the mind from feelings that are causing anguish. this may be achieved by tricking the mind into believing that the present suffering being felt is caused by the self-harm instead of the issues they were facing previously: the physical pain therefore acts as a distraction from the original emotional pain. to complement this theory, one can consider the need to "stop" feeling emotional pain and mental agitation. "a person may be hyper-sensitive and overwhelmed; a great many thoughts may be revolving within their mind, and they may either become triggered or could make a decision to stop the overwhelming feelings." alternatively, self-harm may be a means of feeling something, even if the sensation is unpleasant and painful. those who self-harm sometimes describe feelings of emptiness or numbness (anhedonia), and physical pain may be a relief from these feelings. "a person may be detached from themselves, detached from life, numb and unfeeling. they may then recognise the need to function more, or have a desire to feel real again, and a decision is made to create sensation and 'wake up'." those who engage in self-harm face the contradictory reality of harming themselves while at the same time obtaining relief from this act. it may even be hard for some to actually initiate cutting, but they often do because they know the relief that will follow. for some self-harmers this relief is primarily psychological while for others this feeling of relief comes from the beta endorphins released in the brain. endorphins are endogenous opioids that are released in response to physical injury, acting as natural painkillers and inducing pleasant feelings, and in response to self-harm would act to reduce tension and emotional distress. many self-harmers report feeling very little to no pain while self-harming and, for some, deliberate self-harm may become a means of seeking pleasure. as a coping mechanism, self-harm can become psychologically addictive because, to the self-harmer, it works; it enables them to deal with intense stress in the current moment. the patterns sometimes created by it, such as specific time intervals between acts of self-harm, can also create a behavioral pattern that can result in a wanting or craving to fulfill thoughts of self-harm. autonomic nervous system emotional pain activates the same regions of the brain as physical pain, so emotional stress can be a significantly intolerable state for some people. some of this is environmental and some of this is due to physiological differences in responding. the autonomic nervous system is composed of two components: the sympathetic nervous system controls arousal and physical activation (e.g., the fight-or-flight response) and the parasympathetic nervous system controls physical processes that are automatic (e.g., saliva production). the sympathetic nervous system innervates (e.g., is physically connected to and regulates) many parts of the body involved in stress responses. studies of adolescents have shown that adolescents who self-injure have greater physiological reactivity (e.g., skin conductance) to stress than adolescents who do not self-injure. this stress response persists over time, staying constant or even increasing in self-injuring adolescents, but gradually decreases in adolescents who do not self-injure. treatment several forms of psychosocial treatments can be used in self-harm including dialectical behavior therapy. psychiatric and personality disorders are common in individuals who self-harm and as a result self-harm may be an indicator of depression and/or other psychological problems. many people who self-harm have moderate or severe depression and therefore treatment with antidepressant medications may often be used. there is tentative evidence for the medication flupentixol; however, greater study is required before it can be recommended. emergency departments are often the first point of contact with healthcare for people who self-harm. as such they are crucial in supporting them and can play a role in preventing suicide. at the same time, according to a study conducted in england, people who self-harm often experience that they do not receive meaningful care at the emergency department. both people who self-harm and staff in the study highlighted the failure of the healthcare system to support, the lack of specialist care. people who self-harm in the study often felt shame or being judged due to their condition, and said that being listened to and validated gave them hope. at the same time staff experienced frustration from being powerless to help and were afraid of being blamed if someone commits suicide. therapy dialectical behavior therapy for adolescents (dbt-a) is a well-established treatment for self-injurious behavior in youth and is probably useful for decreasing the risk of non-suicidal self-injury. several other treatments including integrated cbt (i-cbt), attachment-based family therapy (abft), resourceful adolescent parent program (rap-p), intensive interpersonal psychotherapy for adolescents (ipt-a-in), mentalization-based treatment for adolescents (mbt-a), and integrated family therapy are probably efficacious. cognitive behavioral therapy may also be used to assist those with axis i diagnoses, such as depression, schizophrenia, and bipolar disorder. dialectical behavior therapy (dbt) can be successful for those individuals exhibiting a personality disorder, and could potentially be used for those with other mental disorders who exhibit self-harming behavior. diagnosis and treatment of the causes of self-harm is thought by many to be the best approach to treating self-harm. but in some cases, particularly in people with a personality disorder, this is not very effective, so more clinicians are starting to take a dbt approach in order to reduce the behavior itself. people who rely on habitual self-harm are sometimes hospitalized, based on their stability, their ability, and especially their willingness to get help. in adolescents multisystem therapy shows promise. pharmacotherapy has not been tested as a treatment for adolescents who self-harmed. according to the classification of walsh and rosen trichotillomania and nail-biting represent class i and ii self-mutilation behavior (see classification section in this article); for these conditions habit reversal training and decoupling have been found effective according to meta-analytic evidence. a meta-analysis found that psychological therapy is effective in reducing self-harm. the proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%). psychological therapies with the largest effect sizes were dialectical behavior therapy (dbt), cognitive-behavioral therapy (cbt), and mentalization-based therapy (mbt). in individuals with developmental disabilities, occurrence of self-harm is often demonstrated to be related to its effects on the environment, such as obtaining attention or desired materials or escaping demands. as developmentally disabled individuals often have communication or social deficits, self-harm may be their way of obtaining these things which they are otherwise unable to obtain in a socially appropriate way (such as by asking). one approach for treating self-harm thus is to teach an alternative, appropriate response which obtains the same result as the self-harm. avoidance techniques generating alternative behaviors that the person can engage in instead of self-harm is one successful behavioral method that is employed to avoid self-harm. techniques, aimed at keeping busy, may include journaling, taking a walk, participating in sports or exercise or being around friends when the person has the urge to harm themselves. the removal of objects used for self-harm from easy reach is also helpful for resisting self-harming urges. the provision of a card that allows the person to make emergency contact with counselling services should the urge to self-harm arise may also help prevent the act of self-harm. alternative and safer methods of self-harm that do not lead to permanent damage, for example the snapping of a rubber band on the wrist, may also help calm the urge to self-harm. using biofeedback may help raise self-awareness of certain pre-occupations or particular mental state or mood that precede bouts of self-harming behavior, and help identify techniques to avoid those pre-occupations before they lead to self-harm. any avoidance or coping strategy must be appropriate to the individual's motivation and reason for harming. epidemiology deaths from self-harm per million people in 2012 3–23 24–32 33–49 50–61 62–76 77–95 96–121 122–146 147–193 194–395 world-map showing the disability-adjusted life year, which is a measure of each country's disease burden, for self-inflicted injuries per 100,000 inhabitants in 2004. no data less than 80 80–160 160–240 240–320 320–400 400–480 480–560 560–640 640–720 720–800 800–850 more than 850 it is difficult to gain an accurate picture of incidence and prevalence of self-harm. this is due in a part to a lack of sufficient numbers of dedicated research centres to provide a continuous monitoring system. however, even with sufficient resources, statistical estimates are crude since most incidences of self-harm are undisclosed to the medical profession as acts of self-harm are frequently carried out in secret, and wounds may be superficial and easily treated by the individual. recorded figures can be based on three sources: psychiatric samples, hospital admissions and general population surveys. the world health organization estimates that, as of 2010, 880,000 deaths occur as a result of self-harm. about 10% of admissions to medical wards in the uk are as a result of self-harm, the majority of which are drug overdoses. however, studies based only on hospital admissions may hide the larger group of self-harmers who do not need or seek hospital treatment for their injuries, instead treating themselves. many adolescents who present to general hospitals with deliberate self-harm report previous episodes for which they did not receive medical attention. in the united states up to 4% of adults self-harm with approximately 1% of the population engaging in chronic or severe self-harm. current research suggests that the rates of self-harm are much higher among young people with the average age of onset between 14 and 24. the earliest reported incidents of self-harm are in children between 5 and 7 years old. in the uk in 2008 rates of self-harm in young people could be as high as 33%. in addition there appears to be an increased risk of self-harm in college students than among the general population. in a study of undergraduate students in the us, 9.8% of the students surveyed indicated that they had purposefully cut or burned themselves on at least one occasion in the past. when the definition of self-harm was expanded to include head-banging, scratching oneself, and hitting oneself along with cutting and burning, 32% of the sample said they had done this. in ireland, a study found that instances of hospital-treated self-harm were much higher in city and urban districts, than in rural settings. the case (child & adolescent self-harm in europe) study suggests that the life-time risk of self-injury is ~1:7 for women and ~1:25 for men. gender differences in general, the latest aggregated research has found no difference in the prevalence of self-harm between men and women. this is in contrast to past research which indicated that up to four times as many females as males have direct experience of self-harm. however, caution is needed in seeing self-harm as a greater problem for females, since males may engage in different forms of self-harm (e.g., hitting themselves) which could be easier to hide or explained as the result of different circumstances. hence, there remain widely opposing views as to whether the gender paradox is a real phenomenon, or merely the artifact of bias in data collection. the who/euro multicentre study of suicide, established in 1989, demonstrated that, for each age group, the female rate of self-harm exceeded that of the males, with the highest rate among females in the 13–24 age group and the highest rate among males in the 12–34 age group. however, this discrepancy has been known to vary significantly depending upon population and methodological criteria, consistent with wide-ranging uncertainties in gathering and interpreting data regarding rates of self-harm in general. such problems have sometimes been the focus of criticism in the context of broader psychosocial interpretation. for example, feminist author barbara brickman has speculated that reported gender differences in rates of self-harm are due to deliberate socially biased methodological and sampling errors, directly blaming medical discourse for pathologising the female. this gender discrepancy is often distorted in specific populations where rates of self-harm are inordinately high, which may have implications on the significance and interpretation of psychosocial factors other than gender. a study in 2003 found an extremely high prevalence of self-harm among 428 homeless and runaway youths (aged 16–19) with 72% of males and 66% of females reporting a history of self-harm. however, in 2008, a study of young people and self-harm saw the gender gap widen in the opposite direction, with