Coping with self-harm
Welcome to Priory Bitesize. This month we spoke to Dr Paul McLaren, General Adult Psychiatrist and Medical Director at Priory Hospital Hayes Grove, about the issue of self-harm, its social stigmas and the importance of early treatment.
Self-harm is a common sign of psychological dysfunction. It has seeped into popular culture and spans the generations from childhood to old age. 80% of self-harm episodes involve stabbing or cutting the skin with a sharp object. Self-cutting and overdosing are the most common forms, but other self-injurious behaviour includes:
- Punching hard objects
- Picking at skin
- Hair pulling
- Swallowing foreign bodies
More complex behaviours such as piercing or tattooing, while socially sanctioned, can have similar psychological drivers in some individuals. Munchausen’s syndrome and factitious disorder also share some of the psychopathology.
Rates of self-harm are difficult to measure. It is often done in secret with active measures being taken to conceal it from close friends and family, let alone professionals. Shame can drive this desire to conceal and incidents are high and rising.
This article discusses the importance of recognising the signs of self-harm and how to support a patient who presents with this behaviour, with treatment such as dialectical behaviour therapy (DBT). We will also discuss possible underlying causes and the effect that popular culture has had on what people think of self-harm.
A World Health Organisation (WHO) survey published in 2014 identified that a fifth of teenagers in England said that they had self-harmed in the previous year – a three-fold increase from the previous decade. It is estimated that only 15% of people self-harming present to clinical services, with many only coming in crisis. Multiple healed scars on a forearm may only be spotted when an arm is exposed for blood pressure readings, so it is important to recognise the signs and symptoms in order to offer early support.
Self-harm is a symptom of mental distress and in a high proportion of those presenting for help, it is evidence of underlying psychiatric disorders or emotional distress. A wide range of psychological processes can lead to self-harm and in adolescence, emotional distress is common and self-harm can emerge as a maladaptive coping strategy.
Common underlying diagnoses are:
With these conditions, self-harm can emerge as a strategy for managing distressing feelings. The physical pain can replace the mental pain, at least temporarily. This temporary reduction in distress can reinforce the behaviour and increase the risk of recurrence. In a small proportion, this can generate compulsive recurrence and the behaviour can have an addictive quality. If self-injury is extreme or bizarre in quality, such as stabbing or attempted amputation, then a psychotic process should be considered.
Those who have not suffered the experience find it hard to understand the mechanisms. Mothers can be left feeling shocked and confused when they discover that their child has cut themselves. Our understanding of the pathological processes which underlie the behaviour is limited.
We do know that self-mutilation is a well-recognised phenomenon in non-human primates. In macaque monkeys, predisposing factors for self-harm are laboratory rearing and isolation. More serious self-mutilation is usually associated with a triggering stress. It is also associated with other behaviours which are usually exhibited in a fighting context. This suggests that self-harm may be driven by primitive mental processes rather than higher manipulative ones. When cornered, the fight mechanisms are activated and in the absence of a physical threat the behaviours get turned on the self. Anger is an emotion which is commonly associated with self-harm.
Self-harm is a significant risk factor for suicide and is evident in 40 to 60% of completed suicides. While the majority of those who self-harm will not complete suicide, there is still a significant danger. 70% of those with borderline personality disorder (BPD) engage in self-harm and it is often recurrent.
Self-harm and popular culture
There are websites which promote self-harm and popular songs which recount the experience create the impression that self-harm is self-indulgent and an affectation.
Self-harm is a social phenomenon. It sends a message from the individual to those around them that they are distressed and understanding that message is the key to managing the behaviour. It elicits powerful emotional reactions from others which also need to be managed.
Much psychiatric epidemiology has been done to distinguish self-harm from attempted suicide, on the basis that the latter is serious and the former less so. This division is invalid, has generated confusion and can lead to inappropriate treatment. People who self-harm should be afforded the same respect and dignity as everyone else. Not so long ago this would not have been the case and patients who presented with non-lethal overdoses or self-cutting would have been treated with ambivalence at best or with overt hostility at worst. The reasons for this are probably grounded in stigma and societal attitudes to suicide.
The belief that ‘being kind’ to a young person who has self-harmed may in some way reinforce that behaviour and increase the risk of repetition, is misguided.
Assessment is often challenging. A common scenario is for someone to present following an episode of self-harm, but want to leave after physical treatment but before they have a psychiatric assessment. Capacity of the individual should be rapidly assessed and many will have capacity to decline further assessment at that time. Some may not and will require an urgent Mental Health Act assessment.
Patients who self-harm will often present in a highly aroused emotional state. Anger, irritability and shame may dominate. The first exchanges in the interaction are critical to its subsequent course. Any signs of irritation or critical judgement in the assessor may lead the patient to withdraw or to transfer their anger to the process or the assessor.
A calm, assured and open approach to the assessment will help, but will not guarantee positive engagement due to the following reasons:
- The factors which got the patient into the position where they self-harmed will still be raw
- They may have felt out of control or disempowered and self-harm was a signal of distress
Active listening and genuinely trying to understand the motivation for the act will facilitate the assessment process. The severity of the physical injury is not a reliable indicator of intent or subsequent risk. A first attempt should always be thoroughly assessed irrespective of the seriousness of the physical complications. Even in repeated self-harmers, the motivation and intent may change with subsequent acts. An initial attempt may have been a dysfunctional attempt to manage painful emotions in the early development of a depressive episode, a second or third may reflect serious suicidal intent driven by worsening depression.
In respect of treatment, the physical complications should be managed first. This should be done promptly and efficiently and that can set a positive tone and facilitate subsequent communication. Treatment will depend on the underlying psychiatric conditions. If they are depressed or anxious, those conditions should be treated assertively.
In recurrent self-harm, a harm-minimisation approach may be appropriate with advice on the management of scars. For patients who have developed a pattern of recurrent self-harm then specific psychological interventions such as DBT are appropriate. This is a form of cognitive behavioural therapy (CBT) which is skills-based and is focused on improving emotional regulation and impulse control. Treatment can be given very quickly following an appointment and patients are often engaged in their first therapy session within a week of referral.
Even in a time-limited GP consultation, an open, empathic approach with genuine listening can enable an accurate assessment of risk and point to effective treatment. It is important to prevent the problem worsening to an extent where it can become more difficult to treat. It is often easier to treat a mental health problem if the person accesses therapy fairly soon after onset.
In a young person, an act of self-harm may be a cry for help. Listen as carefully as you can; a cause could be experiencing abuse and if you suspect this then a safeguarding referral can be considered.
Priory has a nationwide network of hospitals and wellbeing centres that are well placed to support your patients and offer fast access to therapy.