Although the psychiatric community first recognized self-injurious behavior (SIB) in the 19th century, SIB has attracted treatment professionals' attention most significantly in the last decade. In recent years, professionals who treat eating disorders are talking about SIB as a common co-occurring condition with anorexia and bulimia. This accompanies other common comorbid disorders diagnosed with eating disorders, such as substance abuse, depression and anxiety.
Estimates of SIB in the general U.S. population range from 14 to 600 per 100,000 annually, or less than 1 percent. Given the current U.S. population of 280 million, this indicates that between 39,200 and 1,680,000 people engage in SIB each year. Rates are higher among adolescents and young adults, including an estimated 12 percent in college populations.
SIB is on the rise throughout our country, especially among teenage girls with eating disorders. In eating disorders, prevalence ranges from 25 percent to 45 percent. In one study, SIB had simultaneous onset with the eating disorder in 48.5 percent of patients, later onset in 40 percent of patients, and previous onset in only 11.5 percent. At Remuda Ranch, approximately 40 percent to 50 percent of the women and girls we treat have either reported a history of self-injury or are presently engaging in these behaviors.
Defining, understanding SIB
SIB relates to any socially unacceptable behavior involving immediate, deliberate, direct and usually repetitive physical injury to one's own body. This behavior results in mild to moderate harm, usually without suicidal intent.
SIB typically includes behaviors such as scratching, cutting, carving, burning, rubbing, abrading, punching, pinching, biting, head banging, and hair pulling. In cutting, the tool most often used is a razor blade. The most common body parts cut are the wrists and forearms, followed by the legs.
Similar to eating disorders, cutting is often mystifying to many people and can be frightening to families when someone they love is struggling. We often hear: “Why would she starve herself, or harm her own body? What do we do?”
One patient admitted that her eating disorder is her “pain” and the cutting is her “voice.” However, it is difficult to understand the triggers and influences of SIB in eating disorders.
Similar to the forces that influence one's vulnerability to developing an eating disorder, self-harming tendencies evolve and are reinforced through a blend of biological and environmental factors. However, both are complex.
The truth is that the powerful urge to cut can emerge out of nowhere, and the relief experienced is often described as addictive. A series of crises, difficulty managing life stressors, a unique predisposition to impulse and emotional dysregulation, and traumatic and abusive histories all powerfully influence the tendency toward self-harming behaviors.
We realize that cutting serves a very important purpose and can quickly become a maladaptive coping tool, one that has an immediate, short-term effect in attempts to just “feel,” to bring relief during an uncomfortable situation, or to dull negative and painful thoughts and emotions.
The most common functions have been explained well by authors Vanderlinden and Vandereycken1 as follows:
Emotional release: Attempts to regulate strong negative emotions that overwhelm. Cutting can provide an outlet for feelings of anger, fear, shame, weakness, or guilt.
Relaxation/escape: Attempts to reduce stress and self-soothe. There can be a sense of pleasure from the warmth of the blood and the sensation of pain providing comfort and control.
Stimulation/grounding: Sometimes people cause pain to reassure themselves that they are “still here.” They need to feel feelings and their own bodies in order to feel alive, or re-ground themselves in reality.
Diversion: The act of self-harm can produce a trance-like state. This allows the individual to avoid unpleasant feelings, emotions or suicidal thoughts.
Cry for help: Most of those who harm their bodies do it in areas that will not be seen: the inside of the thighs or upper arms, the lower abdomen, even the breasts. However, if the result of the action is highly visible, it can be the only way one is able to cry for help.
Scarification/alteration: Making one's body unattractive may serve as a protective measure in attempts to ensure they will not be assaulted again.
Social motives: Many of those who have anorexia perceive themselves as strong because they have “conquered” the need for food. Similarly, cutters may view their action as one of great strength and believe it makes them appear powerful.
Treatment for SIB
Sometimes we may not know why people engage in their destructive behaviors; it is important not to get too bogged down with trying to figure it out. Diving into the cause of psychopathology might take you on a wild goose chase and thus prove unproductive. It was once said, “You take an aspirin because you have a headache, not because you have an aspirin deficiency.” Regardless of the reason for the self-harm, we need to move forward in treatment.
It is important to validate the patient and her family in that SIB is understandable and reasonable given the pain and agony she may be experiencing. This does not mean you are encouraging or condoning the behavior. You are simply saying that given the pain she is experiencing, you as the therapist understand why she cuts.