Self-inflicted injury more than a symptom

By Ivana Susic

Many of us have known someone with mysterious marks displayed on his or her skin too aligned to have resulted from an accident.

Cuts or scratches may appear in a row, or in areas such as the forearm that are easy to cover up.  This person may not appear suicidal or even overly depressed.  According to, it is estimated that roughly 2 million people in the United States engage in self-harm.

The Web site also states this number is probably an underestimate because the majority of cases go unreported.

The Diagnostic and Statistic Manual of Mental Disorders, published by the American Psychiatric Association, is used by psychiatrists to diagnose psychiatric illnesses. Its fourth edition was published in 1994 with minor revisions made in 2000, but no new disorders were added at that time. In 2013, the DSM will be revised and include several new disorders.

According to the APA, one of the new disorders listed will be non-suicidal self-injury.

Currently, self-injury is often considered a symptom of borderline personality disorder. Under the new revision, self-injury will be defined by the APA as engaging in “intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain … [and] performed with the expectation that the injury will lead to only minor or moderate physical harm.”

John Bozeday, a licensed clinical social worker in Evanston, said it is a good idea to define self-injury as its own disorder instead of a symptom of something else because it will help provide these individuals with more proper care.

“This more formally separates suicide from self-injury. For many people it’s not suicidal at all,” he said. “Do I think it’s worth having it as a separate diagnosis? Yes.”

While self-injury is alarming, it is rarely suicidal, Bozeday said.

Rather, the individual engages in behaviors that seem to serve as a way to relieve stressful situations. According to the National Institute of Mental Health, cutting is the most common form of self-harm.It is defined as using sharp objects to scratch or pierce the skin. Other forms of self-injury include branding and picking at skin or scabs.

Cutting is a behavioral pattern and the impulses associated with the behavior need to be addressed, Bozeday said. Rather than a suicidal attempt, poor judgment is exhibited, because the individual does not know another way to deal with problems.

“Cutting is a way to reduce tension or overwhelming emotions,” Bozeday said. “It’s a manifestation of emotions they feel they can eliminate by cutting.”

Bozeday also said that reclassifying self-injury will prevent people from overreacting.

The behavior should always require immediate attention but he said he is not sure people who are cutting always need to be hospitalized. Often, therapy and antidepressants work best.

“Antidepressants reduce the intensity of emotions,” Bozeday said. “Think of it as turning the volume down like on a radio dial.  If the volume is turned down, you’re less likely to cut.”

Mark Reinecke, professor of psychiatry and behavioral science at Northwestern University, said one way to tell if a behavior is a bad habit or disorder is its impact on day to day life; a disorder or disease will disrupt what he called “normal functioning.”

“You need to figure out, is it a symptom, a bad habit or a disorder?” he said.

Unlike disorders such as autism or schizophrenia, Reinecke said individuals are able to adapt self-harm to work for them; it makes them feel calmer or more in control.  It is a technique often used by those who feel overly anxious or depressed.

“The condition was there all along, we’re simply putting a label on it,” he said. “It was covered up and under one’s sleeve, so to speak.”

Jeanne Segal, sociologist and managing editor and co-founder of, said the DSM has tremendous power. Once the APA decides something is a disorder, the official diagnosis can make it easier for people to get the help they need because it will fall under the scope of insurance coverage.

“It’s like a rose by any other name,” she said. “By giving it its own jurisdiction … people have a better chance of being reimbursed [by insurance companies].”

While cutting is not considered life-threatening, many who attempt suicide have a history of cutting, Segal said.

The problem comes in diagnosing someone with a particular disorder, because there are common characteristics for many of the mental health disorders. What it comes down to is judgment and experience, she said.

“There’s no test for any of this in mental health,” Segal said.

There is a big difference between what the DSM defines and what practitioners experience with their patients, she continued.

Even though the board in charge of revising the DSM is a group of individuals with extensive knowledge, they are still people.

“It’s just opinions,” Segal said.

Another problem is the increasing reliance on medication without the benefit of therapy.Without finding the source of the problem, there is little hope to conquer the issues that cause self-injury in the first place.

“Medications are a resource, not a cure,” Segal said. “We’re told we can take a pill and be fine, but that’s just not true.”

Stigma is an issue for all disorders, especially ones associated with mental health. It can often cause a person to feel shut out or different.

“Once you’re labeled, that label can follow you forever,” Segal said.

Sometimes, those labels also come from within us,  she said. Patients can stop seeing themselves outside of the disorder name. Both Reinecke and Segal expressed a hope that the differentiation of self-injury will cause a greater acceptance.

With the new DSM guidelines, Segal said the greater chance of having insurance coverage for treatment will lead more people to seek help.

“Hopefully it gets the attention it needs,” she said.