DELIBERATE SELF-HARM, PATTERNS

DELIBERATE SELF-HARM, PATTERNS 153

DELIBERATE SELF-HARM, PATTERNS

J Payne-James, Forensic Healthcare Services Ltd, London, UK

ß 2005, Elsevier Ltd. All Rights Reserved.

Introduction

Individuals may harm themselves in many ways and for many different reasons. These factors may them- selves be influenced by a variety of personal and cultural factors. In many cases, the method of self- harm is clear and unambiguous. An individual who survives an attempt at self-harm will generally be able to give an account as to the reasons for the attempt. In fatal self-harm, the circumstances may not clearly indicate self-harm and thus investigation will be required to determine the circumstances sur- rounding the death. The stigma associated with self- harm in some societies means that it is important to establish clearly whether suicide was intended. In some jurisdictions (e.g., England and Wales), a coro- ner will give a verdict of suicide only when strict criteria have been applied to the circumstances. A belief that a suicide attempt was intended may be a misinterpretation in other circumstances, e.g., auto- erotic asphyxia. An attempt at hiding criminal activ- ity may result in the staging of a death to look like suicide. It is thus clear that the investigation of puzzling or unusual deaths should be rigorous and extensive. This article will focus predominantly on the range of physical patterns of injury where the question of deliberate self-harm may be obscured, misinterpreted, or misleading.

Range of Self-Harm

In the living individual attempts at self-harm or self- multilation may indeed be deliberate acts, but can occasionally mask other activities. One example is the need to try and differentiate between injuries in torture cases, where it may be extremely difficult to determine whether an injury is self-inflicted or acci- dental by evaluating solely the distribution of trau- matic lesions or scars on the patient’s body. Table 1 gives further examples of the potential motives for self-harm, over and above an intent to commit suicide because of depression.

It is important to realize that patterns of delib- erate self-harm vary from country to country, from culture to culture and also depend on the occupation and characteristics of the self-harmer. Reviews of studies from around the world indicate variations in

incidence and methods of self-harm that may result in death or injury. In Oman, most cases involve females, students, or the unemployed, with a high incidence of family, marital, and psychiatric or social problems. The methods used most often are the use of analgesics (e.g., paracetamol) and nonpharmaceutical medica- tions. Self-burning is rare in Europe, but a study from Iran showed a high incidence, with an average age of 27 years, 83% of them being female. Most were married homemakers with high-school education; 62% had had an impulsive suicidal intention and the major motive was marital conflict. The mortality rate was 79%. A similar study on cases of self- inflicted burns in Australia showed the presence of schizophrenia, depression, and personality disor- der in 71%, with the majority of the remainder showing evidence of intoxication. These cases were divided into attempted suicides almost all of which involved males, and 60% had a major psychiatric illness, and ‘‘self mutilations,’’ where the self-harmers suffered much less serious burns and all survived. In the UK, a recent study found that self-harm in 15–16-year-old schoolchildren was more common in females than males (11.2% vs. 3.2%). For females, the factors associated with self-harm included: self- harm by friends, self-harm by family members, drug misuse, depression, anxiety, impulsivity, and low self- esteem. For males, the associated factors were suicidal behavior in friends and family members, drug use, and low self-esteem. Other diagnoses with strong links with potential for self-harm include bulimia (almost 25% reporting suicide attempts), and this increased to about 50% where there is a dual diagnosis of alcoholism. A recent review of the epidemiology of parasuicide (defined as suicide attempts and deliberate self-harm inflicted with no intent to die) from the USA showed an annual rate of parasuicide within the last three decades as ranging from 2.56 to 11 000 per 100 000 and lifetime prevalence rates ranging from 720 to

Table1 Examplesofreasonswhyindividualsmayself-harm

Psychiatric and associated disorders Malice (attempting to give the impression that the individual has

been assaulted by another) Allegationsofsexualassault To avoid work (prevented by the injury) To ‘‘reinforce’’ or ‘‘re-emphasize’’ an injury that already exists Attention-seeking behavior Insurance fraud Benefits fraud Factitious injury – to imply a medical problem (e.g., a slow-

healing skin ulcer)