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Hayley: The emotional pain that comes with mental health disorders and addiction can sometimes be too much to bare. Unfortunately, sometimes individuals turn to self-injury in an attempt to regulate their emotions. My name is Hayley, and on today’s episode of Straight Talk With The Doc addiction medicine specialist, Dr. Bhatt, is going to explain why someone would hurt themselves and how self-harm and addiction may be linked. There are varying levels of self-harm, from minor to major injuries, but it may be more common than many people think. Dr. Bhatt, statistics from one study I came across stated that about 17% of all people will harm themselves at some point. How often do you actually see this in your field?
Dr. Bhatt: Well, statistically, the ranges have been depending on what articles you cite or research you cite, it’s between 15 and 20% prevalence around the world. In our field, due to the fact that addiction and mental health are risk factors for somebody to harm themselves, we do see that quite a bit. I see it probably in anywhere from 20-40% of individuals that we are brought in to evaluate for potential self-injury or suicidal ideation. But, it’s common. It’s pretty consistent with the numbers that we see and it’s probably about up to a quarter of the population that I see in treatment.
Hayley: And what are these people doing, what is the most common method of self-harm?
Dr. Bhatt: A lot of times we do see in younger populations, that’s where we see it start, cutting is often a common methodology. When it’s mixed with somebody who suffers with substance abuse it can vary, because there are symptoms of certain substances that lead to physical sensations that often co-exist with the non-suicidal self-injuries and behaviors that might be coming from their mental illness. For example, somebody who might be cutting or picking at their skin due to obsessive or compulsive thoughts and behaviors who might also be using Methamphetamines or Cocaine. Unfortunately, Methamphetamines and Cocaine can also lead to somebody having sensations of crawling on their skin that further negatively reinforces them skin picking. But cutting, issues with skin- skin mutilation, burning, that’s often the more common things that we come across.
Hayley: So, what kind of relief does this provide for those who are self-harming?
Dr. Bhatt: Well, really there’s a lot of theories I would say- use that term, that people have researched as to why somebody would deliberately hurt themselves. We have to look at and distinguish the intent that helps classify: was it a suicide attempt, was the intent of anybody’s self-harm to actually die, or is it for non-suicidal self-injury behaviors for some other reason? And I think what you’re asking is, what’s those other reasons? And those have been explored but they really haven’t been mastered. But some of the theories that I have come across are that oftentimes, people do self-injure without the intent to commit suicide due to relief, trying to relieve themselves from certain types of pain. Some hypotheses exist that when you cut yourself or harm yourself there’s potentially this internal release of what we call endogenous endorphins, your own natural Opioids that are released that can cause someone to feel a sense of euphoria or relief and that will alter or regulate some emotions. Sometimes people cut or harm themselves actually to provide self-soothing and self-care. And that might sound somewhat paradoxical, right, when you’re cutting how are you caring for yourself? But that’s often when people who are so detached or dissociated that they feel only alive or focused on themselves once they actually harm themselves. Other things people might cut themselves for is to seek attention from others. We’re not saying that all people who cut themselves are doing it just for attention seeking, but that is often why people might harm themselves. So, those three plus there’s a multitude of other reasons, and intoxication is another. Sometimes people who are intoxicated become so dysregulated and we become so disinhibited that negative emotions will arise and lead us to feel self-loathing and poor self-esteem and disgust, and often we want to punish ourselves, and that often leads to people self-harming.
Hayley: And for the populations that are getting this relief, you even mentioned the word euphoria. Is it possible for them to be addicted to self-harm?
Dr. Bhatt: Yeah, that’s another whole potential disorder that’s still further being explored in psychiatric and behavioral sciences. But, there’s often this component of this almost obsessive ruminating thought that somebody needs to actually self-harm that creates a whole level of anxiety. It gets so pent up that until they actually harm themselves, they don’t get relief. And again, I want to clarify that a lot of this does not have to do with actually wanting to kill themselves or commit suicide, but it’s this negative relationship with themselves, with their mental health, and it creates a cycle and that can become somewhat addictive where people are very consumed with those obsessive thoughts, and until they actually self-injure, they don’t get that relief.
Hayley: Does self-injury always predict a future suicide attempt?
Dr. Bhatt: We have to be able to differentiate intent. Many people who have self-injury behaviors are not intending to actually die. But the risk factors for actual suicide attempts or previous suicide attempts, the presence or absence of a mental health disorder, often being single, unmarried, not having a good support system, substance abuse, those are all risk factors for future suicide. But I warn people that when they’re dealing or working with people who have a non-suicidal self-injury not to just assume because of their previous non-suicidal self-harm that they’re not going to potentially cross over into suicidal intended self-harm. So, we just have to keep cautious of that also. But usually, the things I mentioned earlier, those are risk factors for suicide attempts in the future.
Hayley: Dr. Bhatt, I’d like to talk about the association between self-injury and substance abuse. Can you talk about that a little bit?
Dr. Bhatt: Well, a common risk factor for both is the presence of mental health issues. Mental health issues- depression, anxiety, and other mental illnesses- are risk factors to develop addiction and substance use disorders. And it’s those people also who often have risk factors for self-injurious behaviors. In the adolescent population, 12, 13, 14, early teenage years, we often see the first attempt of people who may self-harm without the intent to necessarily commit suicide. But that often is a coping mechanism. It’s a coping mechanism for negative feelings- being bullied, developing depression, feeling isolated, feeling like they don’t fit in, often times leads to dysregulated emotions and sometimes cutting brings a sense of control and again, we discussed earlier the many theories of why people might self-harm, but again, it could bring them relief, it could bring them into a depersonalized detached state or state of mind. Often, the fact that somebody gets a reward, gets a relief, similar to when we use substances, so that whole cycle of introducing a behavior or a substance that relieves us from a negative situation kind of brings that association between self-injury and self-harm or negative behaviors and substance use. So, they are correlated. And if something leads to a reward, that actually plays into the same cycle that addiction does because addiction, dopamine, certain areas in the brain have common pathways and that develops a common behavioral relationship. And so, we see that in behavioral addictions, substance use addictions, and often these cutting behaviors or self-injurious behaviors can follow that same pathway.
Hayley: Okay, so they’re almost doing it for the same reason sometimes, looking for some sort of relief.
Dr. Bhatt: Yeah, definitely.
Hayley: And what typically comes first, drug and alcohol use or self-injury?
Dr. Bhatt: It really depends on the individual. We often will see in that specific population when we look at the research and the studies that are out there most people who self-injure are younger, they’re 12, 13, 14. We see that, and that’s when we’re talking about non-suicidal self-injury. So, that often predates any substance use at that time. But then when we get older, we see less prevalence of people who have non-suicidal self-injury. It’s less as we get into adulthood. But then when we talk about major types of self-injury, the actual possible suicide attempts, the major attempts of skin cutting or other bodily harm- amputations, that often happens when we’re intoxicated. And so, being under the influence of a substance may play a part in a different type of self-injury that might be more significant or severe. And for people who are suffering with depression or other types of mental health issues, it does get worsened when we’re using. So, that leads to that impulsive type of self-injury that unfortunately could be irreversible where we might take something or we might take a gun or take a number of pills, overdose and ultimately it does lead to death. So, it’s really fascinating to explore and to look at but it’s also something that as healthcare providers and loved ones or family members or people that are suffering from it, to make note of all of these things because although we have seen statistically maybe some of these self-injurious behaviors and suicidal behaviors maybe plateau out, it’s still a big problem in the United States and around the world.
Hayley: So, are you saying that someone is more likely to self-harm while under the influence of drugs or alcohol?
Dr. Bhatt: What I’m saying is when we see self-injury in an emergency setting, often alcohol or drugs play a part in up to 25-40% of these individuals. And then also people who have substance use disorders potentially have increased risk for suicide, so there is a significant association.
Hayley: If someone’s listening to this who could be a friend or a parent, what are some signs that somebody is self-harming?
Dr. Bhatt: A lot of times people do self-harm on their bodies- they start cutting on their thighs or their arms and they feel guilty about it. They don’t want to expose it, it’s shameful. So, you’ll start to see a lot of changes in the way that they wear their clothing. A lot of times people who might be walking around in shorts or t-shirts where their extremities are exposed are going to start wearing a lot of things covering them up. If you see a pattern where people just start to change their attire and there was some history of depression or whatever there, you want to investigate that and see if there is cause for concern. Sometimes you see items missing in people’s houses. As a childhood adolescent psychiatrist as well I’ve seen parents report that their knives or utensils went missing, and they’re often found in the child’s bedroom, and the child’s bedroom is where the child was cutting and hiding. When you see behavioral changes, things missing, changes in attire, or you see cuts, sequential things. It might not also get hidden. If you see cuts or skin marks that don’t appear to be easily explained you probably want to investigate there and tactfully question that person. Often people will get very defensive, it’s a very sensitive thing. Nobody’s often proud of hurting themselves or harming themselves and often that can lead to a really difficult response. But at the same time, as a parent especially, we’re talking about populations that are often very young, we need to look for that.
Hayley: And what treatment options are available for those who are struggling with self-harm, a child or an adult?
Dr. Bhatt: There’s two main stays of treatment and that’s often therapy or medications. I’m of the mindset that we want to be conservative first in the sense that we want to try not to add medicine if we can do something without it. But at the same point, it really depends on the degree of the impairment and the underlying issues. If somebody’s cutting and it’s not really due to an underlying major mental health issue, there’s different types of cognitive and behavioral therapies that are out there that can assist in somebody to change their behaviors and develop healthier and adaptive coping mechanisms aside from that. Therapy is a main stay. But if there’s an underlying depression or anxiety or other mental health issue that needs other types of treatment and therapies not working, there are medications out there that can help and they address the primary underlying problem. If substance abuse is a part of it and somebody is only cutting or making suicidal threats or behaviors while under the influence or associated with substance use, getting that addiction or substance use problem addressed is another modality getting them to treatment, and so that’s important. I think the hallmark or take-home point from this is whatever associated or underlying problem is there to that negative behavior or that self-injurious behavior, it needs to be addressed first through therapies, medications, and rehabilitations.
Hayley: Dr. Bhatt, is there anything else on this topic that you think people should know?
Dr. Bhatt: It’s a difficult thing for people to talk about and it’s often hidden. Just becoming aware and having awareness of the fact that self-injury is not always equated to the intent of someone wanting to die. But at the same time, it’s not a healthy way to manage your emotions and there is help out there in the form of treatments- therapies, medications. And if it is associated with a substance use problem, getting into a licensed treatment center or going to a licensed practitioner to get help. But the point is, there is help out there to help you live a life without harming yourself and developing alternative helping mechanisms to get through difficult times and difficult feelings.
Hayley: Thank you for sharing that. If anyone that’s listening to this who is struggling with self-harm or know someone who is, don’t wait to reach out for help. There are treatment options available and professionals who can offer guidance. To learn more about mental health, addiction, and treatment options, you can go to AddictionCenter.com or you can check out more podcast episodes wherever you get your podcasts. Thanks for listening to this episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.
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