What Does Self-Injury Mean?

Self injury can be briefly defined as self-harm. This behavior involves people harming their bodies in a way to reduce emotional pain, improve their relationships with others, or to avoid suicide. Self-injury often results in physical damage caused by cutting, burning, hitting, or other bodily harms and is also considered a sign of underlying psychological difficulties.

“What Is Self-Injury?”

It is observed that various definitions exist in the literature regarding self-harm behavior. The biggest drawback of this situation is that it causes serious conceptual confusion. After this topic began to be examined as a separate area, this confusion increased even further, and many more definitions continued to emerge. In the literature addressing physical self-harming behaviors, there are many terms used to explain self-harm. The prominent ones are as follows:

Autoaggression, intentional injury, malingering, symbolic wounding, masochism, Munchausen syndrome, deliberate self-harm, local self-destruction, delicate self-cutting, self-injurious behavior, self-mutilation, self-destructive behavior, aggression against the self, parasuicide, attempted suicide, and focal suicide are among these terms. In this study, the term “self-injury” will primarily be used. The reason for this is that individuals engaging in such behaviors do not intend to mutilate or disable themselves.

To understand self-harm behavior and distinguish it from other indirect pathological self-damaging behaviors and suicide attempts, as well as from self-mutilation, it is necessary to clearly understand their definitional frameworks. For this purpose, the definitions of self-injury and other self-directed harmful behaviors are examined in detail below.

Self-Destructive Behavior: This includes a wide variety of conditions. True suicide attempts, suicidal tendencies, discontinuation of life-sustaining treatments such as dialysis, engagement in high-risk jobs, and hobbies such as speedboat racing and parachuting are included. Acute intoxication, chronic alcoholism, severe obesity, heavy smoking, and self-mutilation also fall within this category.

Self-mutilation: There are many definitions in the clinical literature regarding self-mutilation. It generally refers to a direct and intentional form of self-destruction that occurs once, occasionally, or repeatedly, without suicidal intent, resulting in varying degrees of tissue damage. Besides moderate physical harm, self-mutilation includes major forms such as eye enucleation, castration, and amputation of body parts, most commonly linked to schizophrenia and rarely seen in transsexual individuals. It must occur without the help of another person and must result in tissue-damaging wounds. Acts with suicidal intent or sexual desire are not classified as self-harm. Pathological self-mutilation includes behaviors not socially acceptable even within subcultures. Some authors exclude major self-mutilations associated with psychosis and stereotypical self-injury observed in mentally retarded or autistic children from this definition.

Self-injuring behavior: This refers to repetitive, intentional physical self-harm that does not aim to cause life-threatening injury but results in moderate bodily damage such as cutting, scratching, or burning. Although recommended for more specific use, the term is often used interchangeably with “self-harm.”

Self-harming behavior: This term is used for indirect forms of self-harm such as overeating, alcohol abuse, and excessive smoking, which harm health.

According to the Explanatory Dictionary of Psychiatry, the term self-mutilation means “to injure or mutilate oneself.” It also includes the intentional production of symptoms or syndromes. According to the Turkish Medical Language Guide, self-injury/self-mutilation refers to wound, injury, or damage. The Merriam-Webster Dictionary defines “mutilate” as “to cut off or permanently destroy a limb or essential part” (1995, p. 342). Self-harm may sometimes be part of a self-destructive impulse and may represent aggression directed toward oneself or introjected parental figures. It may be seen in soldiers trying to avoid military duties. One of the most common forms observed in psychiatric hospitals is repeated wrist cutting or burning the inner forearm with cigarettes. These individuals often appear to admire their wounds and experience little to no pain. Some authors view wrist cutting as a protective action against life drives and also as an auto-erotic act that satisfies inner impulses. Cutting the skin symbolizes female genital organs. Another view considers wrist cutting, more common in women, not as a neurotic distortion but as a more severe pathology. Wrist cutting may provide a way to regain self-control during overwhelming stress. The behavior helps individuals escape depersonalization and relieve internal tension. Seeing the blood flow serves as proof of their experience and denial of the loss of bodily control.

Since the mid-1990s, the terminology used for behaviors such as cutting, scratching, burning, striking oneself, picking scabs, and similar actions has changed. Previously known as “self-mutilation,” the term shifted to the more general and socially acceptable “self-injury.” Researchers (Hyman, 1999; Connors, 2000; Simeon & Favazza, 2001) recommended replacing “self-mutilation” because of its stigmatizing and disturbing connotations. They emphasized that individuals who self-harm often use these behaviors as a mechanism to alleviate psychological pain. They also noted that these behaviors have an adaptive component and defined them broadly enough to include even mild physical harm and long-term repetition.

The general definition of self-injury can be stated as follows: It is intentional, effective, self-directed bodily harm with low lethality, socially unacceptable in nature, and aimed at alleviating psychological pain. The term “self-injury” was suggested as an alternative to “self-mutilation” to avoid its stigmatizing connotations. Considering the components of the definition, it is a deliberate behavior, not accidental, and is directed at the self. In this study, self-injury is differentiated from “self-inflicted” harm, as the latter is not always intentional or voluntary. Self-injury does not involve the help or intervention of another person. While self-harm among adolescents toward each other is not uncommon, the type of self-injury described here differs from such peer interactions. Another component is its low lethality. For example, another harmful behavior, self-harm (in broader terms), may pose moderate risks to life and therefore differs from self-injury.

‘Four Criteria Used in Self-Injury Behavior’ are as follows:

1. Repeated behaviors such as cutting or burning oneself,

2. Feeling tension prior to the act,

3. Experiencing relief, pleasure, or satisfaction along with physical pain,

4. Attempts to hide the marks due to shame and fear of social stigma.

Psychiatric literature indicates that there is no single definition or explanation of self-harm behavior. Examining the common points across definitions, the goals of self-harm include:

• Reducing tension and/or pain,
• Expressing emotions such as anxiety, anger, shame, and guilt,
• Self-punishment,
• Using harm as a tool to manipulate others into doing what they want (Favazza, 1989),
• Relieving unbearable tension or anxiety; many people who self-harm report feeling relief afterward (Favazza, 1989).
• Triggering the body’s biochemical pain-relief response; stress and trauma stimulate endorphin release.
• Ending dissociative episodes. Dissociation is a mental splitting process occurring when certain memories or thoughts cannot be consciously tolerated. Some individuals report feeling “dead inside” during dissociation; harming themselves helps them “feel alive” again (Favazza, 1989).

Self-harm behavior can be a symbolic form of acting out, especially among women in certain cultures. This theory is used to explain why a majority of individuals who self-harm (nearly 75%) are women or young girls (Noll et al., 2003; Hall, 2003; Gallop, 2002).

Alternatively, some researchers view it as an impulse-control disorder. Other studies suggest it may be an effort to manage traumatic childhood experiences or to end dissociation and depersonalization (Nijman et al., 1999).

According to Favazza (1998), self-injury is a fast but temporary self-help mechanism used to escape depersonalization, guilt, feelings of rejection, hallucinations, sexual problems, and emotional turmoil. In some cases, especially cutting helps individuals return to reality and reduce tension and anxiety (Goldney & Lester, 1997; Walsh, 1998).

Self-harm is not defined as a separate disorder in DSM-IV-TR or ICD-10 but appears as a common symptom in several psychiatric disorders, especially antisocial and borderline personality disorders. Only trichotillomania is classified under a separate category. In DSM-IV, it appears as a diagnostic criterion in “Stereotypic Movement Disorder” and “Borderline Personality Disorder” (APA 1994, cited in Kanat 1999). Broadly defined, self-harm refers to any deliberate action directed toward one or more body parts, without suicidal intent, designed to cause bodily damage. However, socially accepted cultural rituals (tattooing, piercing, religious offerings involving bodily injury) are excluded from this category.

Stereotypic Movement Disorder

A. Repetitive, seemingly purposeful but non-functional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing objects, self-biting, skin picking, or poking body openings, hitting the body).

B. The behavior significantly interferes with normal activities or results in self-inflicted bodily injury requiring medical treatment (or would result in injury if protective measures were not taken).

C. Even if mental retardation is present, the stereotypic or self-injurious behaviors are severe enough to be the focus of treatment.

D. The behavior cannot be better explained by a compulsion (as in OCD), a tic disorder, or a stereotypy associated with a pervasive developmental disorder, nor by hair pulling (trichotillomania).

E. The behavior is not due to a substance or a medical condition.

F. The behavior lasts for four weeks or longer.

With Self-Injurious Behavior: This specifier applies when the behavior results in bodily injury requiring treatment (or would have done so without protective measures).

Borderline Personality Disorder

1. Frantic efforts to avoid real or imagined abandonment.
2. Unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly unstable self-image or sense of self.
4. Impulsivity in at least two potentially self-damaging areas (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to marked reactivity of mood.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Trichotillomania

• Recurrent pulling out of one’s hair resulting in noticeable hair loss.
• Increasing sense of tension before pulling or when attempting to resist the behavior.
• Pleasure, gratification, or relief when pulling out the hair.
• The disturbance is not better accounted for by another mental disorder and is not due to a medical condition (e.g., dermatological disorder).
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.