Consultant
May 1, 2001

What’s Your Diagnosis? Self-Inflicted Injuries
By Henry Schneiderman

Sharpen Your Diagnostic Skills

HISTORY

* A 19-year-old girl is seen for burning skin pain and throbbing in her legs. She recounts no history of trauma.
* Has not changed laundry detergents recently.
* Denies any history of sexually transmitted diseases. No known exposure to tuberculosis.

PHYSICAL EXAMINATION

Young woman who is in no acute distress. Vital signs, normal. Unremarkable habitus. No erosions of posterior enamel. Skin of left shin as shown. No skin lesions elsewhere on her body. This patient repeatedly traumatized her own skin as a manifestation of psychic distress. Like almost all per sons who do this, she strongly denied the behavior when asked directly about it. A decade ago, a “What’s Your Diagnosis?” column discussed a patient who picked off most of an earlobe by repetitive intentional self-injury.1 Why re-address the problem now? Because the diagnosis is notoriously difficult. For all that we consider ourselves capable of envisioning the worst in people, we have a tendency to discount egregious self-injury, especially if the patient is reasonable in conversation. Factitial dermatitis thus offers a prototype of a diagnosis rendered more difficult because the patient misleadingly denies all knowledge of the origin of the lesions.2

PHYSICAL FEATURES

This patient’s largest ulcer provided perfect features from which we might suspect and then diagnose self trauma: the lesions were all located on areas of the body readily accessible to the patient’s hands. The ulcer formed a bizarre, sharply defined, geometric shape that does not con form to usual lesions of endogenous or infective origin.2

Antecedent symptoms were reasonably typical, although sometimes a sense of burrowing or crawling in the affected areas precedes the lesions, which can sometimes be necrotic.

External unintentional injury could produce the pattern of, for instance, a machine that struck the shin and caused a hexagonal defect. An exposure to allergen-containing cloth in this shape might make a similar-shaped lesion, though never one that caused such deep tissue loss as to expose the subjacent adipose tissue. In a psychiatrically normal person, a straightforward description of an initiating external event would put one onto the right track.

PSYCHIATRIC CONTEXT

If the patient’s history includes a credible diagnosis of self-mutilation or his or her actions during history and physical examination are frankly bizarre, we are more likely to entertain the diagnosis of self-injury. How ever, patients can present a most deceptively intact demeanor to the world, including to the physician. It is precisely in the patient “who would never dream of doing such a thing” and who has no psychiatric history that we are likely to miss the diagnosis or make it only after many exposures. We may feel inept, but perhaps ought not patients who have fooled us have been practicing this art of hiding for years. Their time expended on it will exceed ours spent on their case. In short, they may conceal far better than we can probe.

A typical personality for such patients has been proposed, including self-absorption and immaturity.3 However, numerous persons who mutilate themselves lack these features or have more striking traits that overshadow them. Sadly, self-injurious patients very rarely recognize their behavior as a cry for help. Resentment and termination of the relationship with the physician occur all too often when the diagnosis is made and the patient perceives it as a rejection or a condemnation.2 This sequence is prone to occur regardless of the sensitivity and support offered by the clinician. In this case, repeated psychiatric hospitalization led to dramatic resolution. In other instances, intensive approaches have yielded favor able outcomes when patients are amenable to insight and intervention.4

CULTURAL VARIANTS

Sometimes self-injury represents a culturally sanctioned medical intervention, as with forceful massage by hand along a series of parallel lines, often with a spoon retracing the lines repeatedly afterward, such that ecchymoses are formed in the Asian practice of cao gio to treat febrile or other illness.5,6 Among Guaymi Indians from Panama, a hot nail is sometimes applied to the abdomen to release evil spirits and allow a poor appetite to improve.7 Unless the patient is reticent when talking with the physician, who may well be from outside the group, these practices would be reported in the history, helping to exclude not only factitial dermatitis but also the other prospects, such as scabies with secondary bacterial infection.

Victims of self-injury can, of course, also suffer violence at the hands of other people. If you thought that some of the healed lesions looked like cigarette burns,8 you would be well advised to consider who has associated with this person. Then one must decide whether there is cause to notify the police. In children, the differential diagnosis of cao gio and of hot nail dermatitis will prominently include child abuse unless these well-intended folk-medicine practices are not recognized.

Deliberate self-injury with malingering intent can occur in all societies: a memorable report detailed 3 soldiers who ground garlic to release more of its potentially injurious contents and rubbed it into the ankle area; the resultant erythema and vesiculation were first misinterpreted as a phytocontact dermatitis.9 In fact, the reaction to a plant substance came not from casual con tact while walking through a field but rather by deliberate acts.

EXTRAORDINARY VARIETY

Hair-pulling, or trichotillomania, is a closely related practice, though the competing differential diagnoses are fewer, eg, alopecia areata.10 Repetitive, habitual or tic-like picking at an area, with resultant tissue loss, may produce a similar physical end point of self-injury, but it has a different psychodynamic and is not so prone to be intention ally misreported.

Among the dizzying array of reports, perhaps the most stunning recounts staphylococcal bacteremia that developed from self-injury, with a subsequent hematogenous epidural abscess whereby factitial dermatitis led to real paraplegia.11 No catalog of the bizarre variants of these strange practices would be complete without invoking those entities liable to be mistaken for factitial dermatitis—aggregately described as pseudofactitial dermatitis.12

A creative way to test the hypothesis that a patient may have a factitial dermatitis is to tell the patient, “I think the next lesion may appear here” and circle an area of accessible skin. If a lesion does in fact pop up there shortly, one has strongly supported the presumptive diagnosis and is left with only the very difficult task of management.

Dr Schneiderman is physician-in-chief at Hebrew Home & Hospital, West Hartford. He is also professor of medicine [geriatrics) and associate professor of pathology University of Connecticut Health Center, Farmington.

REFERENCES:

1. Schneiderman H. Ear tissue loss produced by self-trauma: factitial dermatitis. Consultant 1991;31:37-8.
2. Halprin KM. The art of self-mutilation, III: factitial dermatitis or dermatitis artefacta. JAMA 1967;199:155.
3. Fabisch W. What is dermatitis artefacta? Int J Dermatol. 1981;20:427-8.
4. Simmons DA, Daamen MJ, Harrison JW, Weishaar ME. Hospital management of a patient with factitial dermatitis. Gen Hosp Psychiatry 1987;9:147-50.
5. Schneiderman H. Coin-rubbing, folk remedies, and physical examination of immigrants. Consultant 1995;35:1349-52.
6. Silfen E, Wyre HW Jr. Factitial dermatitis—cao gio. Cutis 1981;28:399-400.
7. Menon PA, Wyre HW Jr. Hot nail factitial dermatitis. Cutis 1982;29:486487.
8. Schneiderman H. Cigarette burns and skin-popping signs: effects of battering and addiction. Consultant 1995;35:841-2.
9. Kaplan B, Schewach-Millet M, Yorav S. Factitial dermatitis induced by application of garlic. Int J Dermatol 1990;29:75-6.
10. Messinger ML, Cheng TL Trichotillomania. Pediatr Rev 1999;20:249-50.
11. Burket JM, Burket BA. Factitial dermatitis resulting in paraplegia. J Am Acad Dermatol 1987;17:306-7.
12. Lachapelle JM, Bataille AC, Tennstedt D, Marot L Pseudo-factitial dermatitis: a useful clinical and/or histopathological concept. Dermatology 1994;189(suppl 2):62-4.


Scottish Daily Record
May 24, 2001

When a Cut Blanks Out the Pain of Life; Experts Discuss the Secret Torment of People Who Harm Themselves
By Grace Mclean

TODAY will see the first-ever conference in Scotland on the issue of self-harm. Almost 300 hospital staff, social workers and psychiatric staff will hear how and why people mutilate themselves. The Motherwell conference will hear from those who work closely with people who cause themselves harm. Here, we look at how one group of women deal with this.

YOUNG mum Victoria Clelland took a 10-inch kitchen knife, hacked at her arms and watched the blood seep out before gulping down a handful of pills. By the time her husband found her lying at the bottom of the stairs Victoria was unconscious.

When she reached the local hospital she went into cardiac arrest and medics battled to save her life.

Victoria, 28, tried to take her own life because she is caught in a destructive cycle of self-loathing, despair and self harm

She has regularly cut herself after being diagnosed with multiple sclerosis.

Feeling that those she loved would be better off without her, four weeks ago she tried to end their suffering by killing herself.

Victoria is an articulate, intelligent young woman with a good marriage and a six-year-old son. She seems to have everything she could want—but the scars on her arms reveal an a inner torment. Victoria is what psychologists call a self-harmer—what she calls a “hacker.”

She was 21 and had just been diagnosed with MS and Crohn’s Disease when she first cut her arms with a pair of scissors.

Instead of pain, she felt an overwhelming sense of relief.

Victoria, who lives in a Lanarkshire village, said: “I cut in desperation. I feel pain inside and by cutting I can see something visible, something tangible.

“I feel ashamed and embarrassed about it. It’s not something I want to show the outside world. It really began when I was diagnosed with MS in hospital. I felt nobody was listening to me. A month ago I decided I didn’t want my child to grow up with a sick mother. I felt he and my husband would be better off without me and I tried to take my life.”

When Victoria hurts herself it is her left arm she attacks most because it has been left virtually paralysed by MS.

She was courageous enough to tell her story to the Daily Record to remove the stigma surrounding self-harm.

She is a member of GASH—Group Around Self-Harm—which meets every Thursday in Wishaw in Lanarkshire.

Today experts from across the country will discuss the issue of self-injury at a conference organised by GASH in Motherwell.

Victoria is just one of dozens of women—and men—who cut or burn themselves but self-starving, alcohol and drug abuse are also recognised forms of self -harm.

The common thread which ties the majority of members of GASH together is sexual abuse. Many suffered abuse as children, others have spent lengthy spells in psychiatric units.

One 45-year-old divorcee told how she has had 10 sessions of electric shock therapy.

During her first session at the age of 22, doctors told her it would help wipe out the memory of a rape just months before.

Later they said it would help her stop hurting herself and drinking too much.

She said: “Years ago you didn’t question such treatment. It didn’t wipe out the memory of rape but it did affect my long-term memory.”

One woman told how she would stick her arm over the steam of a kettle as a child. Now, she sears her arms with curling tongs.

The 51-year-old mother-of-two said: “The only hurt I feel is against those who abused me and they are gone.”

In Hartwood psychiatric hospital in Lanarkshire, she broke plastic cutlery, running the splintered pieces along her arms.

Each story is horrific but what these women have in abundance is courage.

By attending GASH, which has been running for three years, they are trying to come to terms with their problems.

While they might mutilate themselves, there is not one among them who would take out their frustration on anyone else.

And all have fought against terrible circumstances to hold down jobs, bring up children, and are caring, genuine individuals.

For them self-harming is not about attention seeking. They hide their wounds under clothing. They describe wounding themselves as a “release” from the mental torture from which they can not escape.

Almost every one of the women describes a build up of emotion—anger, frustration or hurt—in the days or weeks leading up to self-injury.

But the two women who run the group are well qualified to deal with the problems which come up on a weekly basis.

Irene Wylie has a background in addiction work while Sandra Toyre works for Women’s Aid.

Sandra said: “We want everyone to realise that these women are people first and have problems second.”

Irene added: “For many of them self-harming is a way of staying alive. They say if they didn’t do it they might be capable of killing themselves.”

Not everyone who attends the group cuts themselves.

Another woman has a problem with cannabis but also cut herself with glass as a child. The 35-year-old, who has Parkinson’s Disease, said: “I was getting stoned out of my head every night just to forget about things.”

Abused as a child, she believes that no one truly loves her and is full of self-hate. But, like all the women in the group, she is a survivor and refuses to see herself as a victim.

Victoria is already on the road to recovery after joining the group three weeks ago. She said: “I can choose whether I self-harm or not and I now choose not to.”


The Irish Times
June 18, 2001

One man’s experience of self-injury

“John” came to Karl Tooher in distress. Now in his mid-30s, he had been injuring himself since he was 12 years old. He had faced many difficulties, including problems at work, but it was the break-up of an important relationship that caused his greatest crisis.

After that, John cut and hit himself every day, but not in a way that required hospital treatment. The cuts were superficial and did not leave scars, and he was able to cover up the bruises.

He told his therapist that self-injury was his way of coping with life. It emerged that John had a difficult and unloving childhood.

He did not learn the normal ways of coping with problems, which meant he had no way of handling stress.

Tooher started examining ways to help John cope. He encouraged John to take better care of himself and be more sensitive to his needs.

This was a concept that seemed alien to John. While he was thoughtful and would help others, John appeared rarely to think of his own needs.

Tooher also encouraged John to notice the warning signs of stress building up, so he could take action before the stress reached crisis level.

Gradually, John reduced his reliance on self-injury. He injured himself on a stop-start basis for a while, but after a year of counseling he was no longer injuring himself.

While the initial focus was on the break up of the relationship, his therapist noted that John’s need to have a relationship lessened as his self-esteem grew.

Almost a year after he finished counseling, John has not started injuring himself again.


The Irish Times
June 18, 2001

Stop beating yourself up
By Alison Healy

People often talk about beating themselves up or pulling their hair out. But while most of us use the terms figuratively, and go to great lengths to avoid hurting ourselves, some people use them literally, regularly setting out to injure themselves. Cutting, burning, hair pulling and hitting are just some of the things they do.

Their reasons are as varied as their methods, according to Karl Tooher, a psychotherapist. He has specialised in treating self-injury cases and would like to set up support groups for people affected by self-injury. He is also planning a forum for people whose work brings them in contact with the issue. In many cases, self-injury is a way of coping with difficulties, says Tooher. Just as some people will kick a chair in frustration, others will lash out at themselves to release their feelings. Sometimes, they are in such emotional pain that the physical pain temporarily takes their minds off their emotions. In other cases, strong self-hatred creates the need to hurt oneself.

Tooher has come across cases where people run into walls, insert objects into their bodies and, in extreme situations, pull their eyes out. “But that is very rare, and it’s important that we do not sensationalise it. Self-injury is different for every person,” he says.

Many difficulties can be traced back to what he describes as “invalidating childhoods,” where children suffer emotional or physical abuse or neglect.

“This can get in the way of people learning the normal coping mechanisms. They haven’t had the opportunity to learn how to deal with stress or traumatic events. It’s not exclusively a childhood problem, but the majority of cases have experienced invalidating childhoods.”

Because there is no forum on self-injury in the Republic, there are no clear figures on the numbers of people who self-injure here. In England and Wales, more than 100,000 people are admitted to accident-and-emergency departments each year for self-injuries. As most people do not need to be hospitalised, however, the real incidence is thought to be much higher. Tooher believes the figure is similar to the number of people with eating disorders. It is estimated that about 14,500 people suffer from eating disorders in the State.

“Here in Ireland, we are very much at the early stages of understanding what this is about, and why people do it.” Many myths surround self-injury, he says. One is that self-injury is a suicide attempt.

“All self-injury acts do not have suicidal intent. The vast majority have a great will to live. Self-injury is their coping mechanism. For some people, it keeps them alive.”

For that reason, the patient rather than the action should be treated. “Getting to the root cause of the behaviour and coping with it is the most important thing. Then, ultimately, the need to self-injure is no longer there.

“Otherwise, if you take away their only coping mechanism, what do they do then? People who self-injure are doing the best they can. They are not lashing out at other people. They are taking their aggression out on themselves.”

Another myth suggests that self-injury is a form of attention seeking. Tooher says that most people who self-injure do so in private and go to great lengths to hide their injuries. “Some feel a great shame about it. The vast majority are not doing it to manipulate, but some people feel manipulated by it.”

While it appeared to affect more women than men in years gone by, recent studies have found very little difference in occurrence between men and women.

It affects people of all ages, but most commonly those aged from their late teens to late 30s. Tooher has heard of cases in children as young as eight.

Because therapists are working with such patients in limbo, he would like to provide training for those who encounter self-injury cases. He is looking at best practice in Britain and elsewhere with a view to setting up a forum and support groups in the Republic.

Self-injury is so well recognised in Britain and the US that both countries have awareness days, and the issue has featured on programmes such as Beverly Hills 90210 and 7th Heaven.

“The UK national self-injury day took place on March 1st,” says Tooher. “We should be in a position in Ireland to run such a self-awareness day with the UK next year.”

Anyone interested in getting involved in a self-injury forum or support group can contact Karl Tooher by telephone on 01-8360033 or 087-2709800 or by e-mail at ktoo@eircom.net


St. Louis Post-Dispatch
June 25, 2001

Self-Mutilators Face Internal, External Pain

Dear Open Mind: I know someone who is into self-mutilation. This self-abuse is almost a daily occurrence. If she doesn’t hurt herself for two weeks she thinks she is doing really well. She has visible cuts and scars on her body as well as hidden ones that are sexually oriented.

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Self-mutilation is a confusing and upsetting symptom that indicates a high level of internal pain. The type of self-mutilation that you describe is not rare; it occurs most often in individuals who have experienced a history of sexual abuse.

Frequently, these people, both male and female, have been sexually molested in ways that are then mimicked by the self-mutilating behavior. Your friend probably is acting out the self-hatred and shame that originated with the abuse. With few exceptions, victims of sexual abuse blame themselves for the abuse.

The younger the child when the abuse begins, the more likely this reaction is to occur. It is not at all unusual for victims to loathe the parts of their body that indicate to them and the world that they are sexual beings. Consequently, mutilating the sexual parts of one’s body becomes a way of attacking the part of their body that caused the trauma in the first place.

Many victims of trauma learn not to feel so that they can survive. The greater the degree of trauma or the longer the duration, the more likely one is to cut off from one’s feelings - both emotions and physical feelings. Cutting, burning and other self-mutilating behaviors can serve to re-connect the individual to feeling something. For some, this even relieves a tension that builds up when a person is not engaged in this type of behavior. I hope your friend is receiving therapy.

If not, one thing you could do, if you were so inclined, would be to recommend that therapy is needed. Many excellent resources exist for adult survivors of sexual abuse. Call the Mental Health Association of Greater St. Louis 314-773-1399 for referrals.

Judith Schectman, MSW
Licensed Clinical Social Worker

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Self-mutilation, such as you describe, is associated with the most severe histories of childhood sexual and physical abuse. This behavior is largely unheard of by the lay person, because it is usually a hidden, solitary practice of which the abuse survivor is afraid and ashamed. Self-mutilation can provide several psychological functions for the survivor.

For some survivors, it provides a sense of relief and a decrease in tension associated with memories of abuse. For instance, a child lies awake every night fearing her father will abuse her, and only after he leaves can she relax and go to sleep. Later, as an adult she can only achieve this state of calm by first abusing herself.

Others self-mutilate as a way to anesthetize themselves against the pain of abuse. For still others, it is a form of self-punishment. These survivors have internalized the abuser’s hostility and have become self-hating. Lastly, self-mutilation is often a silent cry for help.


Ventura County Star
August 12, 2001 Sunday

What can lead to self-mutilation?
By Barbara Freedman

DEAR DR. BARBARA: When my son was 19, we realized he was severely depressed and suicidal. He also was involved in self-mutilation. We sought professional help, but it didn’t seem on target. He kept spiraling downward and, about three months after we began the counseling, he committed a crime. The district attorney seemed very focused on his self-mutilation. Even though it had nothing to do with the crime, she seemed convinced he was evil and should be put away forever because of this. She had no understanding, nor did we at that time, about the mutilation releasing emotional pressure. She hated him for something she did not understand. As a result, she was much more harsh with him. I am writing to ask if you could give me a little more information about this problem. We would like to understand this a little better. ñK.T.

DEAR K.T.: While cutting, or self-mutilation, is not a new phenomenon, the public has had little or no familiarity with it until the late Princess Diana revealed she had been a cutter.

Self-mutilators are overtaken by a compulsion to cut, to try to free themselves from an enormously painful emotional state. Self-mutilation is a severely disturbing psychiatric behavior, which takes an intense emotional bond between psychotherapist/ psychiatrist and the sufferer, plus medication and much time in therapy to repair the damage. New research suggests there are biological underpinnings that include profound changes in brain chemistry as a result of early or childhood traumas.

According to SAFE (Self-Abuse Finally Ends) Alternatives, experts estimate the incidence of habitual self-injurers at nearly 1 percent of the population, with a higher proportion of females than males. The typical onset of self-harming acts is at puberty.

Some years ago, a patient of mine described her cutting like an injection of Novocaine. It helped her to numb out. She enjoyed watching the knife slowly cut her arm and the blood running down her forearm or ankle; she stated it was as if she was watching someone else do the cutting.

She had experienced much abuse growing up. Pain was familiar. She used cutting to help her out of her emotional pain—which is invisible.

While there is no diagnosis in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, self-harm can be a symptom of several psychiatric illnesses, including personality disorders; bipolar disorder; depression; anxiety disorders; and psychoses such as schizophrenia.

I hope this helps. For more on this topic, I suggest Cutting: Understanding and Overcoming Self-Mutilation by Steven Levenkron or A Bright Red Scream: Self-Mutilation and the Language of Pain by Marilee Strong.

Your son is not evil. He needs serious emotional counseling and the proper medication. I wish you well.


Press Association
August 17, 2001

Parents’ Separation ‘Can Cause Self-Harm In Children’
By Anita Singh

Around one in 75 children aged between five and 10 have tried to harm or kill themselves, according to new figures released today.

They are almost twice as likely to attempt self-harm if they are from single-parent families.

The incidence of self-harm also rises if the children have witnessed the separation of their parents, have suffered serious illness or have experienced the death of a close family member. The alarming figures were compiled by the Office for National Statistics from information collected from parents in 1999.

Among five to 10-year-olds, approximately 1.3% have tried to harm or kill themselves.

The lowest rate was among five to seven-year-old girls (0.4%) and the highest was among eight to 10-year-old boys (2.1%).

The rate of self-harm increased dramatically according to whether the child suffered from any mental disorder.

Young children with no mental health problems had a rate of 0.8%, rising to 6.2% for those diagnosed with an anxiety disorder and 7.5% for those with disorders including conduct, attention deficit or less common conditions.

In England, the incidence of self-harm among children aged between five and 10 was higher than the rest of the UK at 1.4%, compared with Scotland (0.8%) and Wales (0.7%).

The statistics also showed that around one in 50 (2.1%) of 11 to 15-year-olds had tried to harm or kill themselves—the highest rate (3.1%) being among girls aged 13-15.

Across the age groups, the children of parents in unskilled occupations were almost three times as likely to harm themselves as those whose parents were in professional jobs.

An NSPCC spokeswoman said: “This shows why children and young people need to have someone to turn to whom they trust before they cross the line and harm themselves.

“Children and adolescents are deeply affected by bereavement, frequent punishment, and family discord and breakdown, and can direct their hurt against themselves.”

She said the NSPCC Full Stop campaign was developing a number of services to which children could turn for help.

Peter Wilson, director of children’s mental health charity Young Minds, said that parents under-estimate how deeply young people can be affected by family problems.

“These figures highlight the fact that there is a significant proportion of children who feel very distressed and can find no other way of expressing that than through self-harm,” he said.

“It is an indicator of how desperate some children are—desperate about their lives, their families and what is going on around them.

“Extreme life events such as a parent dying, or disappearing through divorce or separation, are dramatic for children but people under-estimate how sensitive they are.

“We always think children are resilient but they don’t have much choice other than to keep going. What these children are saying is that it is very hard for them to keep going.”


Western Mail
August 18, 2001

Many Children Have Tried to Kill or Harm Themselves

AROUND one in 75 children aged between five and 10 have tried to harm or kill themselves, according to new figures released yesterday.

They are almost twice as likely to attempt self-harm if they are from single-parent families. The incidence of self-harm also rises if the children have witnessed the separation of their parents, have suffered serious illness or have experienced the death of a close family member.

The alarming figures were compiled by the Office for National Statistics from information collected from parents in 1999.

Among five to 10-year-olds, approximately 1.3% have tried to harm or kill themselves.

The lowest rate was among five to seven-year-old girls (0.4%) and the highest was among eight to 10-year-old boys (2.1%).

The rate of self-harm increased dramatically according to whether the child suffered from any mental disorder.

Young children with no mental health problems had a rate of 0.8%, rising to 6.2% for those diagnosed with an anxiety disorder and 7.5% for those with disorders including conduct, attention deficit or less common conditions.

In England, the incidence of self-harm among children aged between five and 10 was higher than the rest of the UK at 1.4%, compared with Scotland (0.8%) and Wales (0.7%).

The statistics also showed that around one in 50 (2.1%) of 11 to 15-year-olds had tried to harm or kill themselves—the highest rate (3.1%) being among girls aged 13-15.

Across the age groups, the children of parents in unskilled occupations were almost three times as likely to harm themselves as those whose parents were in professional jobs.


The Independent (London)
August 18, 2001

Rates of Self Harm Higher for Children from Broken Homes
By Lorna Duckworth

CHILDREN OF divorced or single parents are almost twice as likely to harm themselves or try to commit suicide as those from two-parent families, new figures revealed yesterday.

Self-harm is also more common among children who have been disturbed by events such as a major illness, a parent or close relative dying, or serious discord in the home.

Girls aged 13 to 15 are generally at greatest risk with 3.1 per cent having tried to hurt themselves, according to a survey of parents conducted by the Office for National Statistics. Among five- to 10-year-olds, more than one per cent of children had tried to harm or kill themselves. The lowest rate was among girls under the age of seven and the highest rate among boys aged eight to 10.

For young children from single-parent homes, the rate of self harm rose to 1.9 per cent and for those from families with a large amount of discord the rate rose to nearly four per cent.

The likelihood of self-harm also rose dramatically among children who had suffered mental disorders such as anxiety, attention deficit or behavioural problems.

Peter Wilson, of the children’s mental health charity Young Minds, said that parents underestimate how deeply young people can be affected by family problems. “There is a significant proportion of children who feel very distressed and can find no other way of expressing that than through self-harm. It is an indicator of how desperate some children are—desperate about their lives, their families and what is going on around them.

“Extreme life events such as a parent dying, or disappearing through divorce or separation, are dramatic for children, but people underestimate how sensitive they are.”

Across the age groups, the children of parents in unskilled occupations were almost three times as likely to harm themselves as those whose parents were in professional jobs.

A spokeswoman for the children’s charity, the NSPCC, said: “Children are deeply affected by bereavement, frequent punishment and family breakdown, and they can direct their hurt against themselves.”


The Guardian (London)
August 18, 2001

Survey Shows 1 in 75 Children Under 10 Try to Harm Themselves
By James Meikle

One in 75 children aged five to 10 try to hurt or kill themselves, according to alarming figures which will intensify debate over whether modern society is putting too much pressure on its youngest members.

Boys between eight and 10 are most prone to self-harm, and children who have experienced family separations, tragedies or dysfunctional home lives or whose parents have unskilled jobs or are unemployed are also at higher risk.

Figures published by the office for national statistics suggest that young people diagnosed with mental or behavioural disorders are far more likely to endanger themselves. The claims come from a survey which questioned parents of nearly 5,300 children of 10 or under. Fewer than one in 100 of the children with no mental problems were said to have tried self-harm, but this increased to 6.2% of those with anxiety disorders, 7.5% of those with troublesome, aggressive and antisocial conditions and more still among those with attention deficit problems.

There was no difference between children from white or non-white families although English children were more likely to hurt themselves than those in Scotland and Wales. Those from unskilled families were three times more at risk than children of professionals.

Interviews with parents and children among more than 4,500 surveyed in the 11-15 age bracket suggested that one in 50 adolescents were hurting themselves or trying to commit suicide with the highest rate, 3.1%, being found in girls aged 13-15. Here, too, those with no mental disorder were less at risk, with 1.2% having attempted self-harm. This rose to 9.4% of those with anxiety disorders and 18% of adolescents diagnosed as having depression.

Peter Wilson, director of the charity Young Minds, said: “We often think children are resilient but they don’t have much choice other than to keep going. What these children are saying is that it is very hard to keep going.”

The analyses were commissioned by the Department of Health, which is developing mental health strategies for young people. It said the data “show a significant association, but not direct causal connection, between rates of self-harm among young people and risk factors arising from family discord and dysfunction and the child’s mental health status.”


Morning Star
August 18, 2001

Self-Harm on the Rise

CHILDREN from poor families are three times more likely to try and kill themselves, official figures revealed yesterday. The Office for National Statistics reported that children of parents in unskilled occupations were almost three times as likely to harm themselves as those whose parents were in professional jobs.

It said that around one in 75 children aged between five and 10 have tried to harm or kill themselves.

They are almost twice as likely to attempt self-harm if they are from single-parent families.

The incidence of self-harm also rises if the children have witnessed the separation of their parents, have suffered serious illness or have experienced the death of a close family member.


The Mirror
August 18, 2001

Growing Pain; One in 50 Kids Try to Hurt Themselves
By Sara Nuwar

ONE in 50 children have tried to injure or kill themselves, according to official statistics released yesterday.

And young teenage girls are the most vulnerable group when it comes to self-mutilation or attempted suicide. Children in single parent families or whose parents have split up are nearly twice as likely to suffer from depression and try to injure or kill themselves said the Office for National Statistics.

Experts analysed a 1999 mental health survey more than 10,000 children’s parents.

It found that among five to 10-year-olds, 1.3 per cent had tried to harm themselves.

The rate was lowest in five to seven-year-old girls—0.4 per cent—and highest in eight to 10-year-old boys - 2.1 per cent.

Among 11 to 15-year-old children, 2.1 per cent were affected, with the highest rate—3.1 per cent—among girls aged 13-15.

But the rate rose to 9.4 per cent of those with anxiety disorders and 18.8 per cent of those with depression.

The report said: “Self harm among 11 to 15-year-olds rose with an increase in the number of stressful life events, like separation of parents, serious illness and death of a parent or close relative.”

Self-abuse is more common among step children and in families with only one child, or more than four, or those in rented homes.


Agence France Presse
September 30, 2001

Singapore girls slash arms in cry for help

Singapore school girls are adopting the bizarre craze of self-mutilation, slashing their hands and arms in what psychiatrists say is a cry for help because they cannot manage their emotions.

With no one to talk to, teenaged girls are using penknives and other sharp objects to cut themselves as an escape from school, family and relationship problems.

“By concentrating on the pain in my arm, I forget about my emotional pain,” one 15-year-old told the New Paper. Incidents of self-mutilation had been detected at five girls schools, the newspaper reported Sunday

Child psychiatrist Brian Yeo said many cases went undetected because the girls did not seek treatment and the scars were not obvious.

“Some also wear thick watches or friendship bands to hide their scars,” he said.

Doctor Linda Semlitz of the Adam road Hospital said girls suffering from personality disorders cut themselves to seek attention.

“They’re overwhelmed so they hurt themselves to get help,” she said. “Many of them report substantial relief after cutting themselves.”

One 15-year-old, identified only as Mary, said she had repeatedly cut herself over the past two years after failed relationships with other girls and because she could not cope with exam stress.

“I can’t control my feelings. Sometimes, I regret it and tell myself not to do it again. But cutting my hand is the fastest way to relieve pain,” she said.

Another girl said she started cutting herself because her parents gave all their attention to her younger sister.

“It was painful, but it was nothing compared to the pain in my heart,” she said.

Last week after a quarrel with her boyfriend she carved his initials on her left hand with a knife.

Pyschiatrist Yeo said self-mutilation was mainly a refuge for girls. Boys with emotional problems tended to turn to alcohol, drugs and fighting, he said.


UK Newsquest Regional Press—This is Wiltshire
November 9, 2001

How help is handed out

Project Spear (Self-Preservation Encouraging Active Response) aims to increase awareness and understanding of deliberate self-harm and to relieve the illness of the those who take this action.

Clients are most often contacted through a quarterly newsletter that includes creative writings, support tools, poetry, practical solutions, information on other groups, and support posters.

Telephone support is also available.

Clients work predominantly with their own local keyworker but peer support is available in order to address the issues connected with their deliberate self-harm.

Clients also receive a workbook where they can record their past and present experiences of self-harm, and the causes of it through creative writing, art, photographs and poetry. The workbook can then be used to explain their individual situation to other professionals, reducing the number of times that they have to relive the experience in words with each first visit to a service provider.

Spear will also offer publications to the client’s family, friends and the agencies that they use in order to increase their understanding of deliberate self-harm.

Sue runs study days and workshops at events such as Beyond Rough Sleeping in order to address the issue with professionals.

Self-harm is an intentional, considered course of action which occurs when a person feels trapped by their situation. This triggers off a manifestation of that person’s past traumatic experiences and emotions.

These previously hidden memories stir emotions that come to the surface in disguised reactions to present situations.

Self-harm can be motivated by the need to absolve the negative emotions that have built up, release the bad feelings, and show the world how a person really feels.

It sometimes gives people a sense of satisfaction from seeing the damage and knowing that they are in control of something, and it provides a distraction from the thoughts racing through their heads.

Methods of self-harm range from the socially acceptable such as smoking, drinking, overwork, and debt to the socially unacceptable, anti-social, and dangerous.

Self-injury such as self-mutilation, burning, scratching, and eating disorders are anti-social because it is so deeply offensive to the eye of the beholder.


University Wire
December 6, 2001

Authorities dispel self-injury myths
By Stephanie Richards, The Daily Universe, Brigham Young University

Heidi Hamilton had just gotten out of the hospital after a suicide attempt and didn’t want to keep hurting her family.

“My mom asked me to live for them or for my future children. I turned to self-injury as a release, as a lifesaver,” said Heidi Hamilton of Provo, Utah.

Hamilton was fighting a little-known but medically recognized ailment called self-injury. After her four-year battle with self-injury, Hamilton has sought medical help and is now an advocate to others who are fighting her same battle.

Self-injury is a coping mechanism used to deal with a variety of stressors, said Deb Martinson, founder of American Self-Harm Information Clearinghouse Committee.

For Hamilton, self-injury expressed emotions, especially anger and resentment, the only way she knew how.

“Punishing myself was like an atonement for my own sins. The shame and guilt I feel for my own sins, for even being alive.” Hamilton said. “But the next day, I’m left with feeling shameful of the scars—the damage I’ve done to my temple.”

Self-injury can express emotions and deal with feelings, unreality or numbness. It also helps to make flashbacks stop, punish the self and stop self-hating thoughts, Martinson said.

It is more about relieving tension or distress than is it about anything else, Martinson said.

Before self-injuring, Hamilton said she felt anxiety, rapid thoughts, burning and self hate. However, during the self-injury, Hamilton said she experienced a release.

“I felt a release as I saw the blood flow, the flush of blood feels good, like a dam breaking, cleansing in a way.” Hamilton said. “It was representative of washing away the dirt and the badness inside.”

Approximately 2 million people in the United States—or 1 percent of the population—use physical self-injury as a way of dealing with overwhelming feelings or situations, often using it to speak when no words will come, Martinson said.

Sonja Smith, licensed clinical social worker for Wasatch Mental Health, said self-injury is also fairly common in Utah. In a community the size of BYU with 30,000, as many as 300 people could suffer from self-injury.

“A lot of the people that we see do self-injury,” Smith said. “It is usually seen with Borderline Personality Disorder.”

Despite the prevalence of self-injury, there are many myths and misunderstandings that surround this psychological ailment, Martinson said.

These myths often result in self-harmers being treated badly by police, doctors, therapists, and emergency room personnel, Martinson said.

The first myth that arises with self-injury is that it is a failed suicide attempt, Martinson said.

“Many, if not most, self-injuring people who make a suicide attempt use means that are completely different to their preferred methods of self-inflicted violence,” Martinson said.

A second myth that exists is that people who self-harm are trying to attract attention.

Most people who self-injure go to great lengths to hide their wounds and scars, Martinson said. Many consider their self-harm to be a deeply shameful secret and dread the consequences of discovery.

Hamilton said she wore long sleeves in the summer to conceal her scars and if people asked, she said it was a cat scratch.

Other myths include that self-injury is a method to manipulate others, Martinson said.

It is difficult to see warning signs in self-injurers because they try to hide it, Smith said.

“Usually people will wear long sleeves and cut on their wrist, leg, or stomach where it is not noticeable,” Smith said.

However, one warning sign is hairline scars on the wrist, Smith said.

Self-injury is really kept in the closet, Hamilton said. However, she advocated that help is available for those that need it.

Smith recommends that the best way to help individuals suffering from self-injury is to acknowledge their pain and talk them into student counseling services.

Other suggestions include not making judgmental statements about self-injury, being supportive, maintaining an accepting attitude and being understanding, Martinson said.

Individuals suffering from self-injury can contact the Counseling and Career Center or the Comprehensive Clinic for help, said Adrienne Sotuyo, Women’s Services and Resources employee.


Belfast Telegraph
December 17, 2001

Self-harm overtakes suicide for desperate
By Claire Regan

THE rate of self-harm among people in Ulster—including attempts at suicide—is on a far greater scale than actual suicides, it was claimed today.

Spokesman for the Samaritans, Paul O’Hare, today spoke of his concern over the level of self-harming after the recent inquest of a 15-year-old schoolgirl who died after sniffing lighter fluid.

The inquest heard that the west Belfast teenager had a history of self-harming, with some of those episodes seen as suicide attempts. But the young girl’s family and the coroner both agreed that her tragic death had not been intentional.

Mr. O’Hare said the inquest had importantly highlighted the emerging issue of self-harm.

“The Samaritans believe these instances of people who are carrying out acts which result in their own injury—some of these acts might even be described as attempts at suicide—runs at a far higher rate than the number of completed suicides,” he said.

“This issue, along with that of suicide, is an issue which needs to be highlighted—particularly for the communities and families deeply affected by this tragic death.

“The coroner’s court heard the several ways in which this girl harmed herself.

“If anyone feels in crisis, particularly if they have heard details of other people who they may identify with and feel this may be the solution to their emotional pain, we urge them to give us a call first.”

Mr. O’Hare also reassured anyone concerned that a friend or relative may be self-harming that it is possible to help by encouraging them to talk in their own time about how they feel.

“It could be an idea to give them the number of a helping agency—like The Samaritans—so they know where to go when they need help.

“We are here for anyone in an emotional crisis, not just people who are suicidal. You definitely do not have to feel suicidal to contact us. No one should ever feel that their problems are too small to tell a Samaritan.”

Samaritans can be contacted on 08457 909090 or on e-mail via www.samaritans.org.


The Washington Times
December 23, 2001

Self-Injury May Signal Deeper Problem
By Dr. Sylvia Rimm

Q: I’m concerned about the emotions of my 7-year-old daughter and the way she may deal with stress. Her father and I divorced when she was 3 months old, and we both have since remarried.

Recently, my daughter scratched furniture, bit herself and scratched her face because she didn’t get her way. I told her I thought her behavior was horrible and that I was disappointed in her. I asked her why she would try to hurt herself, and she responded, “Because I think I’m nothing.” I was shocked and surprised because we always assumed she had high self-esteem and she is a very caring and polite girl. I tell her daily that I love her and think she’s a great child. I make a point of scheduling time alone with her for activities without her younger half-sibling.

Is she looking for attention or just having a difficult time not getting what she wants? I can’t help but wonder if she does this at age 7 what she’ll try to do when she’s 14.

A: If your daughter is accustomed to getting her way, it may be possible that she has discovered that threatening to harm herself has the power to get your attention and perhaps is even what she wants.

Because there are four parents involved, her manipulations for attention could be subtle. In other words, she may have found that self-destructive statements or behaviors may serve her well with any one parent without the other parents realizing she is habitually using them.

It would be good for you to discuss this with her dad and stepmother to determine whether this is new behavior. If they have witnessed similar behavior, I recommend you take your daughter for immediate psychological help. I don’t mean to suggest this is an emergency but only that it could be very serious.

If this is the first time your daughter has behaved this way in front of any of you, you may wish to determine whether there are other self-destructive statements, whether she is using them only to get what she wants or whether they’re part of a more serious self-esteem issue.

Also, observe both her imaginative play and her play with other children. Sometimes children are not able to express their worries to adults as well as they can to their dolls or in their art or stories. In play with other children, notice if she always has to be in control and what she does when children don’t give in to her. With further observation as to the frequency of the problem, you can bring insight to a psychologist that can help you determine your daughter’s problem.

If all seems well and your daughter seems happy in other ways and in both parents’ environments, I think you can set the threat aside temporarily. My guess, however, is that there is more than what you have seen once and you should get professional help.