After two articles dedicated to the self-harm in adolescentswe received a comment from a reader who complained that the problem was limited only to that age group, which was his (age in which this behavior occurs most frequently) and asked us why we did not talk about the self-harm in adults. According to new data on the Increased cutting among teenagersit must be said that it is not a unique and exclusive behavior of them.
Joaquín, 61 years old, is a freelancer with a very stressful life. He comes to the doctor's office in the middle of July. Although the office is comfortable, with air conditioning, the truth is that that afternoon the heat was oppressive. Despite this, Joaquín never takes off his navy blue suit jacket. Sweat was pouring down his forehead.
I came in search of help to manage stress. Throughout that oppressive summer, Joaquín came to the doctor's office dressed in suits of different colors. One day, when my doubts were already obvious, I told him that the air conditioning was broken… after 40 minutes of dripping sweat, he had no choice but to take off his jacket, revealing both old and recent self-harm.
Studies on self-mutilation in adults
Although it is a behavior that begins in adolescence, there is a study led by Elizabeth Murphy of the University of Manchester1, which is part of the Self-Harm Surveillance Project, which confirms that it also occurs in adults, in whom the risk of suicide increases.
The study, published in The British Journal of Psychiatry, involved 1,177 people of both sexes, aged 60 or over, who had gone to the emergency departments of the six major hospitals in Oxford, Manchester and Leeds after having self-harmed by poisoning (88%), cutting (9%) and violent methods such as hanging or suffocating (3%).
According to the authors of the study «The self-harm rate for people aged 60 or over was 65 cases per 100,000 inhabitants for both men and women, compared to 380 cases for young people aged between 20 and 59.» Of the sample studied, 12.5% had to return to the emergency room for the same reason during the following year, while 1.5% had committed suicide.
Therefore, according to the researchers, the risk of suicide was «67 times higher than that of the general population and three times higher than that of young people who also harm themselves.»
Michael Dennis from Swansea University and David Owens from the University of Leeds stress that it is important keep a close eye onespecially people over 75 years of age because they are at greatest risk of suicide.
Biological and biochemical factors involved in self-harm
According to Wichel and Stanley (1991), the dopaminergic and opioid systems are not involved in self-harm, while the serotonergic system is. Various studies carried out by both researchers highlighted that drugs used to stabilize mood, They also stabilize self-mutilation behaviors in the same way as they would do with obsessive-compulsive disorder. From there, they hypothesize the possible clinical similarities between both disorders.
Simeon et al. (1992) found that self-harm correlates negatively with imipramine binding sites on platelets, which indicates the existence of serotonergic dysfunction that reinforces what has been said.
If we add to this the studies by Stoff et al (1987) and Birmaher et al (1990), according to which the decrease in the imipramine binding sites in platelets correlates with aggressiveness and impulsiveness, we understand why suicidal behavior – as we will see later – can be placed within impulse control disorders, just like kleptomania, trichotillomania or gambling addiction.
For their part, Coccaro et al. (1997) carried out studies to check whether the serotonergic system really had any relationship with suicidal behaviour. The results showed that serotonin is correlated with irritability, so that the behaviour expressed is a function of the serotonin level. Thus, if the serotonin level is normal, irritability is expressed in the form of shouting, throwing things, slamming doors, etc., but if the level is low, irritability increases, we become more aggressive and this aggression can be directed towards ourselves (self-aggression, suicide) or towards others (heteroaggression).
Herpetz and Favazza (1997) investigated how prolactin levels vary in patients who self-harm and found that prolactin levels were low, implying a deficient function of prolactin. Similarly, Stein et al (1996) found similar results but in patients with OCD.
What are the psychological characteristics of adults who self-mutilate?
- Negative emotions frequent, intense, daily. Self-harm is a temporary and very fleeting relief from emotional distress that they suffer from.
- Difficulties in expressing emotions. They may feel that their emotions are altered, they may not know what they are feeling (if they are sad they do not know how to clearly differentiate whether it is sadness, anger or fear) and there are even patients who say they “have no feelings” or “are not able to express feeling X” (generally, a positive emotion such as joy and surprise).
- Very self-critical. Intense experiences of anger and self-rejection. Very low self-esteem. If we are faced with a patient with a high level of negative emotionality and very self-critical, he or she has a high risk not only of self-destructive behaviour, but also of suicide.
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Functions of self-harm
- Emotional regulator. It calms emotional wounds by replacing them with physical wounds, as its main function. It helps to reduce the effect of negative emotions, especially anger, anxiety and frustration.
- Self-punishment. For having self-harmed, for having fallen due to his/her low self-esteem. The patient expresses it as “an old acquaintance”.
- Communicating pain to others. In some cases, this “letting it be known” is used as an element of control over the other person who will spend their time “in fear of…” and which, many times, hides a need for recognition from the other person, from the affected person, or also a disconsolate attempt on the part of the affected person to let the other person know that they exist. In any case, if they receive positive attention, this will reinforce their behavior.
- Ensure your own meaning. The patient often finds it difficult to maintain his boundaries, whether psychological or interpersonal, and therefore needs to hurt himself in order to remain connected between his internal world and the external world.
- Strategies. To recover their sense of self: they prefer to have an unpleasant experience rather than not feel anything because they say “this makes me feel real”, “I stop feeling numb”, “I feel something, even if it is pain”. On the other hand, they resist suicidal attempts by alleviating those negative emotions that usually lead thanatolytic behaviours.
What is the prevalence? Is self-harm normal?
Of the 4% of the total adult population who report self-harm, 1% have a severe history of suicidal behavior and 20% are patients with psychological and/or psychiatric pathology.
Women have a 3 to 4 times higher prevalence than men since they have a certain tendency to internalize anger.
5-15% of hospital admissions are due to self-harm in adults, of whom 50% of men and 25% of women have consumed alcohol in the previous hours. This is very worrying because many of them act impulsively and use drugs. Sometimes, they overdose by having taken larger amounts than they thought they were taking.
Although it is true that 25% of people who are already undergoing treatment for self-harm attempt suicide – in a conscious way – it is also true that there are those who are undecided and “I don’t know if I want to continue living” and who, in this way, put their lives in the hands of a very dangerous cocktail.
Can adults who self-harm have a psychological disorder?
- Mood Disorder. Especially in patients with depression and bipolar disorder.
- Eating Disorder. In women with anorexia or bulimia. According to Favazza (1996) both these illnesses and self-harm are attempts to possess one's own body and perceive it as the self, distinct from the other. She considers that self-mutilation is a release from anxiety and would become an alternative to anorexia or bulimia.
- Obsessive-Compulsive Disorder. It is classified in the ICD-10 as an anxiety disorder while self-harm is classified as an impulse control disorder. Unless self-harm is part of an obsessive ritual to avoid something bad happening, it should not be considered a symptom of OCD.
- Post-traumatic stress disorder. Self-harm (self-mutilation) helps those who have a history of severe repeated trauma understand why they have so much trouble regulating and expressing emotions.
- Dissociative Disorders. They involve problems of fragmented consciousness (dissociative identity disorder) and modification of consciousness (depersonalization disorder). In the latter case, some people react to these episodes of depersonalization by harming themselves, hoping that the pain will bring them back to consciousness.
- Anxiety disorders. People with anxiety use self-harm as a calming mechanism, providing temporary relief from stress as they become increasingly worried.
- Impulse control disorder. Justifies the cycle of self-harm.
When should you stop?
After a certain amount of injuries, the suicidal need becomes saturated and the person feels calmer.
Of those surveyed by Conterio and Favazza (1986), 10% reported experiencing a lot of pain when injuring themselves, 23% reported moderate pain, while 67% reported mild to nonexistent pain. Haines et al. (1995) found that reduction of psychophysiological tension was the primary goal of self-injury.
What do I do if I am self-harming?
Most self-harming patients want to stop. And, in fact, they can achieve this if they develop effective methods of coping with stress. It is important to understand what has led you to do these behaviors because it will be a way of preventing them.
You can use several guidelines to minimize the risk…