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"Cutting, burning, and poking needles in my arm is a security for me because I know that if all else fails and leaves me feeling empty and emotionless, the pain and blood will always still be there for me" (18 year-old waitress as quoted in Favazza, 1988) . Within the past two decades, many different variations of deviant self-harming behavior have become more commonly recognized by members of the health professions, social scientists, and the general public. There has been an escalating awareness about the plight of those who engage in behavior like that described above. The prevalence is now thought to be about 1,400 cases per 100,000 population (Favazza, 1987). Professionals within the health industry have labeled this behavior with many different terms. In fact, one article lists 27 different labels for this type of behavior (Kahan and Pattison, 1984). However, the three most common labels that have emerged are self-injurious behavior, self-harm, and self-mutiliating behavior.

This form of behavior is not really new. Many case reports from earlier psychologists report similar forms of behavior. However, for many decades, self-mutilation has been seen only as another form of suicidal behavior. The first known author to s uggest otherwise was Karl Menninger. In his 1938 book Man Against Himself, Menninger wrote that "Local self-destruction is a form of partial suicide to avert total suicide" (p. 271). He had formulated a very important principle, but at the time, no one was willing to deal with self mutilation in depth. The issue of the difference between self-injury and suicide will be addressed later in this paper. Suffice it to say that it was not until 1983 (Kahan and Pattison) that self-mutilation began to receive more attention within the fie ld. Today, over 250 articles and more than five books have been written on the topic. One of the most prominent researchers within the field, Armando Favazza, has done a great deal of work on how self-mutilation relates to psychological, sociological, and cultural forces.

Technically, self-mutilation can be divided into two broad categories: culturally sanctioned and deviant self mutilation. Culturally sanctioned rituals and practices include ear-piercing in contemporary American society, ritual dances among Native A mericans that involve self-mutilation, and the gential circumcision of Jewish babies. These practices or rituals are widely accepted within the culture in which they commonly occur. They often serve to mark the passage from one life stage to another or to communicate with some form of higher power.

Throughout history, it has always seemed relatively simple to separate these culturally sanctioned rituals and practices from the deviant self mutilation that current professionals work so hard to remove from a patient's life. Recently however, a mo vement known as the Modern Primitive Movement has challenged the separation between the two categories. The leader of this movememt is known as Fakir Musafar. Musafar hopes to bridge the gap between the categories and move what society now labels deviant self-mutilation into the same category as cuturally sanctioned self-mutilation. In fact, he would prefer to call it all "body play." Musafar has garned quite a large following of people who believe that body play offers a method for achieving spiritua l grace, an enhanced state of awareness, and a communion with some form of higher power. Musafar believes that the rituals involving self-mutilation practiced by other societies have many beneficial effects to offer those who approach the practice of bod y play with awareness and respect. He quotes a young woman who entered his piercing parlor and stated, "I'm getting pierced to reclaim my body. I've been used and abused. My body was taken by another without my consent. Now, by this ritual of piercing , I claim my body back as my own." Nevertheless, most healing professionals within our society warn that body play is a dangerous way to achieve spiritual growth and that rituals lose their meaning when they are transported to a completely different cult ure. What is true for Tibetan monks in the mountains of Tibet is not equally true for American adolescents in the family basement.

Today the two categories still remain clearly separated. The second major category (the one which this paper focuses on) consists of actions that Favazza (1987) has labeled deviant pathological self-mutilation. He defines pathological self-mutilati on as the deliberate alteration or destruction of body tissue without conscious suicidal intent. From here and on, the words self mutilation refer to those actions included within the second category. Other authors have defined self-mutilation similarly. Winchel and Stanley (1993) "propose that self-injurious behavior be defined as the commission of deliberate harm to one's own bo dy. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are exclud ed " (p. 306).

Favazza (1987) breaks down this second category into three distinct types of self-mutilation: major, stereotypic, and superficial. Major self mutilation comprises infrequent acts in which a significant amount of body tissue is destroyed. For example, patients who castrate themselves, gouge out their eyes, or amputate limbs would be classified as engaging in major self mutilation. This type of behavior is almost exclusively found among patients who are either extremely intoxicated or suffering from a psychotic disorder. While some patients do seem indifferent to their behavior and cannot provide an explanation for it, most have their own reasons for engaging in the behavior. The most common reasons provided by patients have historically been associated with religion, demonic influences, guilt over sexual thoughts and activities, or heavenly commands. Many patients radiate a calmness following the act which suggests that their actions may have been functional in helping to resolve unconscious conflicts. However, the calmness does not last long, and self-mutilating behavior usually returns.

Unlike major self-mutilation, stereotypic self-mutilation seems to have a fixed pattern of expression, is devoid of symbolism, and is often rhythmic. It also is more likely to occur shamelessly, and in the presence of onlookers. This form of self-m utilation seems to be more organically driven than any other. It is highly prevalent in institutionalized mentally retarded persons, as well as in persons suffering from specific neurological and psychiatric disorders such as autism, Retts disorder, Tour ette syndrome, deLange syndrome, and Lesch Nyhan syndrome (Favazza, 1987; Winchel and Stanley, 1991). In fact, estimates of the incidence of self-injurious behavior among such patients range from 3.5% to 40% (Winchel and Stanley, 1991). Patients are often found to engage in stereotypic self-muti lation by constantly banging their heads against walls, chewing on their fingers, or pressing on their eyeballs (Favazza, 1993). One of the most common functionalist proposals concerning head-banging is that the patient is unconsciously attempting to ree xperience the comfort of the mother's heartbeat.

The most common form of self-mutilation is known as moderate or superficial and can be broken down even further into three smaller categories. Compulsive superficial self-mutilating behavior tends to occur many times daily and is repetitive and ritu alistic. For example, persons under stress may pull on their hair, collect the hair that has been plucked from the scalp, and occasionally swallow it. Other people pick obsessively at real or imaginary skin lesions and in doing so damage the facial tissue enough to leave scars.

Episodic self-mutilation refers to behaviors that occur every so often. Favazza and Conterio (1988) reported the different types of self-injurious behaviors to which survey respondents admitted. Cutting was the most common method (72%), followed by burning (35%), self-hitting (30%), interference with wound healing (22%), hair pulling (10%), bone breaking (8%), and multiple methods (78%). Most respondents reported an average of 50 harmful acts since the beginning of the self-injurious behavior. T he vast majority of patients had visited the emergency room numerous times, had received extensive outpatient therapy, and had been hospitalized at least once for their behavior. Fifty-seven percent had overdosed on drugs at least once, half of those had overdosed at least four times, and a full third of the sample expected to be dead within five years. The authors compiled a portrait of a typical self-injurer. She is female, in her mid-20's to early 30's, 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. In addition, she may suffer from borderline, histrionic, anti-social, or m ultiple personality disorder. Favazza, Conterio and DeRosear have also shown that eating disorders occur much more frequently among self-mutilators (1989). In a survey conducted by the authors, fifty percent of the respondents reported they currently or at some time in the past had had an eating disorder.

Many different authors have suggested quite a long list of motivations for why people engage in this type of self-injurious behavior. The vast majority of those explanations would be seen by sociologists as functional; that is, they contribute to th e coping skills and continued existence of the patient. In fact, Wise (1990) wrote a very relevant article focusing on how each different type of self-injurious behavior had its own functional value to the patient. She listed fifteen different behaviors and provided an explanation for how they functioned to alter the patient's situation. For example, drug abuse served to mask the painful memories of past sexual abuse. One young woman reported cutting her thighs where she had been abused in order to re mind herself that she had not imagined the painful experience. Other researchers have published similarly functional accounts written by respondents. Unless otherwise stated, the following excerpts are taken from the book Bodies Under Seige, by Armando Favazza.

Many patients report mounting tension that they cannot control. A 39 year-old schoolteacher reported that , "the sight of my blood seems to release unbearable tension." By harming themselves, patients reduce the level of emotional and psychological arousal to a bearable one. Others wish to escape from feelings of emptiness, depression, or unreality. They report feeling numb and unable to experience normal sensations (Miller, 1994). The pain that accompanies self-injury helps them to know they ar e still alive and to return them to the present reality. Along a similar vein, many patients report using the pain to distract them from greater psychic pain within themselves. By focusing on the physical pain, they are able to quench the panic that acc ompanies intense, internal feelings of pain. Other patients use self-injury to express rage that they do not know how to express outwardly. A 19 year-old clerical worker reported, "I get my anger out of me when I hurt myself. Cutting gives me a way to vent my anger." Patients have also reported that the self-injurious behavior was an attempt to express emotional pain in a physical way. It is sometimes also an attempt to exert control over ones' environment or ones' body (Miller, 1994). A 22 year-old homemaker stated that, "Self-harm gives me a feeling of control when I cannot find control in the environment." Other reasons listed include harming oneself for security and uniqueness, relief from feelings of alienation, attempts to get attention and t o influence others, and as a primitive way to correct negative perceptions about physical appearances.

One of the most important distinctions that needs to be made is the difference between self-mutilation and suicide attempts. In 1983, Kahan and Pattison proposed the concept of a Deliberate Self-Harm Syndrome (DSH), based on their review of the lite rature. They were attempting to address the clinical problem of the person for whom self-destructive behavior appears to be a chronic coping style in life. The authors stated that, "such behavior may not be suicidal in intent, but rather life preservati ve" (p. 17). They described a syndrome in which the patient engages in chronic, repetitive acts of low lethality mutilation. Similarly, Favazza and Rosenthal (1987) proposed a Repetitive Self-Mutilation Syndrome. The essential feature of RMS is a recurrent failure to resist impulses to harm ones' own body physically without conscious suicidal intent. Bo th teams of researchers listed the syndromes as impulse disorders, and explicitly stated that patients should not be regarded as suicidal. Patients are generally aware of the fine line they walk between self injury and suicide, but are also resentful of doctors and mental health professionals who mistake their self-harm as suicide attempts.

Researchers tend to agree on the general profile of a chronic self mutilator, but disagree on the sex ratio. Favazza and Rosenthal report that chronic self-mutilation seems to be much more common in females. Kahan and Pattison have found no such difference in their own research results. They have suggested that perhap s the disorder seems more common among women because researchers tend to overlook institutions such as prisons in which men engage in large amounts of self-mutilating behaviors. However, the reader must keep in mind that these statistics refer only to pa tients who engage in chronic, low-lethality self-mutilation. Men are more likely than women to commit major acts of self-mutilation, to actually commit suicide, and to express anger outwardly by harming others (Barnes, 1985).

All of the different themes described above in relation to episodic self mutilation also relate to a third category, known as repetitive self-mutilation. This is the category which includes patients diagnosed as suffering from Repetitive Self-Mutilation Syndrome or Deliberate Self-Harm Syndrome. In general, the behaviors inv olved in the two categories are quite similar, as are the motivations. Psychiatrists label a patient a repetitive self-mutilator when episodic behavior has become an overwhelming preoccupation, or when the patient has developed an identity based upon his or her behavior. These patients describe themselves as addicted to their self-injurious behavior. At this point, the labeling theory becomes very useful. Many patients report identifying as a "cutter" or "burner" only after having been hospitalized in a psychiatric institution. Social settings may greatly influence the onset, course, and spread of self-mutilating behavior. In 1969, Podvoll noted that self mutilators who assume an identity as a cutter develop a functional role on hospital wards. "On one hand, staff and the other patients perceive the behavior as a pathological symptom which must be controlled; on the other hand, they may also perceive it a s something seemingly more honest, pure, and disciplined than other behaviors and therefore the object of respect, envy, and collusion" (quoted in Favazza, 1987).

In other cases, self-mutilating behavior may develop for the first time within the context of a total-care institution. In these settings, such as prisons or reform schools, the behavior is often viewed as a coping mechanism that offers a means to e xpress defiance, gain a transfer to a different unit, or attract sympathetic medical attention. Self-mutilating behavior has also been known to occur as an epidemic. Soldiers in the military during times of war have often committed acts of self-mutilatio n in order to be sent home.

Epidemics of self-injury have been reported in correctional facilities for teenagers as well as in adult penal institution. Ross and McKay (1979) described working with female adolescents in such a facility. Over 80% of the young girls carved thems elves with words, letters, and symbols that appeared to carry consciously intended messages of group identification. Their behavior may have been void of the impulsivity that usually characterizes episodic or repetitive self-mutilation.

Research into all forms of superficial self-mutilation has shown that the age of onset for most patients is late childhood or early adolescence. The disorder waxes and wanes and may become chronic. In many patients, symptoms persist for ten or fift een years. Predisposing factors for self-harming behavior include physical and/or sexual abuse in childhood, caregiver neglect, an early history of surgical procedures or illness, parental alcoholism or depression, residence in a total-care institution, proneness to accidents, perfectionistic tendencies, dissatisfaction with body shape or sexual organs, and an inability to tolerate and express feelings. The most common precipitants are real or perceived rejection and situations that produce feelings of helplessness, anger, or guilt.

Physical and/or sexual abuse is one of the predisposing factors that has been largely ignored by researchers until recently. One notable exception is Shapiro's 1987 article focusing on the connections between self-blame in incest victim and self-mut ilation. According to Shapiro, sexual abuse survivors often blame themselves for the abuse, and thus, as adults they harm themselves physically as punishment for their "bad" behavior. They perpetuate the cycle of abuse, and may express feelings of inten se rage turned upon themselves. Survivors often cannot imagine themselves as lovable human beings. They also cannot physically strike out at the abuser, which leads to striking out at themselves. Van der Kolk, Perry, and Herman (1991) found that sexual abuse victims were the most likely of all respondents to cut themselves. The earlier the abuse began, the more severe the cutting was.

Other authors have proposed a neurobiological model for chronic self mutilation which may help to account for these findings (Kirmayer and Carroll, 1987). They noted that persons exposed to repeated shock and injury become physiologically less sensitive to pain and have elevated levels of one of the body's natural painkil lers: enkephalin. Abused children may become habitually accustomed to these elevated levels. As adults, in times of calm or isolation, their enkephalin levels would drop, creating a relative withdrawal state with an increase in tension and dysphoria. S elf-mutilation might be an attempt to alleviate tension and dysphoria by elevating enkephalin levels.

This explanation seems to relate to the theories promoted by Jack Katz in his book, Seductions of Crime. Katz explores the emotional and physiological experiences involved in the performance of criminal acts in order to better understand why people continue to engage in crime. He strives to go beyond traditional sociological theories such as Merton's theory of differential access or Sutherland's theory of differential association. These theories explore societal structures and background fa ctors in early childhood that influence criminal activity later in life. Instead of focusing on these theories, Katz explores crime from the inside by detailing the minute reactions of criminals to their activities. Likewise, the above explanation, as w ell as many of the functional explanations provided by other researchers, seeks to explain self-mutilating behavior in terms of its immediate beneficial sensations and effects.

Katz also details how young women who shoplift often report "sneaky thrills." They have a secret which no one must uncover. They have managed to deviate from society's rules without being caught, and this knowledge infuses the entire situation with an increased level of tension and excitement. Self mutilators report similar feelings. They, too, are pushing the boundaries of acceptable behavior, and must not be caught, either in the act, or by having their scars exposed. If one accepts the theory proposed above, then it can be said that some self-m utilators hurt themselves to increase their sensory levels, in much the same way that shoplitfters sometimes steal to gain the "high" that comes with a successful theft. Both forms of sneaky thrills are harmful to the person involved, but they have very different consequences. In addition, shoplifters often feel quite smug in the knowledge that they have "gotten away with it." Likewise, the self-harming behavior exhibited by many patients can also make them feel smug, special and unique. One 24 year-o ld college student stated, "I cut myelf because I need to be special. Now, although I rarely expose my scars, I feel a smug pride. I'm not eager to give it up. Take it away from me, and I'm just like everyone else" (quoted in Favazza, 1987).

In addition, self-mutilating behavior could also be compared to the emotions described by Katz in his chapter on "Righteous Slaughter." Katz talks about how murderers experiencing rage must find a way to extinguish the rage immediately. Rage is an emotion that focuses consciousness completely on the here-and-now situation. "Rage so powerfully magnifies the most minute details of what is present that ones' consciousness cannot focus on the potential consequences of the action for ones' subquescent life" (p. 31). That statement was intended to refer to murderers, but it could very well apply to the experiences of some self-mutilators as well. The rage and anger often reported by patients turns inward many times. Some patients also report feeling completely unable to cope with the emotions they experience, and so they harm themselves, perhaps to extinguish feelings of overwhelming anger. Often, the actions are done without any thought of the future consequences such as scars or permanent impairment.

Katz's work helps contribute to our understanding of some forms of deviant self-mutilation. There are other authors who have offered their own approaches to the phenomena. Another explanation for the correlation between self-injurious behavior and past sexual and/or physical abuse has been proposed by Dusty Miller in her 1994 book, Women Who Hurt Themselves. Miller proposes that women, in general, have been socialized to internalize anger, pain and aggression, whereas men have been taught t o express it outwardly. "Men act out. Women act out by acting in" (p. 6). According to Miller, some women with a history of severe abuse who feel unable to express inner rage become trapped in a cycle in which they continuously reenact what happened to them as children by inflicting harm on themselves. She calls this Trauma Reenactment Syndrome (TRS). Miller identifies four central characteristics that distinguish the TRS woman from other chronic self mutilators: 1) the sense of being at war with one's own body, 2) excessive secrecy as a central organizing principle of life, 3) inability to protect ones' self from becoming involved in other abusive or dangerous situations, and 4) relationships in which the struggle for control overshadows all else. These women harm their bodies in a variety of ways which include drinking, drug use, excessive dieting, and cosmetic surgery as well as the more commonly known forms of self-injury such as cutting and burni ng. They exhibit excessive secrecy about all aspects of their lives, struggle constantly to feel in control of their lives and their bodies, and yet, seem unable to control their environments enough to avoid becoming involved in dangerous situations. Mi ller's theory received widespread praise from the public, but has not yet been supported by other mental health professionals or incorporated into the literature about self mutilation.

Another sociological explanation involves the family anomie syndrome. In 1979, Wenz took the traditional sociological anomie articulated by Durkheim, and applied it to the family unit rather than the community. He found that adolescents who engaged in self-injurious behavior were much more likely to live in families characterized by high levels of normlessness and powerlessness. Wenz concluded that perhaps the confusion that arises over conflicting definitions of acceptable behavior combined with feelings of being out of control of ones' environment led the adolescents to engage in more self harming behavior than the control sample.

Other authors, who believe that women engage in self-mutilation much more than do men, have postulated sociological theories that emphasize the different socialization experiences of men and women. Instead of focusing on background factors that infl uence self-injury, these authors look at the cultural context in which men and women live. Heshusius (1980) explores how our society portrays women as less competent, less mentally healthy, and as lacking a personal identity separate from a man's. These cultural stereotypes are then internalized by women, which leads to more self-injury attempts among women than among men. Dusty Miller (1994) supports this approach to self-harm, as does Rosemary Barnes, the author of a 1985 study on women and self-inju ry conducted in a Toronto hospital. In conclusion, self-mutilaton has been called disgusting, mysterious, incomprehensable, and a host of other negative adjectives. Most people who do not self-mutilate abhor the thought of pain, and cannot imagine purposefully hurting oneself. While there are exceptions, the majority of our society sees self-mutilation as a very deviant behavior. Part of this negativity stems from the fact that self-muti lation is poorly understood. Human beings fear what they do not understand, be it homosexuality, mental illness, or self-mutilation. Therefore, most self-injurers feel very alone and unable to share their pain with others. Many wear long sleeves and pa nts at all times and are careful to cover their scars while in public. If they reveal the scars or explain the behavior, they risk rejection and social ostracism. When this does occur, it often leads to genuine suicide attempts. Nevertheless, most self- mutilators share the same goals as the rest of society. The desperate methods they employ are upsetting to those of us who try to achieve our goals in a more tranquil manner, but self mutilators seek what we all seek: an ordered life, spiritual peace, and a healthy mind in a healthy body.

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