What are the types of self harm

Youth psychiatrist: "If I give up scratching, how do I get along?"

DEFAULT: You deal very intensively with children and adolescents who injure themselves. Why are they doing this?

Plener: There are many reasons for children and teenagers to harm themselves. Those affected describe self-harming behavior as a way of regulating emotions. Those who hurt themselves set a stimulus in order to free themselves from a negative emotional state.

DEFAULT: What types of self-harm are there?

Plener: It is understood to mean any kind of deliberate, direct damage to the surface of the body. Most of them cut their skin with blades of all kinds, but there are also other types of self-harm, such as getting burned or chafing the skin, which we see again and again in the clinic. Young people who do this experience tension that can result from problems in the family, from problems with friends, from grief, frustration or anger. If you injure yourself, you counter something that is then perceived as relief. Most of all, it's an act that you can control yourself.

DEFAULT: Is it the pleasure in pain?

Plener: We have researched this pain perception very intensively and found that adolescents who regularly injure themselves have a shifted pain threshold. That means they feel less pain when injured. Interestingly, this pain threshold seems to be very variable, because when those affected stop hurting themselves, their pain perception has normalized again after about six months.

DEFAULT: It is often said that the teenagers who harm themselves just want attention. Would you agree with that?

Plener: No, it's not true either. It's one of the many prejudices we fight against and that comes from people who don't really deal with it either. Self-injurious behavior is used to regulate emotions. We and other researchers were able to show that there are also neurobiological influences for this.

DEFAULT: Which?

Plener: Self-harm occurs in adolescents. We observe them from around the age of twelve, and we see the highest rate among 15-year-olds. People are in puberty, their brains are developing, and there are many mood swings. We see that in adolescents with self-harming behavior, the amygdala, a central part of the processing of emotions in the brain, is highly active. This applies to positive as well as negative and neutral stimuli.

DEFAULT: And therefore?

Plener: Not only the amygdala, but also other areas of the brain, which are located in the prefrontal and frontal brain regions, are concerned with regulating emotions. They have both a controlling and a steering function. In those affected, this interaction between the brain regions is less well regulated. This interaction can, however, be improved very well through psychotherapy.

DEFAULT: So when does scribing become a problem?

Plener: Those affected themselves often do not see scratching as a problem at first. What counts for them is the ability to end a negative emotional state. You are in control, so to speak. But almost everyone who does this also knows that it may not be a cheap form. In many young people the self-harming behavior also stops again. There are far fewer adults who scratch themselves. Except for borderline disorders, cracks are a symptom of the disease. But that doesn't mean that everyone who scratches has a borderline disorder. You have to differentiate.

DEFAULT: Who will get help?

Plener: Especially in the case of younger adolescents, it is the parents or the teachers who send the adolescents. And then they sit there and actually often don't want to change anything at first. Although many are very ambivalent. They know that scratching is not a successful solution to problems, and many do not want scars, for example. A first important step is to come into contact with the young people and find out which situations trigger the urge to self-harm. Because the crucial question for young people is: "If I give up scratching, how do I get on with it?"

DEFAULT: How actually?

Plener: We have a really good program for these youngsters. Every Thursday from 9 a.m. to 11 a.m., you can simply come to the outpatient clinic for an open consultation without registering. And then we talk. Most want that. But we also tell them that we can really achieve a lot with psychotherapy. How does scratching help me? That is the crucial question we are trying to find out. Most of them are simply not even aware of how they get into the state of tension.

DEFAULT: And then what?

Plener: The first phase is about finding an alternative to knives, razor blades and lighters. So something that can add a stimulus in a tense situation without hurting. We have had good experiences with spicy foods such as wasabi or chilli, and it can also be ice cubes. We have also had good experiences with ammonia for smelling. And then, as part of psychotherapy, it is about clarifying what difficulties there are and how they could be solved.

DEFAULT: You have worked with many young people: do you see patterns that lead to self-harming behavior?

Plener: Most of the time, it is interpersonal difficulties that lead to emotional stress and result in self-harm. Family arguments are often a trigger, but rejection from friends can also be a cause. Bullying is a massive risk factor. It increases the risk of self-harm by a factor of 12. However, adolescents often get injured when they have traumatic experiences behind them. Psychotherapy is about making young people aware of these emotional states. In the best case scenario, they learn to deal differently with situations that are painful for them.

DEFAULT: Can be difficult at times: the parents, the school, the friends - a lot remains the same?

Plener: However, the experience becomes different when the young people become aware of their emotions and know the mechanisms by which their internal, negative tension arises. The word is already quite trite: But mindfulness training can change a lot for the better. The goal is not to get into this high stress state in the first place. And speaking of parents: They should be involved in the therapy.

DEFAULT: And the bullying at school. Are there any solutions?

Plener: In this context, it is important that the school as an institution takes a clear position and practices prevention. One of the central moments in bullying is that there are always viewers. The aim of prevention would be for these so-called bystander to take a position when they observe acts of bullying. In psychotherapy, on the other hand, individuals learn how to cope with specific malignancies.

DEFAULT: How much does the scratching actually take place in secret?

Plener: Most young people actually do it in such a way that the others do not notice anything - and are also very self-sufficient when it comes to bandaging and caring for the wounds. Usually it is only the scars that make the environment aware.

DEFAULT: But there are pictures of deep wounds on social media that Ritzer put on display ...

Plener: We have studied this phenomenon in great detail. It is true that wounds are shown on Instagram. And it is also true that the deeper the wound is shown, the more "likes" the posts get. So we tried to chat with the people who post these photos and ask them how they experience it online.

DEFAULT: Is there any result?

Plener: Yes, those who post photos of their wounds not only get "likes", but also many offers from people who want to help. So the community is first of all very empathetic towards those who hurt themselves. In our study, we asked exactly the self-injuring Instagrammers. Via chat. Incidentally, 65 out of 100 respondents also took part. And that's why we know that almost everyone shows their wounds exclusively online, not in their real environment, because almost everyone is aware that self-harm is socially unacceptable. As child and youth psychiatrists, we also wanted to use the potential of the internet and launched the Star Project. We offer online therapy for young people who injure themselves. The offer has been well received. Teenagers have no problem chatting with a psychotherapist.

DEFAULT: Many parents of youngsters who scratch are afraid that their children could kill themselves with it. Is this concern justified?

Plener: By definition, and in our experience, self-injurious behavior in adolescence is not suicidal. In the long term and over the entire lifespan, however, many research groups have already established that self-harming behavior in adolescence is a risk factor for later suicide attempts and suicides.

DEFAULT: Could it be that adolescents who cut themselves continue to do so as adults?

Plener: That can be true, but it is rather rare. The youngsters often stop their self-harming behavior. In some, however, you can see a switch to alcohol or other drugs. We think that the decrease is based on learning experiences and also has neurobiological causes. As the brain matures, the impulse control becomes better and better.

DEFAULT: So only the scars remain ...

Plener: That's right, in the best case the scars become part of a successful coping in your own biography, visible proof that you have experienced a difficult phase and successfully left it behind. (Karin Pollack, June 18, 2019)

Paul Plener is a specialist in child and adolescent psychiatry and heads the University Clinic for Child and Adolescent Psychiatry at the Medical University of Vienna / Vienna General Hospital. His research focus is self-harming behavior in children and adolescents.

Event notice:

From June 30th to July 2nd, Europe's largest congress for child and adolescent psychiatry (ESCAP) will take place in the Vienna Hofburg. The latest results regarding self-harming behavior are also presented there.

For further reading:

Many youngsters encounter suicide and self-harm on Instagram

Why people hurt themselves

After abuse: careful handling and professional help

Help in crises

There are a number of contact points for people in crisis situations and their relatives. At www.suizid-praevention.gv.at you can find emergency numbers and first aid for suicidal thoughts.

Telephone help in the event of a crisis is also available from:

● Telephone counseling 142, daily, from midnight to midnight.

● Crisis Intervention Center 01/406 95 95 (Monday to Friday, 10 a.m. to 5 p.m.); also personal and e-mail advice: www.kriseninterventionszentrum.at.

● Social psychiatric emergency service / PSD daily from midnight to midnight, Tel .: 01/31330