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Section 3
Self-Injury Behavior: How can Nurses Help?

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Self-injury behavior (SIB) is a complex group of behaviors involving deliberate destruction or alteration of body tissue without conscious suicidal intent (Cerdorian, 2005; Favazza, 1996). The self-injury is non-life threatening (Shaw, 2002), done to alter a perceived intolerable mood state by inflicting physical harm serious enough to cause pain and tissue damage to the body (Levander, 2005, p. 3). Self-injury is used as a coping mechanism to help the individual deal with emotional pain or to break feelings of numbness by arousing sensation (LifeSigns Self Injury Guidance and Network Support, 2005, p. 5).

Although McDonald (2006) referred to this phenomenon as self-mutilation, most authors use the term "self-injury"  (i.e., American Self- Harm Information Clearinghouse, 2005;Van Sell, et al., 2005). Others use the terms "self-harm"(Ayton, Rasool, & Cottrell, 2003; Harris, 2000), "self-wounding" (Sharkey, 2003), or "self-inflicted violence" (SIV) (Alderman, 1997). Because the term "self-mutilation" evokes grotesque images and implies permanent damage or alteration to one’s body (Alderman, 1997), it is particularly annoying to those who self-injure (Hoyle, 2003; Levander, 2005; Sutton, 2005). In contrast, SIB usually is temporary and often unnoticeable or hidden.

Common Self-Injuring Behaviors
The most common are cutting and burning or branding. Other behaviors include stabbing, needle sticking, punching oneself, interference with wound healing (reopening wounds), excessive scratching (Kehrberg, 1997), hitting or bruising, nail biting, pulling out hair (trichotillomania), breaking bones, and drinking substances not intended for human consumption (Alderman, 1997; Murray, Warm, & Fox, 2005).

The tools most often used are razors, knives, lighters, broken glass, matches, sewing needles, pencils (sharpened lead and erasers), and sandpaper. Cerdorian (2005) asserted that SIB often is inflicted repeatedly on the same part of the body. Contradicting the notion that persons who self-injure are seeking attention, most self-injuring adolescents wear clothing that covers their scars and wounds (Cerdorian, 2005;Hoyle, 2003; Shannon, 2005).

Four Types of SIB
Self-injury is not classified as a disorder or syndrome in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychological Association, 2000). However, SIB has been classified into four types. It can be related to psychosis, in which hallucinations or delusions prompt a mentally ill person to self-injure, to organic physiology from autistic disorders, to developmental or physiologically induced disabilities (lip biting, head banging to stimulate or sooth), or to emotional factors. The latter is the most common, typical SIB (Alderman, 1997).

Most persons who self-injure begin during adolescence, usually around the ages 12 to 14 years (Cerdorian, 2005). Self-injurers typically are high school educated. They usually have a history of physical or sexual abuse or come from a home with an alcoholic parent (Murray,Warm, & Fox, 2005; Ross & Heath, 2002; Santa Mina et al., 2006). Much of the research on SIB has been conducted with adolescent girls, suggesting that SIB is more common among females, but this is not validated. Some self-injurers (~13 percent) witnessed another person self-injuring (Levander, 2005), and then began to self-injure themselves.

Those who self-injure find SIB to be an effective coping mechanism that brings inner pain to the surface (Strong, 1998) and maintains equilibrium. Research confirms that SIB provides "temporary relief from a host of painful symptoms" (Favazza, 1996, p. xix). Women ages 20 to 45 years have reported a feeling of cleansing, as explained by one participant, "I was trying to cut out all the bad inside me" (Harris, 2000, p. 166). Self-injurers report that SIB is a survival tactic, even allowing a good night’s sleep (Sutton, 2005).

The Eight C’s
Specific motivations for SIB have been summarized as the eight Cs: coping and crisis intervention, calming and comforting, control, cleansing, confirmation of existence, creating comfortable numbness, chastisement, and communication (Sutton, 2005, p. 137).

Adolescents who self-injure claim the behavior affords them a sense of desired control. Some describe a feeling of relief when experiencing the pain of SIB because it is then that they know they are truly alive. Others claim it produces a state of numbness or dissociation. Such chastisement is self-punishment for imagined or real mistakes or shortcomings, in which the self-inflicted wound is a conduit for the voice that the adolescent lacks (Sutton, 2005).

The stories of three young women who self-injured throughout their adolescent years illustrate the emerging patterns of this phenomenon (Lesniak, 2006; Lesniak, 2007a; Lesniak 2007b). The women described feelings of frustration, anxiety, anger, and tension. As their emotions escalated, the self-injury act occurred, resulting in relief, calmness, and relaxation. Later, the women described feelings of shame.

They felt stigmatized and experienced increasing feelings of abandonment as their friends and family members did not understand their self-injury. These negative feelings led them back to the desire for temporary relief. As one participant stated, "I just cut myself and thought about the pain, and I cried and then it was over. I felt better until the next time problems came, whether they were the same problems or different ones, and I did the same thing. It was just something that got me through it." (Lesniak, 2007b).

In essence, the inability to cope with intolerable feelings leads to alternate ways of expressing those feelings. Self-injurers may experience relief from SIB. However, the shame resulting from the act of harming oneself leads in a patterned manner back to emotions that are unacceptable. Other researchers describe the cycle of self-injury in adolescents using six points: mental anguish (escalating emotions), emotional engulfment (fright, anxiety), panic stations (loss of control, detachment), action stations (act of self-injury), better/different feeling (relief, control regained), and the grief reaction (shame, guilt) (Sutton, 2005,p. 114).

Nursing research is needed to explore the correlation between SIB and the spiritual needs of adolescents. Shannon (2005) stated that SIB is a common precursor to suicide. If adolescents at risk for this behavior are identified earlier, perhaps fewer teens will be lost to suicide. Although many use self-injury as short-term relief from their problems, it is repetitive in nature. If nurses are able to assist adolescents in interrupting emerging patterns of SIB, future self-injury may be prevented.

Adolescents at risk for self-injury behavior are searching for a way to give voice to their pain. When approached with a caring attitude that reflects the love of Christ, when listened to with intentionality, and when nurtured by an authentic presence, self-injurers are relieved to externalize their difficult emotions through verbal means rather than to record their pain with visible stories on their skin. For even when the wounds heal, the scars remain a visible reminder of the hurt hiding within. In essence, the history of the self-injurer is recorded on their skin.

- Lesniak, R. Self-injury behavior: How can Nurses Help. JCN Oct 2008; 25, 4 (186-193)

Personal Reflection Exercise #3
The preceding section contained information about how nurses can help with self-injury behavior. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 3
What are the four types of SIB? To select and enter your answer go to CE Test

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