Self-harm: it's more than just attention seeking behaviour

To recognise the forthcoming Self-injury Awareness Day, we revisited Dr Paul McClaren (BA, MA, MBBS, MSc), Medical Director at Priory Hospital Hayes Grove, to explore this behaviour further. In his article, he discusses the common misconceptions of self-harming, explores why people cause injury to themselves, and how best to offer care and management to individuals you are concerned about.

Self-harm is defined as the intentional injury to oneself, without suicidal intent. However, there is overlap between self-harming behaviour and suicidal behaviour and individuals who self-harm are at increased risk of suicide. A history of self-harm is found in up to 60% of people who complete suicide and the vast majority of people who self-harm have attempted suicide.

The term 'attention seeking' is often used negatively in relation to self-harm. The implication is that the individual self-harms just to get attention but it is important to understand that this is rarely the main motivation. One of the key aspects in managing self-harm is to understand the individual enough to subsequently understand their behaviour. This takes time and it can be difficult to achieve in a busy practice.

Self-harm can be the first manifestation of a mental health disorder. It is most typically associated with personality disorder, in particular, borderline personality disorder (BPD), which is also known as emotionally unstable personality disorder (EUPD). There are however a number of other mental health conditions which self-harm can be a symptom of. These include:

• Depression
• Panic disorder
• Generalised anxiety disorder (GAD)
• Eating disorders
• Post-traumatic stress disorder (PTSD)
• Autistic spectrum disorders (ASDs)

If you are concerned about a patient, the most common signs and forms of self-harm to look out for include:

• Cutting the skin with a sharp object
• Cigarette burning
• Scratching
• Picking
• Banging or hitting body parts
• Hair pulling
• Swallowing objects or toxic substances

Who self-harms?

It has been estimated that about 1 in 10 admissions to UK medical wards are the result of self-harm. While it is most often associated with angst-ridden adolescents, self-harming is known to occur in younger children right through to older age. It can occur at any age, however it is more likely to be missed in the elderly.

It is recognised that self-harm is most common in young people, usually between the ages of 12 and 24 years, but it is important to be open minded and understand that anyone presenting in an unusual mental state with an injury, may be self-harming.

Why do people self-harm?

In most situations, self-harm is a maladaptive coping mechanism used to modify painful feelings or to communicate distress.

Abuse in childhood is recognised as increasing the risk of self-harm, as well as early losses and troubled relationships.

In terms of personality disorder, it has been estimated that about three quarters of people who have BPD will engage in self-harm at some time in their life. Those with ASDs may also engage in self-harm, often quite severely, and can include biting and head banging.

Understanding why individuals self-harm

Understanding why people self-harm is key to successful psychological and psychiatric assessment. This may be difficult to do when the individual who self-harms is still in an aroused or agitated emotional state. Attempts to probe or to question too deeply, too soon, risks falling on deaf ears or alienating the patient. This may make it less likely that a meaningful assessment of risk will be completed, to devise an appropriate treatment plan.

In understanding why an individual self-harms, it is important to consider what the motivation is for them. Potential triggers of self-harm are:

• Coping mechanism to provide relief from intense feelings
• Controlling emotional pain
• An attempt to break out of a dissociative state or a state of emotional numbness
• Making others feel guilty
• Alcohol can be a disinhibiting factor and many individuals who self-harm will do so in association with drinking

While for some, self-harm may bring them back into reality from a dissociative state, for others it may take them away from and allow them to distance themselves from emotional pain, which they struggle to deal with in healthier ways. The physical pain supersedes the emotional pain and allows them to, at least temporarily, free themselves from that state.

We know that our brain chemistry changes in response to physical injury; opioids are released and that could be one of the psychopharmacological mechanisms in which self-harm can modify inner feelings.

Management of self-harm

Treatment for self-harm and management of this behaviour can be divided into two main areas:

• The immediate management on presentation
• The longer-term management and treatment

In the first instance, the key to management is getting a clear understanding of the behaviour and that involves taking the time to 'interview' the individual at a time and place when they are able to give as much information as they can about their mental state.

In the longer term, individuals may only have contact with practice nurses, GPs or A&E departments to simply dress their wounds. It is so important that the opportunity is taken during wound dressing to engage with the patient and show them that you are interested in understanding why they have self-harmed. Treating your patient with respect, understanding and kindness at this stage will improve their chances of engaging positively in further psychological treatment.

There may be some instances where urgent care is required for someone who has self harmed, but there are crisis support options available. Whether it's for immediate care or just someone to talk to, crisis support helplines can help.

Most effective treatment

For those who present with recurrent self-harm, the most effective psychological treatment is dialectal behaviour therapy (DBT). DBT is a modified form of cognitive behavioural therapy (CBT) which is focused on improving emotional regulation skills. It is usually done in a group setting with elements of individual support, and involves helping the patient to understand their subjective state around an episode of self-harm or impulsive behaviour, which ultimately improves their regulation and reduces the chances of it happening again.

Alongside any intervention such as DBT, which addresses the act of self-harm directly, it is also important to assertively treat any underlying mental illness, such as depression or anxiety. This can also be done using DBT, CBT and other therapies such as mindfulness.

Priory has a nationwide network of hospitals and wellbeing centres that are well placed to support your patients and offer fast access to therapy for self-harming behaviour.