTIONS OF SELF-MUTILATION
Stanley et al., (2001) report that approximately 55%-85% of self-mutilators
have made at least one attempt at suicide. Although suicide and self-mutilation
appear to possess the same intended goal of pain relief, the respective
desired outcomes of each of these behaviors is not entirely similar.
Those who cut or injure themselves seek to escape from intense affect
or achieve some level of focus. For most members of this population, the
sight of blood and intensity of pain from a superficial wound accomplish
the desired effect, dissociation or management of affect. Following the
act of cutting, these individuals usually report feeling better (Levenkron,
Motivation for committing suicide is not usually characterized in this
manner. Feelings of hopelessness, despair, and depression predominate.
For these individuals, death is the intent. Consequently, though the two
behaviors possess similarities, suicidal ideation and self-mutilation may
be considered distinctly different in intent.
Levenkron (1998) reports that individuals who self-mutilate are often
accused of "trying to gain attention." Although self-mutilation may be
considered a means of communicating feelings, cutting and other self-harming
behavior tends to be committed in privacy. In addition, self-harming individuals
will often conceal their wounds. Revealing self-inflicted injuries will
often encourage other individuals to attempt to stop the behavior. Since
cutting serves to dissociate the individual from feelings, drawing attention
to wounds is not typically desired. Those individuals who commit self-harm
with the intent of gaining attention are conceptualized differently from
those who self-mutilate.
Dangerousness to others
Another reported misconception is that those individuals who commit
self-harm are a danger to others. Although self-mutilation has been identified
as a characteristic of individuals suffering from a variety of diagnosed
pathology, most of these individuals are functional and pose no threat
to the safety of other persons.
TREATMENT OF THE INDIVIDUAL WHO SELF-MUTILATES
Methods employed to treat those persons who self-mutilate range on a
continuum from successful to ineffective. Those treatment methods that
have shown effectiveness in working with this population include: art therapy,
activity therapy, individual counseling, and support groups. An important
skill of the professional working with a self-harming individual is the
ability to look at wounds without grimacing or passing judgment (Levenkron,
1998). A setting that promotes the healthy expression of emotions, and
counselor patience and willingness to examine wounds is the common bond
among these progressive interventions (Levenkron, 1998; Zila & Kiselica,
Research shows that self-mutilation has been in existence far longer
than the understanding and accurate conceptualization of the phenomenon.
Therapeutic interventions have improved substantially over the past two
decades. However, further study is imperative to insure that those who
practice the behavior continue to receive effective care.
Favaro, A. & Santonastaso, P. (2000). Self-injurious behavior in
anorexia nervosa. The Journal of Nervous and Mental Disease, 188(8), 537-542.
Favazza, A.R. & Rosenthal, R. J. (1993). Diagnostic issues in self-mutilation.
Hospital and Community Psychiatry, 44, 134-140.
Levenkron, S. (1998). Cutting. New York, NY: W. W. Norton and Company.
Stanley, B., Gameroff, M. J., Michalsen, V., & Mann, J. J. (2001).
Are suicide attempters who self-mutilate a unique population? American
Journal of Psychiatry, 158(3), 427-432.
Suyemoto, K. L. & MacDonald, M. L. (1995). Self-cutting in female
adolescents. Psychotherapy, 32(1), 162-171.
Zila, L. M. & Kiselica, M. S. (2001). Understanding and counseling
self-mutilation in female adolescents and young adults. Journal of Counseling
& Development, 79, 46-52.