Body Areas That Are Harmed
The locations on the body where self-harm behaviors are carried out are also very important. The body area provides us with significant information about self-injury. The two most commonly used areas are the arms and legs. The primary preferred area is the arms. Since one hand can most easily and comfortably reach this area, the arms are the most commonly used region for self-harm. Other areas include the wrists and the forearm between the wrist and the elbow. The upper part of the arm is more difficult for the person to reach. Another reason for choosing the arms is that scars can often be hidden with long-sleeved clothing (including summer months). The wrist and forearm (between wrist and elbow) are areas that may carry secondary meanings associated with suicidal behavior.
According to Walsh & Rosen, Favazza (1987), and Ross & McKay (1979), wrist cuts have a very low likelihood of causing death; however, cuts in this area always express the individual’s sense of helplessness. Individuals who self-harm want others to understand the pain they experience internally and make efforts toward this.
Even if they mention suicide in their messages, this is actually a call for help, and they are receptive to intervention. In this regard, “wrist cutting” serves as an important signal or clue for establishing communication with the person who self-harms. The individual can be prevented without seriously endangering their life or engaging in a lethal attempt. The primary question is why that specific body part is chosen. For many patients, the chosen body area may carry symbolic meanings, and the symbolic meaning of the skin and the damage inflicted on it is significant and striking in self-harm behavior.
The therapist must learn what the chosen body area means for each individual and why it was selected. A clinician working with someone who self-harms will gain insight into how the person relates to their own body and how they connect their internal distress to the selected body area.
For many individuals, body image may become a central focus in treatment. Another important detail regarding the choice of body area is whether the adolescent previously preferred a different area. Sometimes this shift may indicate an increase in psychological pain or distress and suggest the need for urgent psychiatric intervention. The behavior of a 16-year-old patient I currently treat, B., two months before coming to me, is an example of this. B.’s self-harm by cutting began in eighth grade, starting with the forearm and wrists. After breaking up with her boyfriend, the area she cut shifted to her neck. Following this breakup, B. deeply cut her neck and remained in intensive care for about a week.
Self-harm by cutting initially begins with needles, pencil sharpeners, and pen tips. We observe that the transition to more harmful tools and the selection of riskier areas indicate that the behavior is not merely imitative experimentation. High-risk body areas include the face, eyes, chest, and genitals, as well as the neck, as in the example above. In some cases, individuals may shift between nearby regions. For instance, someone who previously cut their arms or legs may suddenly move to the biceps or hips. Persistent damage to the same body area may provide important information about the nature of the pathology or the symbolic expression.
The depth of the cuts, the location, the type of cutting instrument used, and the level of internal conflict are closely related. The goal in self-mutilation is to control the pain. If pain can be controlled through a superficial cut, the goal is achieved, and the behavior is postponed until the next episode of internal distress arises. However, during severe emotional pain, the cuts become deeper and the instruments sharper. The case of S., diagnosed with PTSD and hospitalized after the development of self-harm behaviors following trauma, is another example. S. described her hospital behavior as follows: “First I broke a glass and hit my upper arm with a piece of it, making a cut; but I noticed my anger wasn’t easing, so I hit it again, and still my anger didn’t go away. I tried a third time; that one was very deep, and I felt relieved and calmed down.”
The shift of self-harm from easily accessible, low-lethality areas like the arms and legs to more dangerous areas is associated with the progression and worsening of pathology. We now know that the aim of self-harm is to calm down, find relief, and maintain ego integrity. If the behavior shifts toward mutilation or disabling injury, this may indicate a move away from the goal of calming down. As seen, the chosen body area can offer diagnostic clues. The body area also provides information about the risks of the behavior. Marks and symbols on the body can be made with a pen tip, a serrated bread knife, or a sharp razor. While a pen may leave only a scratch, a razor may cause deep and risky wounds. For example, another adolescent patient I treat, Ş., stated that she always carried a utility knife in the back pocket of her pants for cutting and had three spare ones at home. One of them was very large and sharp. Ş. explained that although she had never used the large one, she would if her emotional pain increased, stating: “I am already in pain now, but the small ones help me control it.” Her words may be considered a signal of a potential suicide attempt or a more lethal self-harm behavior.
Body Areas That Carry Alarm Features
According to Walsh’s experience, four areas of the body carry special meaning in self-harm behavior. According to Walsh, harming the face has unique significance because the face is the first part encountered in social acceptance and interpersonal relationships. Therefore, harming the face contains distinct messages: “I hate myself and what I see. I do not care whether people accept or reject me based on my appearance or how they evaluate me.” Cutting the face may also reflect the depth of inner pain and social disconnection.
In my clinical experience, facial self-harm is very rare. There are several reasons for this. Cutting behavior is most intense during adolescence. Adolescents who self-harm struggle significantly with body image. Even if they severely harm other body areas, the face is special to them, and their sensitivity regarding it is extremely high. Based on my experience, I have only encountered facial self-harm in individuals under the influence of heavy alcohol or drugs. Furthermore, considering the definition and purpose of self-harm, adolescents often say: “When I cut, I need to see the cut and the flowing blood; because with the blood, all the hatred and anger inside me flows out.” Since the face does not always allow blood to flow visibly, and because the desire to be seen conflicts with this, facial cutting becomes less likely.
Self-harm that occurs under the influence of alcohol has no calming or affect-regulating function. These behaviors differ from the type of self-harm discussed in this study. Individuals state that cuts made under alcohol become extremely painful once the effect wears off. By contrast, individuals who self-harm for emotional regulation do not become distressed by their wounds and report not feeling pain. They only seek calmness and relief, often entering a trance-like state.
Self-harm to the eyes is associated with more severe pathology. Harming the eye to relieve emotional pain is extremely extreme and may lead to permanent disability. At this point, the behavior shifts toward the realm of self-harm with mutilation. Likewise, harming the genital organs or chest parallels eye harm. These areas are usually hidden from others. The chest and genital regions are highly sensitive to pain and stimuli. These regions are more frequently harmed in psychotic disorganization or trauma. The eyes, chest, genital areas, and face are regions that warrant emergency psychiatric intervention because they indicate both the depth of pain and the severity of pathology. In self-mutilation, the goal is to express pre-verbal material in pre-verbal ways. The wounds themselves provide as much information as verbal descriptions.
