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Why do teens hurt themselves? review of literature.

INTRODUCTION

Rachel, aged 16 years, had presented many times to the general hospital with self-harm behavior, usually involving wrist cutting and/or overdose with over-the-counter analgesic medication. The precipitant was most often conflict with her adoptive mother, who was at a loss to know how to manage her. Rachel met diagnostic criteria for borderline personality disorder, complicated by substance misuse and dysthymia. She had not attended school for two years. Once in hospital, Rachel would often cut herself again using a razor blade hidden in her belongings. Recognizing that there was a pattern to Rachel's behavior, the consultant psychiatrist providing outpatient treatment organized for Rachel to always be admitted to the same medical ward, where a very experienced nursing sister supervised her care. (1)

Deliberate self-harm describes an act of non-fatal, self-destructive, behavior that occurs when an individual's sense of worry outweighs their inherent survival instinct. (2) Deliberate self-harm is behavior not an illness. It is any act by an individual with the intent of harming himself or herself physically and which may result in some harm. (3)

Self-injury is widely misunderstood. It is an uncomfortable subject to think about, to talk about, a difficult behaviour to accept, and dealing with the issue presents many challenges to caregivers. (4) It is a behavior prevalent in all cultures and across all socioeconomic levels. (5)

Although it may occur at any age, self-injury is associated with adolescence, because it typically emerges during this developmental period. (6) Research suggests that women are more likely than men to practice deliberate self-harm. Favazza and Conterio (1988) (7) found that 97 percent of their self-harmers were women. Similarly, Ross and Heath (2003) (8) found that 64 percent of their adolescent self-injurers were female.

The most common form of self-harm appears to be skin cutting (9), and most individuals who engage in it typically cut on their forearms, although it is not necessarily restricted to that area. (6) Self-injury may take other forms as well, including severe skin scratching, picking at wounds, inserting objects into the body, or banging one's head. (10)

[FIGURE 1 OMITTED]

It is true that those who self-harm are very much at high risk of eventual suicide. Therefore, there is a definite relationship between self-harm and suicide. (11) If we better understood the functions served by self-harming behaviors, we might be able to understand suicidal thoughts, an attempt and completed suicide. (12) It is estimated that up to 2% of people who self-harm dying within the following year, rising to 7% after 9 years. (13)

[FIGURE 2 OMITTED]

What would cause people to do things that damage their bodies and may result in injury or death? People who practice self-harm are part of a heterogeneous group. That means that there is a lot of variety among people who choose to harm themselves. For some, self-harm is a cry for help and might be a first step to a suicide attempt. For others, self-harm is a coping mechanism that makes life more bearable. Self-harm can be used as a voice; an external expression of internal pain. Some people practice self-harm for an extended period of time, perhaps over many years. Others might only experiment with self-injury, perhaps as part of a group in adolescence. Although research about the causes of self-injury is in its early stages, most scholars agree that self-harm occurs as a result of biological, psychological, and social factors. (14)

Many researchers on self-harm (15) (16) (17) (18) (19) (20) have uncovered possible motivations for self-injurious behavior that include: 1. Escape from emptiness, depression, and feelings of unreality; 2. Easing tension; 3. 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 tolerable one; 4. Relieving anger: many self-injurers have huge amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings; 5. Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive; 6. Grounding in reality, as a way of dealing with feelings of depersonalization and dissociation; 7. Maintaining a sense of security or feeling of uniqueness; 8. Obtaining a feeling of euphoria; 9. Preventing suicide; 10. Expressing emotional pain they feel they cannot bear; 11. Obtaining or maintaining influence over the behavior of others; 12. Communicating to others the extent of their inner turmoil; 13. Communicating a need for support; 14. Expressing or repressing sexuality; 15. Expressing or coping with feelings of alienation; 16. Validating their emotional pain, the wounds can serve as evidence that those feelings are real; 17. Continuing abusive patterns: self-injurers tend to have been abused as children; 18. Punishing oneself for being "bad"; 19. 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; 20. Diverting attention (inner or outer) from issues that are too painful to examine; 21. Exerting a sense of control over one's body; 22. Preventing something worse from happening.

Unfortunately, the reasons for self-injurious behavior are often misunderstood. One common misconception is that self-harmers engage in these behaviors in order to receive attention. Alternatively, others might expect that someone who chooses to cut oneself must have a desire to die. (14) Gaining an understanding of the motivation can be important not only in providing a fuller picture of the nature of self-harm in individual cases, but also in addressing prevention of future episode. (21)

Date of Submission: April, 16, 2013 / Acceptance: July, 25, 2013

ACKNOWLEDGMENTS AND DISCLOSURE

The author declares that he has no potential conflicts of interest to disclose.

REFERENCES:

(1.) Hawton, K., van Heeringen, K. (eds.). The International Handbook of Suicide and Attempted Suicide. Chichester: Wiley, (2000) P.544.

(2.) Mitchell, J. A., Dennis, M. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg. Med. J., 2006; 23: 251-255.

(3.) Isacsson, G., Rich, L. C. Regular review: Management of patients who deliberately harm themselves. BMJ, 2001; 322: 213-215.

(4.) Sutton, J. Healing the hurt within: Understand Self--Injury and Self--Harm, and Heal The Emotional Wounds. 3rd ed. United Kingdom: How To Content, A division of How To Books (2007).

(5.) Lieberman, R., Poland, S. Self-mutilation. In Bear, G. G. & Minke, K. M. (eds.), Children's needs III: Development, prevention, and intervention. Bethesda, M. D. National Association of School Psychologists, (2006) (pp. 965-976).

(6.) Nixon, M. K., Heath, N. L. (eds.) Introduction to non-suicidal self-injury in adolescents. In: Self-injury in youth: The essential guide to assessment and intervention. New York: Routledge, (2009) (pp. 1-6).

(7.) Favazza, A. R., Conterio. K. The Plight of Chronic Self-Mutilators, "Community Mental Health Journal", 1988; 24, no. 1: 22-30.

(8.) Ross, S., Heath, N. L. "Two Models of Adolescent Self-Mutilation", Suicide & Life-Threatening Behavior, 2003; 33, no. 3: 277-287.

(9.) Klonsky, E. D., Muehlenkamp, J. J. Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In Session, 2007; 63: 1045-1056.

(10.) D'Onofrio, A. A. Adolescent self-injury: A comprehensive guide for counselors and health care professionals. New York: Springer, 2007.

(11.) McLaughlin, C. Suicide-related behaviours: understanding, caring, and therapeutic responses. England: John Wiley & Sons, 2007.

(12.) Skegg, K. Self-harm. Lancet, 2005; 366: 1471-83.

(13.) Owens, D., Horrocks, J., House, A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry, 2002; 181: 193-199.

(14.) Veague, H. B. Cutting and Self-Harm. New York: Infobase Publishing, Chelsea House, 2008.

(15.) Miller, D. Women Who Hurt Themselves: A Book of Hope and Understanding. New York: Basic Books, 1994.

(16.) Favazza, A. R. Why patients mutilate themselves. Hospital and Community Psychiatry, 1989; 40 (2): 137-145.

(17.) Favazza, A. R. Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry. 2nd ed. Baltimore: The Johns Hopkins University Press, 1996.

(18.) Connors, R. Self-injury in trauma survivors: 1. Function and meanings. American Journal of Orthopsychiatry, 1996; 66: 197-206.

(19.) Solomon, Y., Farrand, J. "Why don't you do it properly?" Young women who self-injure. Journal of Adolescence, 1996; 19 (2): 111-119.

(20.) Suyemoto, K. L. The functions of self-mutilation. Clinical Psychology Review, 1998; 18: 531-554.

(21.) Rodham, K., Hawton, K. Evans, E. Reasons for Deliberate Self-Harm: Comparison of Self-Poisoners and Self-Cutters in a Community Sample of Adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 2004; 43 (1): 80-87.

Safwat G. EL SHAFEY--M.B.B.Ch., Drd., "Carol Davila" University of Medicine and Pharmacy, Bucuresti, Romania; M. Sc. Psychiatry, Arab Board Psychiatry; Psychiatry Department, Rashid Hospital, Dubai, United Arab Emirates

Correspondence: Safwat G. EL SHAFEY

Address: Psychiatry Department, Rashid Hospital, P.O. Box 4545, Dubai, United Arab Emirates

Tel.: + 971.504.513.666

E-mail: saf_sha_9@hotmail.com
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Title Annotation:POINTS OF VIEW
Author:Shafey, Safwat G. El
Publication:Bulletin of Integrative Psychiatry
Article Type:Viewpoint essay
Date:Sep 1, 2013
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