Deliberate self-harm (DSH) is a much-misunderstood condition, which still carries a heavy social stigma. The number of people who self-harm is comparable to the number of people with eating disorders, but many of those that suffer don't seek help because of the stigma.

What is it?
Deliberate self-harm is a term used when someone repeatedly injures or harms themselves on purpose, for reasons other than sexual gratification. (Self-harm in a sexual context is a completely different situation.) Various other terms have been used to describe DSH, such as self-inflicted violence, self-abuse, and self-mutilation, but these terms imply motivations that are not correct. The self-mutilation label is particularly disliked by sufferers of DSH, as it is not the desired outcome of the behaviour, but rather an unfortunate consequence.

What are the most common types of DSH?
Surveys have shown that DSH involves the following behaviours:
Cutting — 72%
Burning - 35%
Self hitting or head banging - 30%
Interference with wound healing - 22%
Hair pulling - 20%
Bone breaking - 8%
Multiple methods from the above -78%

In one survey, sufferers admitted to an average of 50 acts of DSH, and 66% admitted to having performed an act within the last month.

Who is likely to inflict DSH?
It is estimated that around 1% of the population engage in DSH. Women are more likely to self-harm than men. Around 70% of all sufferers are female.

Those afflicted come from all walks of life and all social and economic backgrounds. Their ages range from early teens to early 60s. However, some common characteristics have emerged, which has led to a model of a 'typical self harmer - female, in her mid 20s to early 30s and has been hurting herself since her teens. She tends to be middle or upper-middle class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent.' None of these features are definitive, and some sufferers show none of the above traits, but it is a description that fits well for many.

Are there other common background features?
There are other characteristic personality traits and emotional backgrounds that feature prominently in people who self-harm. They often dislike themselves, are hypersensitive to rejection, and feel chronically angry, usually with themselves. They have high levels of aggressive feelings, which they disapprove of, and so they tend to suppress their anger or direct it inwards. They are more impulsive than average, and tend not to be able to regulate their emotions well, so often act according to the mood of the moment. They have low self-esteem, are often chronically anxious or depressed and may have suicidal tendencies. They don't have an extensive repertoire of coping skills, and regard themselves as being poor copers and poor forward planners. They are likely to be in psychotherapy or on medications for an underlying mood disorder, commonly depression or an eating disorder. They may have attempted suicide in the past. In one study of a group of self-harmers, 57% had previously taken an overdose, half of those had overdosed at least 4 times, and a third of the entire group expected to be dead within the next 5 years.

What triggers it?
The two emotional states most commonly reported in self-harmers at the time of the harm are anger and anxiety. When intense emotions build up, self-harmers feel overwhelmed and unable to cope. By causing pain, the emotional tension is released, and the turmoil becomes bearable again. This calming effect is very rapid and dramatic, and is a reliable way for the sufferer to escape from the unbearable intensity of their emotional state. It quickly becomes a primary coping mechanism for people with this trigger situation.

Some other sufferers say that they inflict pain on themselves in order to escape numbness; the pain lets them know that they can still feel something. Others say that it is a way of preventing themselves from attempting suicide.

Why are women more likely to self-harm?
There are theories about why women are more likely to self-harm than men. It is thought to relate to social conditioning, in that women are socialised to internalise anger, whereas men are socialised to externalise it. Men who are very angry or in a heightened emotional state are more likely to externalise it in seemingly unprovoked acts of violence.

Also men are socialised to repress emotion, so are less likely to develop the intense emotional state that triggers episodes of self-harm in many sufferers.

Does brain biochemistry play any part?
Some studies have suggested that the underlying personality traits and emotional background of sufferers (angry, anxious, aggressive and impulsive tendencies) may be due to a deficiency in the brain transmitter serotonin.

What treatment is available?
At present, there is no medical agreement on how or whether to treat DSH with medication. The studies about serotonin levels may lead to a breakthrough in drug treatment using a group of drugs called SSRIs (selective serotonin re-uptake inhibitors). These are currently used to treat depression, but may have a role in DSH if taken at higher doses. There have been case reports of another group of drugs, called atypical neuroleptics, being used to treat DSH, but no well-controlled studies have as yet been undertaken.

The main treatments at present focus on any underlying mood disorder such as chronic anxiety and depression. These may be treated with conventional medications or with psychotherapy.

Specific psychotherapy can be directed at helping self-harmers to learn new coping mechanisms and teaching them how to use these techniques in preference to self-harming. All these services can be accessed through GP surgeries, so this should be the first port of call for DSH sufferers seeking help.

Family and friends of self-harmers often feel that the sufferer should be admitted to hospital if they turn up in an A&E department with self-inflicted injury. However, this is not helpful unless the person is clearly a danger to her/his own life or to others.

An offer of mental health follow-up services is more helpful to the sufferer, and is less likely to discourage them from attending hospital to get medical attention for their wounds.