Selfharming behaviour

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Classification according to ICD-10
X60-X84 Deliberate self-harm
L98.1 Dermatitis factitia
ICD-10 online (WHO version 2019)

Self-harming behavior (SVV) is defined as the voluntary, direct destruction or alteration of body tissue without suicidal intent, which is socially unacceptable, direct and repetitive and usually leads to small or moderate damage. Those affected must have deliberately inflicted damage to body tissue on five or more days within a year. Other terms are auto-aggressive behavior or artifact action.

Actions with suicidal intent, stereotypical behavior in the case of a profound developmental disorder or psychosis , so-called body modification through piercings or tattoos as well as self-harm for the purpose of a medical examination in the context of Munchausen syndrome are differentiated from self-harming behavior.

Although SVV has no suicidal aspect by definition (does not necessarily apply to ICD-10 classifications of willful self- harm ), but mostly serves to regulate (negative) feelings, SVV can be associated with suicidality in up to a third of those affected. In such cases it can be assumed that the self-harm also serves to regulate suicidal thoughts. About 10% of sufferers commit sooner or later actually suicidal .

A psychological explanation for such behavior is that there is a disorder of the body schema in which the own body is not experienced as belonging to the self. SIA can also be used for self-punishment. This behavior goes beyond other forms of self-harm, such as shortening one's life expectancy through heavy smoking .

Comorbidity

Self-injurious behavior can occur, among other things, in:

Methods and causes

Self-harm as proof of love
Forearm of a borderline patient with incisions at various stages of wound healing

People often practice different types of self-harm. The most common types include:

  • cutting, scratching or scratching (so-called scratching ) the skin on the arms and legs with pointed and sharp objects such as razor blades, knives, scissors or shards; An accumulation of scars can be found on the non-dominant (lower) arm , but both arms can also be covered with scars, such as the abdomen, legs, chest, genitals or the face
  • repeated "head banging" (with the hands against the head, in the face or with the head against objects)
  • Punches against hard objects until bruises or bleeding occur
  • hitting the body (e.g. arms and legs) with objects
  • pulling out hair ( trichotillomania )
  • In-the-eye drilling to auto-enucleation
  • pricking with needles (e.g. safety pins)
  • Biting into accessible parts of the body, also biting off fingertips and "chewing" the inside of the cheeks or lips
  • Burns and scalds (sticking cigarette smears on your body, holding your hand over a candle)
  • Ingestion of harmful substances (such as detergents)
  • Intravenous, subcutaneous, or intramuscular injection of harmful substances
  • Chemical burns to the body
  • prolonged spraying of deodorants or body sprays until frostbite occurs
  • Fingernail biting ( onychophagia ); lighter forms based on nervousness are not necessarily counted as self-harm; However, painful nail injuries and tearing of the nails represent self-harm
  • the constriction of body parts.

It is controversial whether endorphins ( happiness hormones ) are released when one's body is injured , which alleviate pain, as is the case with physical exertion or giving birth. These are released in connection with adrenaline, as the body is put into a form of stress by the self-harm . A genetic-physiological basis is assumed for the development of autoaggression at least as a causal aspect. The focus is on the neurotransmitters serotonin and dopamine.

Often a habituation takes place, which leads to more severe self-harm (deeper cuts, larger burns ) in order to achieve the desired satisfaction. Those affected develop an addiction .

It has not been therapeutically proven whether autoaggressive behavior is a matter of self-reward or self-punishment .

In a multiple-choice study on the subject available on the Internet , it was found that many people with self-harming behavior practice several types of self-harm (sometimes combining them):

Cutting (scoring) was reported with a frequency of 72%, 35% burned themselves, 30% hit themselves, 22% prevented wounds from healing, 22% scratched different parts of the body with their fingernails, 10% said they had their hair ripped off, and 8% intentionally broke bones or injured their joints.

Numbers and dates

With 25–35% lifetime prevalence of at least one-time non-suicidal self-harming behavior (NSSV) among young people within Europe, Germany is one of the countries with the highest prevalence rates. The second most common cause of death among young people between the ages of 15 and 17, after fatal road traffic accidents, is fatal self-harm. In samples from the general population, the proportion of people with NSSI decreases with increasing age. The Federal Ministry of Education and Research is funding several projects in the period 2017–2021 that examine the course and possible influencing factors of self-harming behavior in childhood and adolescence.

age structure

The majority of the onset of the disease is between the ages of 12 and 15, the most frequently mentioned age is 13. While the triggers can lie in the emotionally volatile phase of puberty ( lovesickness , aggression against parents, etc.), causes and Reasons are often sought in childhood. Accordingly, conflicts that could not be resolved there can now lead to SIA.

In Germany, up to 5.6 million young people between the ages of 15 and 24 are affected. Superficial cuts (cracks) are the most common form in adolescence with around 65%. Around two thirds of the young people affected are female.

In Austria, around 20 percent of minors have already inflicted injuries on themselves.

Dealing with those affected

Self-injurious behavior can be triggered by mental illnesses that occur independently of other symptoms.

While only specialist staff can carry out therapy, the family and social environment should contribute to the improvement of symptoms through emotional closeness and socialization in crisis situations.

Attempting to make individual symptoms the subject of discussion is often counterproductive because of the gain in disease . Accusations like “others are doing much worse” do not take those affected seriously.

Treatment is hardly possible against the will of the person concerned. The Federal Constitutional Court states: “The state, as the holder of the monopoly of violence , does not have the constitutional right to 'improve' or prevent its adult citizens who are capable of free will from harming themselves.” This reluctance is based on the law of the individual to self-harm, the limits of which are, however, controversial. In Germany, compulsory treatment is only legally permissible for minors or for people whose ability to form free will is severely impaired.

therapy

Autoaggressive people have the option of psychotherapy . The earlier therapy is started, the greater the chances of a cure . Various therapy concepts are available for treatment; both depth psychological - psychoanalytic as well as behavioral therapy .

The German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP) has issued treatment guidelines that include accompanying treatment with psychotropic drugs.

Depth psychology

The Transfer-Focused-Psychotherapy (TFP) according to Otto F. Kernberg concentrates on the transference and countertransference , whereby special attention is paid to the current situation and the current conflicts of a patient. In contrast to other forms of psychoanalytically based psychotherapy, such as depth psychology-based psychotherapy , TFP does not only rely on supportive techniques, even if these are used depending on the psychosocial situation and constitution of the patient.

Behavior therapy

A therapy concept that deals with the level of suffering and the resulting problem behavior (including self-harm) is dialectical-behavioral therapy according to Marsha M. Linehan . This therapy, which is geared towards the clinical picture of borderline personality disorder , distinguishes between coping strategies for psychological stress ( e.g. through distraction or conscious awareness) and alternatives to behavior that is harmful to the body, so-called stress tolerance skills . Examples of skills are clucking a rubber band, holding onto ice cubes, chewing chili peppers or walking barefoot in the snow. In the clinical setting, the application of a special, highly irritating ointment to the patient's forearms in response to an acutely occurring high pressure of self-harm is practiced. In principle, however, M. Linehan points out that it is not the task of the co-therapeutic skill trainer to intercept severe crises, but the task of the responsible psychotherapist. If this is not guaranteed, there will be a gap in care for the patient. If the patients are only asked to use skills for stress tolerance, this could have a devaluating effect on the suffering and feelings of the patient. For this reason, M. Linehan suggests first starting with skills for inner mindfulness in order to perceive one's own feelings without judgment. The skills for coping with stress should initially only be used for mild and moderate states of tension in order to increase the expectation of self-efficacy. Too early application to severe crises contradicts the principle of behavior formation ( shaping ).

Continuous situation analyzes are indispensable in DBT in order to identify both the individual triggers and the individual consequences of self-harming behavior. If positive reinforcers can be identified that were previously contingently related to the self-harming behavior, these positive reinforcers should be removed. This is intended to "delete" the self-injurious behavior as a conditioned reaction . In addition to deleting self-harming behavior, M. Linehan recommends positive reinforcement (C +) of alternative or incompatible behaviors. Punishment (C-), i.e. the application of aversive consequences that were previously unrelated to the behavior, should be avoided if possible. In particular, arbitrary punishment might be more associated with the therapist. In addition, punishment can only reduce behavior, but not create new, more functional behavior. Based on this consideration, it can be agreed for outpatient therapy not to have an additional emergency talk for 24 hours after self-harm. After a longer period of time, it would be assumed that there is no longer any contingency between the self-harm and the conversation, which means that operant reinforcement can be avoided. So it is not about generally rejecting a conversation, but simply preventing positive reinforcement. From this point of view, a conversation that had already been agreed before the self-harm would not necessarily have to be canceled, as it is not a consequence of the self-harm. Instead, the conversation could be used to prepare a situation analysis. However, the patient's personal goals would initially have to take a back seat in order to prevent positive reinforcement. When agreeing on such a contingency management, it is important to discuss that the assumption of operant conditioning should not assume that the self-harm is motivated by a conscious intention in the sense of an appellative act, but that positive consequences, as an unintended side effect, reinforce the behavior can. Basically, DBT therapists assume that patients are doing their best. If an emergency conversation has to be rejected, taking into account the operant conditioning, this should be done with a brief assessment of the patient's suffering (validation). In contrast to other forms of therapy, discontinuing therapy should only be considered if other treatment approaches fail. In this case, however, the reason for the failure should not be sought in the patient, but the limits of the therapist's performance should be named, with an indication that other therapists or forms of therapy might be more promising.

Self-harm as a means of artistic expression

Action artists like Wolfgang Flatz and Marina Abramovic cross the usual boundaries of artistic expression through self-harm and other self-torturous acts, while Petr Pavlensky uses drastic methods for political statements.

reception

Self-injurious behavior has often been received in the media and artistically, for example by the Austrian action artist Günter Brus .

Songs / songs

Books or movies

Examples:

  • in " Alone ", " Thirteen ", " Secretary " and " Two days with Juliet " the main characters injure themselves.
  • In “ Durchgeknallt ” and “ 28 Tage ” this behavior is shown in a supporting character.
  • The television series Lindenstrasse uses the role of Nastya to show an example of so-called scratching in subjectively perceived emotional isolation combined with external stress.
  • In the seven-volume series of novels Harry Potter - which was also made into a film - there is a house-elf named "Dobby" who compulsively hits his head against walls or hard objects as soon as he has violated something imposed on him ( self-punishment ). As the plot progresses, Harry Potter becomes Dobby's master; he forbids Dobby his compulsive behavior, which initially finds it very difficult (for more details here ; see also Paradox ).
  • SVV plays a central role in Elfriede Jelinek's novel The Piano Player
  • in André Gides Les caves du Vatican ( The dungeons of the Vatican ) SIA is the theme.

literature

  • Stefanie Ackermann: Self-harm as coping act of young women. Mabuse Verlag, Frankfurt am Main 2002, ISBN 3-935964-04-8 .
  • Norbert Hänsli: Automutilation - The self-damaging person in the psychopathological understanding. Publisher Hans Huber Ber, Göttingen 1996.
  • Ulrich Rohmann: Self-harming behavior. Reflections, questions and answers. 1998.
  • Ulrich Sachsse: Self-harming behavior. Psychodynamic psychotherapy, trauma, dissociation and its treatment. 6th edition 2002.
  • Gerrilyn Smith et al .: Self-harm. So that I don't feel the inner pain ... A guide for affected women and their relatives. 2000.
  • Mike Smith: Helping People with Self-Harmful Behavior. 2000.
  • Marilee Strong: A Bright Red Scream. Self-mutilation and the language of pain. Penguin Books, 1999.
  • Kristin Teuber: I bleed, therefore I am. Self-harm to the skin of girls and young women. Centaurus Verlag, Herbolzheim 2000.
  • Jochen Hettinger: Self-injurious behavior, stereotypes and communication. Promoting communication in people with intellectual disabilities or autism syndrome who exhibit self-harm. 1996.
  • Heinz Mühl et al .: Self-harming behavior in people with intellectual disabilities. A textbook from an educational point of view. 1996.
  • Steven Levenkron: The pain is deeper. Understand and overcome self-harm. 2001.

Web links

Individual evidence

  1. ↑ Guideline Non-Suicidal Self-Harmful Behavior (NSSV) in Children and Adolescents S2k Guideline 028/029, as of 02/2015, p. 4
  2. ↑ Guideline on non-suicidal self-harming behavior (NSSV) in children and adolescents S2k guideline 028/029, as of: 02/2015, p. 10
  3. ↑ a b What is self-harming behavior (SVV). In: neurologen-und-psychiater-im-netz.org. Retrieved June 28, 2016 .
  4. ↑ Self-injurious behavior (Volker Faust). In: psychosoziale-gesundheit.net. Retrieved June 28, 2016 .
  5. ^ Phenomenology of Suicide. (PDF) Dissertations Online, FU Berlin, accessed on July 28, 2016 .
  6. ↑ Holger Salge: Analytical psychotherapy between 18 and 25. Special features in the treatment of late adolescents (=  psychotherapy: practice ). 2nd, completely revised edition. Springer, Berlin / Heidelberg 2017, ISBN 978-3-662-53570-7 , pp. 115 , doi : 10.1007 / 978-3-662-53571-4 .
  7. ↑ Volker Faust : Self-injurious behavior. Mental health 151. Liebenau Foundation, Mensch - Medizin - Wirtschaft, Meckenbeuren-Liebenau, 2019. (method, affected body parts, psychosocial causes).
  8. ↑ Jörn Martin Hötzel: The influence of autoaggression on the cortisol response in the serotonergic provocation test with the help of Escitalopram Gießen, Univ-. Diss., 2011, p. 22 ff.
  9. ↑ Paul L. Plener, Michael Kaess, Christian Schmahl, Stefan Pollak, Jörg M. Fegert , Rebecca C. Brown: Non-suicidal self-injurious behavior in adolescence Deutsches Ärzteblatt 2018, pp. 23-30
  10. ↑ Gabriele Ellsäßer: Accidents, violence, self-harm in children and adolescents 2017. Results of the official statistics on injuries published by the Federal Statistical Office , April 7, 2017, p. 7
  11. ↑ Muyang Du: Long-term history of patients with self-harming behavior. Open Access Repository of the University of Ulm. Dissertation, 2018
  12. ↑ STAR - Self-Harming Behavior: Mechanisms, Intervention, Termination Website of the Federal Ministry of Education and Research, accessed on August 27, 2018
  13. ^ Thomas Lempp: Child and Adolescent Psychiatry BASICS 3rd edition, Elsevier Verlag. ISBN 978-3-437-42548-6
  14. ↑ Special consultation hours for self- injuries Joint broadcast of the Tirol Kliniken and the Medical University of Innsbruck, January 26, 2016
  15. ↑ BVerfGE 22, 180/219 f.
  16. ↑ Kai Fischer: The permissibility of imposed state protection against self-harm. Peter Lang / European Science Publishing House. Frankfurt / Main, Berlin, Bern, New York, Paris, Vienna 1997, ISBN 3-631-32569-X .
  17. ↑ Guideline Non-Suicidal Self-Harmful Behavior (NSSV) in Children and Adolescents S2k Guideline 028/029, as of: 02/2015, p. 25
  18. ↑ W. Mertens: Introduction to psychoanalytic therapy. Kohlhammer, Stuttgart 2000.