self-harm self-harm self-harm is intentional behavior that is considered harmful to oneself. this is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. other terms such as cutting, self-injury, and self-mutilation have been used for any self-harming behavior regardless of suicidal intent. the most common form of self-harm is using a sharp object to cut the skin. other forms include scratching, hitting, or burning body parts. while earlier usage included interfering with wound healing, excessive skin-picking, hair-pulling, and the ingestion of toxins, current usage distinguishes these behaviors from self-harm. likewise, tissue damage from drug abuse or eating disorders is not considered self-harm because it is ordinarily an unintended side-effect but context may be needed as intent for such acts varies. self-harmother namesdeliberate self-harm (dsh), self-injury (si), self-poisoning, nonsuicidal self-injury (nssi), cuttinghealed scars on the forearm from prior self-harmspecialtypsychiatry although self-harm is by definition non-suicidal, it may still be life-threatening. people who do self-harm are more likely to die by suicide, and self-harm is found in 40–60% of suicides. still, only a minority of those who self-harm are suicidal. the desire to self-harm is a common symptom of some personality disorders. people with other mental disorders may also self-harm, including those with depression, anxiety disorders, substance abuse, mood disorders, eating disorders, post-traumatic stress disorder, schizophrenia, dissociative disorders, as may people experiencing gender dysphoria. studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions. self-harm can also occur in high-functioning individuals who have no underlying mental health diagnosis. the motivations for self-harm vary. some use it as a coping mechanism to provide temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness, or a sense of failure. self-harm is often associated with a history of trauma, including emotional and sexual abuse. there are a number of different methods that can be used to treat self-harm, which concentrate on either treating the underlying causes or on treating the behavior itself. other approaches involve avoidance techniques, which focus on keeping the individual occupied with other activities, or replacing the act of self-harm with safer methods that do not lead to permanent damage. self-harm is most common between the ages of 12 and 24. self-harm in childhood is relatively rare, but the rate has been increasing since the 1980s. self-harm can also occur in the elderly population. the risk of serious injury and suicide is higher in older people who self-harm. captive animals, such as birds and monkeys, are also known to participate in self-harming behavior. classification self-harm (sh), also referred to as self-injury (si), self-inflicted violence (siv), nonsuicidal self injury (nssi) or self-injurious behavior (sib), are different terms to ascribe behaviors where demonstrable injury is self-inflicted. the behavior involves deliberate tissue damage that is usually performed without suicidal intent. some sources define self-harm more broadly than self-injury, such as to include drug overdose, eating disorders, and other acts that do not directly lead to visible injuries. the most common form of self-harm involves cutting of the skin using a sharp object, e.g. a knife or razor blade. the term self-mutilation is also sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive. others use the phrase self-soothing as intentionally positive terminology to counter more negative associations. self-inflicted wounds is a specific term associated with soldiers to describe non-lethal injuries inflicted in order to obtain early dismissal from combat. the older literature has used several different terms. for this reason research in the past decades has inconsistently focused on self-harming behavior without and with suicidal intent (including suicide attempts) with varying definitions leading to inconsistent and unclear results. nonsuicidal self-injury (nssi) has been listed in section 2 of the dsm-5-tr under the category "other conditions that may be a focus of clinical attention". while nssi is not a separate mental disorder, the dsm-5-tr adds a diagnostic code for the condition in-line with the icd. the disorder is defined as intentional self-inflicted injury without the intent of dying by suicide. criteria for nssi include five or more days of self-inflicted harm over the course of one year without suicidal intent, and the individual must have been motivated by seeking relief from a negative state, resolving an interpersonal difficulty, or achieving a positive state. a common belief regarding self-harm is that it is an attention-seeking behavior; however, in many cases, this is inaccurate. many self-harmers are very self-conscious of their wounds and scars and feel guilty about their behavior, leading them to go to great lengths to conceal their behavior from others. they may offer alternative explanations for their injuries, or conceal their scars with clothing. self-harm in such individuals may not be associated with suicidal or para-suicidal behavior. people who self-harm are not usually seeking to end their own life; it has been suggested instead that they are using self-harm as a coping mechanism to relieve emotional pain or discomfort or as an attempt to communicate distress. studies of individuals with developmental disabilities (such as intellectual disability) have shown self-harm being dependent on environmental factors such as obtaining attention or escape from demands. some individuals may have dissociation harboring a desire to feel real or to fit into society's rules. signs and symptoms eighty percent of self-harm involves stabbing or cutting the skin with a sharp object, sometimes breaking through the skin entirely. however, the number of self-harm methods are only limited by an individual's inventiveness and their determination to harm themselves; this includes burning, self-poisoning, alcohol abuse, self-embedding of objects, hair pulling, bruising/hitting one's self, scratching to hurt one's self, knowingly abusing over-the-counter or prescription drugs, and forms of self-harm related to anorexia and bulimia. the locations of self-harm are often areas of the body that are easily hidden and concealed from the detection of others. as well as defining self-harm in terms of the act of damaging the body, it may be more accurate to define self-harm in terms of the intent, and the emotional distress that the person is attempting to deal with. neither the dsm-iv-tr nor the icd-10 provide diagnostic criteria for self-harm. it is often seen as only a symptom of an underlying disorder, though many people who self-harm would like this to be addressed. common signs that a person may be engaging in self-harm include the following: they ensure that there are always harmful objects close by, they are experiencing difficulties in their personal relationships, their behavior becomes unpredictable, they question their worth and identity, they make statements that display helplessness and hopelessness. cause mental disorder although some people who self-harm do not have any form of recognized mental disorder, many people experiencing various forms of mental illnesses do have a higher risk of self-harm. the key areas of disorder which exhibit an increased risk include autism spectrum disorders, borderline personality disorder, dissociative disorders, bipolar disorder, depression, phobias, and conduct disorders. as many as 70% of individuals with borderline personality disorder engage in self-harm. an estimated 30% of individuals with autism spectrum disorders engage in self-harm at some point, including eye-poking, skin-picking, hand-biting, and head-banging. schizophrenia may also be a contributing factor for self-harm. those diagnosed with schizophrenia have a high risk of suicide, which is particularly greater in younger patients as they may not have an insight into the serious effects that the disorder can have on their lives. there are parallels between self-harm and münchausen syndrome, a psychiatric disorder in which individuals feign illness or trauma. there may be a common ground of inner distress culminating in self-directed harm in a münchausen patient. however, a desire to deceive medical personnel in order to gain treatment and attention is more important in münchausen's than in self-harm. psychological factors self-harm is frequently described as an experience of depersonalization or a dissociative state. abuse during childhood is accepted as a primary social factor increasing the incidence of self-harm, as is bereavement, and troubled parental or partner relationships. factors such as war, poverty, unemployment, and substance abuse may also contribute. other predictors of self-harm and suicidal behavior include feelings of entrapment, defeat, lack of belonging, and perceiving oneself as a burden along with having an impulsive personality and/or less effective social problem-solving skills. the onset of puberty, including the onset of sexual activity, often correlates with the onset of self-harm; this is because the pubertal period is associated with neurodevelopmental vulnerability and comes with an increased risk of emotional disorders and risk-taking behaviors. transgender adolescents are significantly more likely to engage in self-harm than their cisgender peers. this can be attributed to distress caused by gender dysphoria as well as increased likelihoods of experiencing bullying, abuse, and mental illness. genetics the most distinctive characteristic of the rare genetic condition, lesch–nyhan syndrome, is uncontrollable self-harm and self-mutilation, and may include biting (particularly of the skin, nails and lips) and head-banging. genetics may contribute to the risk of developing other psychological conditions, such as anxiety or depression, which could in turn lead to self-harming behavior. however, the link between genetics and self-harm in otherwise healthy patients is largely inconclusive. drugs and alcohol substance misuse, dependence and withdrawal are associated with self-harm. benzodiazepine dependence as well as benzodiazepine withdrawal is associated with self-harming behavior in young people. alcohol is a major risk factor for self-harm. a study which analysed self-harm presentations to emergency rooms in northern ireland found that alcohol was a major contributing factor and involved in 63.8% of self-harm presentations. a recent study in the relation between cannabis use and deliberate self-harm (dsh) in norway and england found that, in general, cannabis use may not be a specific risk factor for dsh in young adolescents. smoking has also been associated with self-harm in adolescents; one study found that suicide attempts were four times higher for adolescents that smoke than for those that do not. a more recent meta-analysis on literature concerning the association between cannabis use and self-injurious behaviors has defined the extent of this association, which is significant both at the cross-sectional (odds ratio = 1.569, 95% confidence interval ) and longitudinal (odds ratio = 2.569, 95% confidence interval ) levels, and highlighting the role of the chronic use of the substance, and the presence of depressive symptoms or of mental disorders as factors that might increase the risk of self-injury among cannabis users. pathophysiology a flow chart of two theories of self-harm self-harm is not typically suicidal behavior, although there is the possibility that a self-inflicted injury may result in life-threatening damage. although the person may not recognise the connection, self-harm often becomes a response to profound and overwhelming emotional pain that cannot be resolved in a more functional way. the motivations for self-harm vary, as it may be used to fulfill a number of different functions. these functions include self-harm being used as a coping mechanism which provides temporary relief of intense feelings such as anxiety, depression, stress, emotional numbness and a sense of failure or self-loathing. there is also a positive statistical correlation between self-harm and emotional abuse. self-harm may become a means of managing and controlling pain, in contrast to the pain experienced earlier in the person's life over which they had no control (e.g., through abuse). other motives for self-harm do not fit into medicalized models of behavior and may seem incomprehensible to others, as demonstrated by this quotation: "my motivations for self-harming were diverse, but included examining the interior of my arms for hydraulic lines. this may sound strange." assessment of motives in a medical setting is usually based on precursors to the incident, circumstances, and information from the patient. however, limited studies show that professional assessments tend to suggest more manipulative or punitive motives than personal assessments. a uk office for national statistics study reported only two motives: "to draw attention" and "because of anger". for some people, harming themselves can be a means of drawing attention to the need for help and to ask for assistance in an indirect way. it may also be an attempt to affect others and to manipulate them in some way emotionally. however, those with chronic, repetitive self-harm often do not want attention and hide their scars carefully. many people who self-harm state that it allows them to "go away" or dissociate, separating