In humans, the destruction of body tissues through various means without the intent to attempt suicide, such as getting tattoos, piercing the body during certain religious rituals, self-inflicted pain by hitting oneself with chains, etc., are culturally accepted behaviors (Favazza, 1998). Tahminen and colleagues (1998) categorized self-harm behavior into two groups based on severity. Major self-harm involves cases such as eye removal or amputations of extremities or genital organs, which are seen more frequently in psychotic disorders or severe sexual identity disorders.
Minor self-harm includes behaviors such as cuts on the skin, burns, needle pricking, bleeding, biting oneself, hair pulling, and bone breaking. Favazza (1998) categorized self-harm behavior into three groups. Major self-harm refers to behaviors that cause permanent harm to the body, such as eye gouging or castration. Stereotypical self-harm includes repetitive behaviors like head banging, biting oneself, which are seen in conditions like Tourette's syndrome and intellectual disabilities. Superficial or moderate self-harm involves episodic behaviors like skin cutting, self-burning, and hair pulling.
Minor self-harm; a relatively common occurrence, has a prevalence ranging from 400 to 1400 per 100,000 people. Psychiatrically, the disorders associated with it include borderline personality disorder, mental retardation, other organic disorders, eating disorders, antisocial personality disorder, Munchausen syndrome, and factitious disorder (Jones and Daniels, 1996; Taiminen et al., 1998). Self-harm behavior typically occurs in individuals aged 15 to 35 and begins during adolescence (Vinona et al., 1995; Chowanec et al., 1991). In situations where aggression cannot be expressed through normal means due to physical constraints, self-harm behavior also occurs. For instance, it is a common behavior in prisoners (Hillbrand, 1996). Similarly, it has been reported that self-harm behaviors are observed in institutionalized aggressive and antisocial adolescents and psychiatric patients, whether physical barriers to social aggression exist or not (Jones and Daniels, 1996).
The underlying cause of self-harm in humans is reported to be insufficient parental care, especially maternal deprivation. Compared to patients who do not show self-harming behavior, adult patients who self-harm have experienced significantly higher levels of separation, family violence, and physical and sexual abuse during childhood (Jones Daniels, 1996; Langbehn, 1993; Zlotnick et al., 1996; Dallam, 1997). Chowanec and colleagues (1991) first reported that Pao (1969) had noted that self-cutting behavior was indicative of severe borderline personality disorder. Later, DSM-III included self-inflicted "physical harm" as a diagnostic criterion for borderline personality disorder. In this disorder, in addition to the intrapsychic elements of self-harm behavior, its interpersonal dimension is emphasized, and it is suggested that feelings of "rejection" triggered by excessive sensitivity to "separation, loss, and failure" lead to self-harming behavior. Some authors, however, have described the internal state in borderline patients as "resentment, anger, and feelings of inadequacy" and regard self-harm behavior as a means of "revenge" on significant others. Family sexual abuse and neglect play a crucial role in self-harming behavior in borderline personality disorder (Dubo et al., 1997).
Comorbidity
“Self-injury—self-mutilation” is commonly seen in diagnostic groups such as personality disorders, acute and chronic psychotic disorders, major affective disorders, and sexual identity disorders. When psychiatric cases with self-harm behavior were examined, it was found that this behavior is most frequently observed in personality disorders, particularly borderline personality disorder. Self-harm behavior can be associated with a variety of problems and disorders. Key perspectives on this include:
1. Among individuals with borderline personality disorder, up to 80% have a history of childhood sexual or physical abuse.
2. A third of self-harming individuals meet the diagnostic criteria for Post-Traumatic Stress Disorder (PTSD).
3. Borderline personality disorder can be a vulnerability factor for PTSD resulting from adult traumatic experiences.
4. Severe childhood sexual abuse can be a risk factor for PTSD, either during childhood or adulthood.
Self-harm behavior is more frequently observed in certain clinical psychopathological conditions. Although self-harm behavior is culturally and religiously accepted in some societies, it is considered pathological in borderline personality disorder, histrionic personality disorder, psychotic disorders, mood disorders, Gilles de la Tourette syndrome, and organic disorders such as mental retardation, Addison’s disease, encephalitis, and intoxications. It is noted that patients with borderline personality disorder are at a higher risk of self-harm behavior compared to other diagnostic groups. Herpetz (1995) found that self-harm behavior is most commonly seen in borderline personality disorder, followed by histrionic personality disorder; however, it can be observed in all personality disorders. Another study has supported data showing that self-harm behavior is seen in borderline, antisocial, and histrionic personality disorders. Repetitive, ritualistic behaviors are more common in individuals with intellectual disabilities, and behaviors like genital self-injury are more frequent in psychotic patients, individuals with autism, and those with borderline and antisocial personality disorders, as well as among male prisoners. Behaviors such as eye gouging and organ cutting are seen in disorders like schizophrenia. Head banging, biting oneself, and scratching oneself can also be seen without a pathological disorder, but compulsive lip biting and nail biting can occur with Tourette syndrome.
Simeon and colleagues supported other studies, stating that self-harm behavior is most frequent in personality disorders, dissociative and anxiety disorders. In another study, it was found that self-harm behavior is most common among prisoners, juvenile delinquents in correctional facilities, and patients with autism, schizophrenia, intellectual disabilities, and brain injuries. In patients diagnosed with borderline personality disorder and those who self-harm, dissociative experiences, susceptibility to hypnosis, continuous anger, and its expression and control were compared to normal controls, and the relationships of these variables with gender differences, childhood abuse, and self-harm history were investigated. In the borderline personality disorder group, 7 participants had a history of childhood abuse, and 17 participants had a history of self-harm attempts. Most of the antisocial personality disorder cases started self-harming due to legal and military problems and often used self-harm to reduce their distress and anger, or to influence others to change their environment and conditions. In borderline personality disorder cases, self-harm was reportedly initiated due to family-related reasons, with self-punishment and the motivation to reduce distress and anger.
Self-cutting has been noted as a potential risk for AIDS. A study conducted with 76 adolescents hospitalized for the AIDS prevention program found that 61.2% of them engaged in self-harm behavior, and 26.7% of these children shared the tools they used to cut with other peers, which was highlighted as an AIDS risk factor. Additionally, it was noted that gender, age, ethnic status, and psychiatric diagnoses did not significantly affect self-cutting behavior.
The rate of substance use and self-harm behavior occurring together or sequentially in the same person is high, and substance use is often observed in people with recurrent self-harm behavior. Substance use is common in individuals with borderline and antisocial personality disorders. It has been reported that 90% of those who self-harm also use substances, with many using multiple substances (66.7%), and substance use being largely at the addiction level (71.1%). Individuals who self-harm tend to start using substances at a younger age compared to those who do not. Studies have shown that 25-40% of people with substance use issues have traumatic life experiences. The frequency of substance use in Post-Traumatic Stress Disorder (PTSD) has been highlighted.
In a study conducted with women who had experienced sexual abuse or traumatic life experiences, it was found that these women used alcohol to cope with PTSD symptoms. In a study of 21 girls who self-harmed, a third of them reported alcohol and substance use.
Taiminen and colleagues (1998; Akt. Ross and Heath, 2002) categorized self-harm behavior into two groups based on severity. Major self-harming behaviors involve permanent bodily harm like eye removal or amputations, which are more commonly seen in psychotic disorders and severe sexual identity disorders. Minor self-harm behaviors include skin cutting, burning, needle pricking, hair pulling, biting oneself, and bone fractures. As case examples, the behavior of a 46-year-old woman who said, "I received a message from God to cut my tongue, it was my duty," and a 26-year-old man who blinded himself by gouging his eyes, saying, "God said that if I didn’t do this, people would suffer, and by doing this, I prevented their suffering," can be shown. A 32-year-old man cut his own testicles and stated that it was a penance for his sins.
Self-harm behavior associated with intellectual disabilities may benefit from various drug treatments, but it remains an area where the underlying causes are not fully understood, especially when accompanied by personality-related problems (Winchel and Stanley, 1991). They have described self-harm as a purposeful, non-lethal, and socially unacceptable behavior.
Self-harm behavior is defined as the act of causing harm to oneself without the intent to commit suicide (Walsh and Rosen, 1989). It can also be frequently observed in individuals with histrionic personality disorder, anorexia and bulimia nervosa, and post-traumatic stress disorder (Ak et al., 1994, Siemon et al., 1992). Favazza and colleagues (1989) proposed a connection between self-harm behavior and eating disorders based on a survey of 256 subjects with self-harm behavior.
Self-harm behavior can occur for reasons such as hatred, regret, self-punishment, or to damage an internalized object (Ak et al., 1994, Rizzuto et al., 1993), as well as due to frustration, anger toward others, substance and alcohol use, or to relax (Ak et al., 1994, Kaplan and Sadock, 2000).
Favazza (1998) categorized self-harm behavior into three groups:
1. Major Self-Harming Behaviors: Permanent body damage behaviors such as eye gouging or castration.
2. Stereotypic Self-Harm: Behaviors like head banging and biting oneself seen in Tourette syndrome and intellectual disabilities.
3. Superficial or Moderate Self-Harm: Episodic actions like skin cutting, self-burning, and hair pulling (e.g., trichotillomania).
Favazza (1989) defined self-harm behavior as a repetitive, non-lethal behavior that is not life-threatening, even suggesting that self-mutilation is the opposite of a suicide attempt. Favazza and Conterio (1989) defined it as a form of self-help and relief resulting from the pressure created by an inability to cope with the situation.
Deiter and colleagues (2000) examined self-harm behavior as direct and indirect subgroups. Behaviors resulting in intentional bodily harm, without the intent to commit suicide, fall under the "direct self-harm behavior" category. Examples include biting oneself, damaging the skin with nails, hitting oneself, hair pulling, swallowing or inserting objects, self-destructive masturbation, hitting the head, scalding oneself with very hot water or steam, and preventing wounds from healing by damaging them. Indirect self-harm behavior is a condition that may accompany direct self-harm behavior and generally includes behaviors like eating disorders, dangerous sexual behaviors, substance abuse, neglect of medical needs, carrying weapons, and careless driving.
Farberow (1980) defined self-harm as serious injury inflicted on oneself, and Walsh and Rosen (1988) described it as an intentional, non-lethal, and socially unacceptable behavior. It is defined as an attempt directed toward one's own body that results in tissue damage without the intention of suicide (Ghazıuddin et al., 1992).
Pathological self-harm behavior is typically recurrent and leads to minor or soothing solutions. Severe damaging behaviors like gouging the eyes or damaging the genitals are mostly non-repetitive and are seen in psychotic individuals. These behaviors do not have the intent to commit suicide. It is important to distinguish self-harm behavior from repetitive self-harming behaviors seen in mentally disabled or autistic children (Suyemoto, 1998). Self-harm behavior is a condition observed between the ages of 15-35 and typically begins during adolescence (Vınona et al., 1995; Chovvanec et al., 1991; Akt. Canat, 1999). This behavior is more commonly seen in women than in men and typically occurs in patients in their twenties (Kaplan and Sadock, 1996). Self-harm behavior must have become a habit for the person to be considered as such. Behaviors performed once by someone with anger control issues or self-destructive actions in contexts such as concerts may be viewed as self-harm, but it would not always be accurate to categorize them as self-harm behavior.
The most common form of self-harm behavior is self-cutting. There have been debates among experts about the existence of "self-cutting syndrome" (Suyemoto, 1998). For some individuals, this behavior helps them return to reality and relieves tension and anxiety (Canat, 1999). Those who self-harm through cutting often say they do not feel pain during the act (Ak et al., 1993; Siemon et al., 1992). It is thought that this may be related to the adrenaline surge and serotonergic system, and dissociation is also a possible explanation (Buttle et al., 1996; Gardner and Cowdry, 1989; Grunebaum and Klerman, 1967; Richardson and Zaleski, 1986). The feeling of pleasure that arises after the adrenaline surge is considered to act as a reinforcement for the behavior (Richardson and Zaleski, 1986; Akt: Siemon et al., 1992). Those who engage in this behavior prefer long-sleeved clothes, even when it is hot, indicating a different need for privacy.
Individuals often feel uneasy when they have to change clothes or undress. In many cases, these individuals also show signs of depression (Storey et al., 2005; Harris, 2000). Before engaging in self-harm, individuals report feeling tense, anxious, and uneasy. As managing these feelings becomes difficult, dissociation occurs as the next step. Razor blades are the most commonly used tool during the act, and wrists and forearms are the most frequently harmed areas. The feeling of pain is often absent during the act. The negative emotions felt often disappear after the self-harming behavior. Patients sometimes express guilt about their actions and disgust at their wounds, but the sense of relief, calmness, and satisfaction outweigh these feelings (Harris, 2000).
It is difficult to estimate the number of individuals who engage in self-harm behavior. This is because the behaviors are partially unreported, and the diversity of self-harm behaviors makes it difficult to assess. However, according to Biere and Gil (1998), 4% of the population and 21% of patients in psychiatric clinics engage in self-harm behavior. The prevalence of this behavior is found to be equal among women and men. Favazza, De Rosear, and Conterio (1989, Akt. Ross and Heath, 2002) found that at least one time, individuals from a college sample group attempted self-harm. Favazza and colleagues (1993) reported that the rate of self-harm in bulimia patients is 40%, and in other psychiatric disorders, it ranges between 24-34%.
It is also difficult to assess the annual occurrence and lifetime prevalence of self-harm behavior. Many individuals who have engaged in self-harm in the past avoid disclosing this information unless directly asked. Similarly, during clinical evaluations, self-harm behaviors and suicide attempts may be confused. Since many self-harm behaviors result in minor injuries, individuals may not seek medical attention or report to health institutions, which reduces the awareness of the condition (Suyemoto, 1998). Again, self-harm behavior is more frequent in psychiatric patients than in the general population. The rate of self-harm behavior in psychiatric patient groups ranges from 4.3% to 20%. A study conducted with outpatient patients found that 47% of the patients had at least one instance of self-harm, and they were adolescents (Suyemoto, 1998).
When looking at the group of individuals who require psychiatric assistance due to self-harm, an important determinant appears to be the presence of other psychiatric diagnoses and a history of sexual abuse and/or suicide attempts. Generally, cases without a history of abuse or other disorders have more favorable treatment outcomes. However, in those with a diagnosis of borderline personality disorder and/or a history of suicide attempts, the process is much more challenging (Brodsky et al., 1995; Haw et al., 2001; Levenkron, 1999
