Getting a Handle on Self-Harm

People who become dependent on self-harm often come to treasure it as their one reliable comfort, therapists say. Images of blood, burns, cuts and scarring may become, paradoxically, consoling. In isolation, amid emotional turbulence, self-injury is a secret friend, one that can be summoned anytime, without permission or payment. “Unlike emotional or social pain, it’s possible to control physical pain” and its soothing effect, said Joseph Franklin, a psychologist at Florida State University.

Dr. Franklin argues that the brain circuits registering physical and mental pain, while distinct, likely have some overlap. The burn of humiliation feels very different from the burn of fire, of course, but there is some evidence that the relief from yanking a hand away from the flame can activate neural circuits that register psychological relief, although this system is far from worked out. In the research literatures, the sensation of release from either physical or social pain is called “pain-offset relief,” and by most accounts from those who self-harm, the use of one to blunt the other can become addictive.

“As a weird quirk of this effect, people who think the relief of psychological pain is worth the physical pain may reason that self-injury is a good idea,” Dr. Franklin said.

In psychiatry, self-injury is considered a symptom, not a stand-alone disorder. As a result, people who habitually injure themselves often receive an underlying diagnosis, like depression, attention-deficit disorder, post-traumatic stress, borderline personality, bipolar or some combination, which may change from doctor to doctor.

“I was diagnosed with bipolar, borderline, depression,” Ms. Dupill said. She didn’t think any of the labels fit her very well, and “some of the drugs they put me on caused me to panic and harm myself badly.” She considered the surges of anxiety and distress she felt, and sometimes still feels, as a post-traumatic reaction to a chaotic childhood.

If a diagnosis does fit, experts say, treatment should integrate it. In a paper that appeared this summer, a team led by Theodore Beauchaine of Ohio State University argued that preadolescent girls with a history of family trauma and attention-deficit disorder are at extremely high risk for later self-injury, and treating the A.D.H.D. as well as the traumatic stress would be a powerful prevention strategy, and could reduce later suicide risk.

The one treatment that appears to be most effective for breaking the habit of self-harm is a specialized talk therapy, originally invented for people with a diagnosis of borderline personality disorder, who are highly suicidal. Habitual self-injury is a risk factor for later suicide, and those who engage in it, like people diagnosed with borderline, endure gusts of dark emotion.

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