ORIGINAL ARTICLE
Defining and Refining Self-Harm A Historical Perspective on Nonsuicidal Self-Injury Cara Angelotta, MD Abstract: Nonsuicidal self-injury (NSSI) is a newly proposed diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Some contemporary historiography dismisses NSSI as a fiction of modern psychiatry. Although the exact definition and psychological meaning attributed to self-harm has not been static over history, there is a clear thread that connects Western asylum psychiatrists' thinking about self-harm to the current standalone diagnostic category of NSSI. Nineteenth-century psychiatrists identified a clinically meaningful difference between self-harm with and without the intent to die, between self-injurers who were psychotic and those who were not, and between self-injurers who made a single, serious mutilation and those who repetitively self-injured without causing permanent bodily damage. These same distinctions are apparent in the definition of NSSI. Thus, NSSI is a formalization of long-held observations about a category of people who repetitively self-injure without suicidal intent. Key Words: Cutting, nonsuicidal self-injury, self-harm, psychiatric diagnosis, DSM (J Nerv Ment Dis 2015;203: 75–80)
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he poorly defined border between mental health and mental illness complicates psychiatric diagnosis. Despite the vulnerability of psychiatric diagnosis to prevailing social mores, psychiatrists have long recognized that it is still necessary. In 1900, George Savage, a British asylum psychiatrist, wrote, “Great difficulty is found in distinguishing the normal and the abnormal reaction of the individual to his circumstances, and hence also in arranging and classifying such reactions. Classification… is, and for the present must be, provisional, and meanwhile rest mainly upon consideration of custom and convenience” (Savage, 1900). Over time, psychiatrists have increasingly categorized psychiatric illnesses, splicing out disorder subtypes from broader categories in an effort to tailor treatments. The first standardized psychiatric nosology, The Statistical Manual for the Use of Institutions for the Insane, contained 22 categories of mental illness. Now, with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), in 2013, the diagnostic bible contains just more than 300 diagnostic categories (Hyman, 2007; Kawa and Giordano, 2012; Spiegel, 2005). Self-harm occupies the fuzzy border between normal and abnormal behavior, making it particularly difficult to categorize. The exact bounds of this border have shifted over time with changing cultural norms. Nonetheless, psychiatrists have slowly carved out self-harm into several specific subtypes since at least the mid-19th century. The classification challenge presented by repetitive, nonlethal self-harm is reflected in the numerous terms for it in the historical literature including self-mutilation, focal suicide, parasuicide, suicide gesture, wristDeWitt Wallace Institute for the History of Psychiatry and Department of Psychiatry, Cornell University New York Presbyterian Hospital, New York, NY. Send reprint requests to Cara Angelotta, MD, DeWitt Wallace Institute for the History of Psychiatry and Department of Psychiatry, Cornell University New York Presbyterian Hospital, 525 East 68th St, Box 140, New York, NY 10065. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20302–0075 DOI: 10.1097/NMD.0000000000000243
cutting syndrome, delicate self-cutting, deliberate self-harm, selfinjury, and self-injurious behavior. Currently, DSM-5 includes several types of repetitive, nonlethal self-injurious behavior: nonsuicidal selfinjury (NSSI), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and suicidal behavior disorder. In addition to these subtypes of self-harm, there are repetitive self-injurious behaviors that DSM-5 classifies as symptomatic of a more global disorder (e.g., head banging in autism). NSSI was included in the DSM for the first time with the publication of the fifth edition in 2013, in which it is listed as a condition for further study in the appendix (American Psychiatric Association [APA], 2013). According to the DSM-5 definition, NSSI can be diagnosed when, on at least 5 days during the course of a year, an individual has engaged in intentional self-inflicted damage to the surface of the body with the expectation that the injury will not lead to death. Typically, the intended purpose is to reduce a negative feeling state or to resolve an interpersonal difficulty. Often the behavior is associated with a sense of urgency and preoccupation followed by relief. Psychosis precludes a diagnosis of NSSI. This definition of NSSI distills what has been learned from many decades of Western psychiatric thought about the broader category of individuals who self-injure. A careful review of the history of the diagnostic category NSSI demonstrates a thread connecting early Western asylum psychiatrists' observations about individuals who repetitively self-injured to the current definition of NSSI. Early psychiatrists were interested in clarifying many of the same features of self-harm as psychiatrists today: suicidal intent, extent of injury, the absence or presence of psychosis, and frequency of injury. Precisely that early psychiatrists differentiated patients on the basis of the same symptoms and signs that cluster together in the modern NSSI diagnosis suggests that NSSI likely represents a historically persistent diagnostic phenomenon. It is not simply an invention of modern psychiatry. Review of the historical record will show that early observations laid the groundwork for formalization of the NSSI category.
CONTEMPORARY HISTORIOGRAPHY OF SELF-HARM Current literature on the history of self-harm comes from a wide range of academic disciplines, including the history of medicine, sociology, feminist theory, as well as psychiatric observation and research (Adler and Adler, 2011; Chaney, 2012; Favazza, 2009; Nock and Favazza, 2009; Shaffer and Jacobson, 2009; Strong, 1998; Walsh and Rosen, 1988). Most recently, Sander Gilman wrote about the history of self-harm (Gilman, 2012, 2013). He says that the existing literature falsely presents NSSI as a transhistorical category. “The idea that there is a standard empirically observable category with its own autonomous history is a fantasy of the present.” He argues that self-harm is a social construct that results from “moral panic” about how to define aberrant behavior that threatens societal norms. In his view, psychiatric diagnosis of NSSI is a means of social control by doctors. He writes “The line [between pathological and normal] in 2013 runs between cutting and piercing.” Here, Gilman suggests that the significant difference between ear piercing and wrist slashing is simply that one is deemed socially acceptable and the other is not.
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This argument neglects that many self-injurers, both historically and at present, report significant suffering and seek psychiatric help to find other ways to cope with psychic pain. The effect is to collapse all forms of self-harm, from tattooing and preventative mastectomy to self-castration and serious suicide attempt, into one category. The implication that separating out different forms of self-harm is a contemporary and unhelpful phenomenon is in stark contrast to the long history of clinical writing about self-harm, which differentiates subtypes of selfharm as early as the mid-19th century. I will argue that there is a clear thread that connects the current conception of NSSI to early asylum psychiatrists' observations about self-injurious behavior. NSSI did not appear out of nowhere. NSSI as a separate diagnosable illness evolved from a long history of mental health professionals attempting to understand how to help a subcategory of individuals who self-injure repetitively without the intent to die. A careful review of the literature shows that there is striking consistency between the self-injurious behavior of this subgroup and the contemporary definition of NSSI, rather than the radical difference Gilman claims. By tracing the evolution of the category of NSSI, we see that it is not a new entity but a carving out of a subtype of self-harm that has long been considered a uniquely troubling clinical problem.
HISTORICAL DEVELOPMENT OF THE NSSI CATEGORY The first description of self-harm as a clinical entity is often attributed to the 20th-century psychiatrist Karl Menninger (Adler and Adler, 2011; Muehlenkamp, 2005; Shaffer and Jacobson, 2009). However, self-harm without suicidal intent appeared in the psychiatric literature much earlier than Menninger's writing. The clinical difference between self-harm with and without suicidal intent was articulated frequently in the 19th-century clinical literature. Mid–19th-century asylum records included case reports of individuals with self-injurious behavior that clearly lacked suicidal intent (Chaney, 2012). Admission papers to Bethlem Royal Hospital asylum asked whether a patient was “disposed to suicide, or otherwise to self-injury” as early as 1844. This, as Sarah Chaney argues, implies separate but related categories of mental symptoms. She proposes that alienists in the later 19th century may have distinguished between self-harm with and without suicidal intent to protect both the asylum's reputation from accusations of medical neglect and to the protect the patient and family from the legal and religious ramifications of a suicide attempt, which was criminalized in midcentury Britain. Medical trainees at the time were taught to make the distinction between self-harm with and without suicidal intent. For example, G. Fielding Blandford, MD, in lectures delivered at the School of St. George's Hospital and published in 1871, differentiated between “those who try in every way to put an end to themselves” and those who “will damage or mutilate … part of their bodies” (Blandford, 1871). The distinction was widely held to be an important component of a thorough psychiatric evaluation. In a three-part 1880 series on how to write a proper medical certificate of insanity for asylum admission published, T. N. Brushfield, a British asylum superintendent, proposed that all certificates should indicate “whether dangerous to self—from non-suicidal motives, or from suicidal motives” (Brushfield, 1880). He said that it is a mistake to classify nonsuicidal acts as suicidal, “These acts [without suicidal motive] are generally termed suicidal in certificates of insanity, but the difference between the two is a very wide one.” Brushfield gives the example of a woman who developed depression with auditory hallucinations after her child died, saying that the voices told her to cut off her hands because the bible says “it was better to lose the left hand or the right eye than be cast into hell.” This woman was documented to be suicidal in the medical certificate because she cut off her left hand at the wrist, “but her motive for doing this was a non-suicidal one.” Distinguishing self-harm based on suicidal intent was not isolated to psychiatrists. George Gould and Walter Pyle, both American ophthalmologists, published a book in 1896 on medical curiosities that 76
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included a chapter on self-mutilation. They divided cases of selfmutilation into three categories: those inflicted “in a moment of temporary insanity from hallucinations or melancholia; with suicidal intent; and in a religious frenzy or emotion” (Gould and Pyle, 1896). Here again, distinguishing between self-harm with intent to die and without intent to die implies that physicians viewed these as separate but related subcategories of self-harm. Asylum psychiatrists also distinguished between nonsuicidal selfharm in insane individuals versus nonpsychotic individuals. James Adam, a Scottish asylum superintendent, wrote about cases of self-harm motivated by delusion or auditory hallucinations compared with cases in which no psychotic symptoms were present (Adam, 1883, 1892). He notes that nonsuicidal self-harm may be the “direct result of hallucination or delusion affecting the special sense.” In an entry on “Self Mutilation” in A Dictionary of Psychological Medicine published in 1892, Adam shares multiple case examples of self-harm in psychotic individuals, including the story of a 45-year-old woman admitted to Crichton Royal Institution in October 1875. The patient “hears voices commanding her to do the [self-mutilation] act” and “if her hands were allowed to be free for one moment, she would gouge out her eyes with her fingers, pull out her tongue, or do something else equally dreadful.” He contrasts cases of self-mutilation motivated by delusion or hallucination with cases of self-mutilation “compatible with reputed sanity.” His examples in noninsane individuals were of people who self-injured but blamed either others or medical illness. Much like Adam, and in a surprisingly contemporary-sounding observation, Savage, the British alienist, delineated a murky continuum between sane and insane. He wrote, “there are very many persons who are of unsound mind but who have no right to be treated as lunatics… Sanity after all is only a relative term” (Savage, 1906). Savage includes self-mutilators as a subtype of hysterical patients who inhabit this “borderland” between sane and insane. Borderland inhabitants include a girl who self-injured repetitively with pins and another who repetitively damaged the surface of her skin with liquor potassae, a caustic irritant. It is clear that 19th-century psychiatrists encountered cases of patients who self-injured with no evidence of psychotic symptoms. This is a defining feature of the modern NSSI construct, which precludes psychosis. Nineteenth-century psychiatrists also distinguished types of selfharm on the basis of the degree of physical injury and whether the injury was inflicted once or repetitively. Blandford thought that the degree of physical injury delineated between acts motivated by suicidal impulse or delusions from less concerning acts. He defined minor selfmutilations as face or hand picking, nail biting, and hair plucking, which “are common among nervous people who are not insane” (Blandford, 1871). In the 1892 dictionary entry on self-mutilation, Adam wrote, “In going round the wards of almost any asylum for the insane cases are continually encountered of what may be described as minor self-mutilations. A patient is met with here and there who inflicts severe punishment upon his own head or body with his clenched fists, causing extensive ecchymosis or even wounding. Another, again, in a maniacal or excited state, will cause self-injury or laceration by dashing himself against walls, or by throwing himself upon the ground. Some of these injuries are undoubtedly self-inflicted for supposed sin or other cause, but a large proportion of the minor mutilations, such as biting the nails into the quick, picking the skin of the face, or head, or hands, arms or body, with finger-nails, needles, pins, glass &c., into sores more or less extensive, are self-inflicted by patients in a state of dementia who do not reflect or reason upon what they are doing, and the mischievous propensities probably arise simply from nervous, fidgety, restless habits, generating a desire to be doing something, or possibly in some cases originating in an irritable state of the skin” (Adam, 1892). Peter Deas, the long-time medical superintendent of the Wonford House Hospital for the Insane at Exeter, also noted a clinically meaningful difference between serious and more minor self-harm. In an 1896 article on the use and limitations of mechanical restraint, he wrote, “I have had many cases of self-mutilation not distinctly suicidal, such as © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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exhibit habits of flesh-picking, biting the fingers, or biting other parts of the body, pulling out hair, or eating rubbish” (Deas, 1896). Henry Rayner, a British asylum psychiatrist, wrote in a 1900 textbook on diseases of women that self-mutilation even without suicidal intent can result in accidental death (Rayner, 1900). These examples show that early psychiatrists linked the degree of physical injury to the degree of mental impairment of the individual, with insane patients more likely to cause grave, permanent damage and neurotic patients more likely to cause minor, reversible damage. In addition to consistently identifying nonsuicidal self-harm as a clinical problem, 19th-century psychiatrists described the behavior pattern of repetitive, nonlethal self-injurious episodes. In 1878, Walter Channing, a psychiatrist at the New York State Asylum for Insane Criminals, published a detailed case report of Helen Miller, a 30-yearold German Jewish woman, imprisoned at Sing Sing for grand larceny (Channing, 1878). She “cut up” in order to be transferred to the asylum, where she resided for 3 years and cut repetitively, usually with windowpane glass or wood splinters. Each episode was set in motion by a depressed or angry feeling state, usually in the context of an interpersonal difficulty with staff or co-patients, which was then relieved by the act of self-harm. For example, in one episode, Miller “again became ‘discouraged’ to use her own word” and then “being enraged because she was refused opium, cut her arms to avenge her wrongs.” A few weeks later, she cut her forearms again when she felt that the staff and other patients were “down on her.” She was preoccupied with urges to cut, “struggling with all her might to control her actions… remissions would last only a short time to be succeeded by doubts, suspicion, jealousy of all about her, and final despondency.” Here, Channing describes Miller's behavioral pattern and motivation for self-harm, foreshadowing the same pattern found in the DSM-5 diagnosis of NSSI. Asylum psychiatrists proposed varied motives for self-harm. Some of the Royal Hospital Asylum psychiatrists equated self-harm with hysteria. For example, Edith Mary Ellen Blyth, a 30-year-old woman, was admitted to the asylum in 1893 when a doctor discovered that the “apparent skin disease” for which she had seen more than 20 doctors was actually self-inflicted. Blyth repeatedly cut herself with scissors then rubbed ammonia into the wounds, saying that she felt an “uncontrollable impulse” to do so. Her doctors considered her symptoms to be hysterical and manipulative, discharging her uncured after 8 months. There are several references among the Bethlem case reports to individuals who cut because they felt that bleeding relieved “pressure” or “distress” (Chaney, 2012). In 1892, Adam wrote, “some additional light may be thrown upon the obscurity which surrounds the whole subject [of self-harm], by an endeavour to trace some of the motives which have prompted to the commission of the acts at various periods of history, and under various religious conditions” (Adam, 1892). He goes on the catalogue cases of self-mutilation without suicidal intent, organized by various motives. Monastic flagellations exemplified “self-torture as an expiation for sin.” Another possible motive for self-harm was “remorse, self-hatred.” Here, Adam refers to the first-known written reference to repetitive self-harm (Favazza, 2009), the story of the Gadarene madman in the Gospel of Mark. This demon-possessed madman spent “night and day … in the mountains and in the tombs, crying out and cutting himself with stones.” For Adam, the madman's cutting represents “a blind rage against himself as the true author of his evil.” Citing the example of a Roman who burned himself to show that “no amount of pain could subdue his spirit,” Adam thought that an individual may engage in self-harm “simply to show endurance of pain and strength of will.” Malingering also motives self-harm “the convict, if opportunity serves him, will mutilate, or even dismember, himself to avoid the performance of his allotted task, or to excite sympathy.” Many of the Bethlem alienists' and Adam's motives for self-harm—attention, manipulation, and relief of psychic suffering—are also found in the contemporary NSSI definition.
Historical Perspective on Self-Harm
The first psychoanalytic case report of repetitive, nonlethal selfharm in a nonpsychotic individual was published in 1913 by L. E. Emerson, PhD (Emerson, 1913). The patient, Miss A, a 23-year-old factory worker who was sexually abused by her uncle, displayed a set of behaviors and symptoms parallel to the current criteria for NSSI. She began cutting intentionally after she discovered that it relieved a headache and a “queer feeling” when she accidentally cut herself with a bread knife during a “scuffle” with her cousin, who was attempting to sexually assault her. Miss A clarified that she had no intention of killing herself , saying, “I sneered at my reflection in the glass and said something about nobody caring if I killed myself, much less if I only cut myself, so I drew the razor slowly across my wrist, and made a deep cut.” Usually she cut to obtain relief from a depressed or otherwise negative feeling, reporting that “when I had cut my arm, the bad feelings went away.” Sometimes she cut to resolve an interpersonal difficulty, for example, describing an episode of cutting brought on by a fight with her mother. She also cut at times to induce a positive feeling, “all week I had been conscious of a feeling of lost… oh I felt so bitter… I would not stand it. I took the razor, I thought a moment, then I opened my waist and cut over the left breast as deeply as the razor would go in, and then I laughed.” She reported frequently thinking about self-harm and being preoccupied with the act before engaging in it, saying, “I had tried hard to control myself ” and “at last I could not stand it any longer….” Similar to Helen Miller more than 40 years earlier, Miss A's words describing her motivations for nonlethal cutting parallel the reasons listed in the DSM-5 diagnosis of NSSI. Her analyst proposed a layered psychoanalytic model for understanding Miss A's behavior. Emerson noted the “multiplicity of motives” inherent in her case, including an inability to “bear mental anguish” because of childhood “psycho-sexual traumas,” a “strong component of masochism” as evidenced by taking pleasure in pain, a sadistic identification with the aggressor, and “sexual relief through symbolical masturbation [i.e. cutting].” He thought that his analysis of these layered motives allowed the patient to consciously consider them and thus allowed her to “believe in her own capacity.” Emerson deemed his treatment a tentative success, stating that Miss A had not cut in 14 months. The early 20th-century psychoanalytic literature presented multiple potential motivations for self-harm (Emerson, 1913, 1914; Houston, 1934; Lewis, 1928). In 1928, Nolan Lewis, an American psychoanalyst, theorized that “the universal castration complex” (i.e., fear of castration or wish to have a penis) motivated self-harm, wherein other body parts may be substituted for the genital organs (Lewis, 1928). W. R. Houston, an American psychiatrist and analyst, wrote in 1934 about a “simple village girl” who for 2 years mutilated skin with caustic potash “in order to gain consideration from her family.” He went on to theorize that self-harm of this type represents “a triumph of the desire for consideration [from others] over the instinct to bodily well-being” (Houston, 1934). Menninger first wrote about what he termed interchangeably focal suicide or partial suicide in a 1933 essay for the International Journal of Psychoanalysis. Menninger was not the first to comment on this condition but rather joined an ongoing dialogue. He wrote, “For, just as neurotic symptoms may be localized, as in conversion hysteria, or generalized as in major hysteria, so self-destruction may be focalized or generalized” (Menninger, 1933). He clarified this concept further in a 1935 essay on self-mutilation, writing, “In self-mutilation the self-destructive tendencies familiar to us in many clinical manifestations are directed upon a part of the body” (Menninger, 1935). These articles served as the foundation for his widely read 1938 book, Man Against Himself, exploring suicide and self-harm (Menninger, 1938). Referencing a Freudian theory about the death instinct, Menninger argued that each of us has “strong propensities towards self-destruction” that are usually outweighed by a stronger will to live. Partial or chronic self-destruction occurs when self-destructive impulses, made up of self-punitive, aggressive, and erotic components, are “partially but not completely neutralized” by the “life-instinct.” Much like his predecessors, Menninger explicitly describes subtypes
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within the larger category of self-harm. In addition to actual suicide, he delineates three types of self-harm: chronic suicide (defined as asceticism, martyrdom, neurotic invalidism, alcohol addiction, antisocial behavior, and psychosis), focal suicide (defined as self-mutilations, malingering, polysurgery, purposive accident, impotence, and frigidity), and organic suicide (defined as organic medical illness). He theorized in cases of focal suicide, “the suicidal impulse may be concentrated upon a part as a substitute for the whole.” In Menninger's view, selfharm is a mechanism to preserve life by substituting a partial suicide for actual suicide. He viewed this as a crude attempt at self-help, “It is as if a bargain had been struck between the instinctive and the repressing forces, and the symptom produced as a compromise.” Although not the first to do so (Chaney, 2012; Channing, 1878; Emerson, 1913), Menninger most clearly articulated a theory that self-harm is a mechanism to diffuse emotional pain. At the same time as Menninger flushed out psychoanalytic theories of self-harm, psychiatrists began systematically studying the epidemiology of suicide and self-harm (Moore, 1937; Piker, 1938; Siewers and Eugene, 1943). In 1937, Merrill Moore, MD, published a report on 1147 cases of attempted suicide treated at Boston City Hospital between 1915 and 1936 (Moore, 1937). He noted, and later research confirmed, that women were more likely than men to attempt suicide but less likely to die because women tended to choose less lethal means (e.g., poisoning) than men (e.g., firearms, hanging). In 1950, Herbert Hendin, a psychiatrist at Bellevue Hospital in New York City, published an article comparing 100 attempted suicides with New York City Department of Health figures on completed suicides for the same year (Hendin, 1950). He distinguished these attempts on the basis of suicidal intent, noting that “not all of those who attempt suicide have the same ‘wish to die.’” Like the earlier literature, he found that women were more likely than men to attempt suicide but less likely to die. He also found that women were more likely to make attempts with minimal intent to die compared with men. Buoyed by emerging epidemiological data, psychiatrists confirmed long-held clinical wisdom that “those who attempt and those who commit suicide represent two different groups of people or, expressed in the language of epidemiology, two different populations which overlap” (Stengel, 1960). Psychiatrists then began to systematically study the epidemiology of self-injurious behavior without suicidal intent (Dorpat and Boswell, 1963; Phillips and Alkan, 1961). Through a series of independent studies of patients admitted to psychiatric hospitals, this process identified—some would argue, created (Millard, 2013)—an archetype of the typical “cutter” as young and female (Gilman, 2012, 2013; Strong, 1998). Psychiatrists Henry Grunebaum and Gerald Klerman wrote the first of these articles in 1967 about patients admitted to Massachusetts Mental Health Center (Grunebaum and Klerman, 1967). On the basis of their clinical experience, they identified the prototypical “wrist-slasher” as female and “generally young, attractive, intelligent, even talented, and on the surface socially adept… They appear ‘normal’ except when periodically overwhelmed by inner emotional tensions.” The authors describe a continuum of suicidal intent in wrist slashers from “bona fide suicidal attempt” on one end to “merely ‘scratching’” for attention or manipulation on the other. “Patients for whom wrist slashing is predominantly a means of tension release and self-mutilation” occupied the middle of the continuum. Other authors in the 1960s and 1970s described nearly identical prototypes of the typical cutter—young, female, and cutting with the goal of relief of inner turmoil (Graff and Mallin, 1967; Grunebaum and Klerman, 1967; McKerracher et al., 1968; Nelson and Grunebaum, 1971; Rosenthal et al., 1972). In addition to identifying a prototypical cutter, this literature described a model of the typical selfinjurious episode. The episode is triggered by an interpersonal disappointment that leads to an increasing feeling of tension, an intense urge to cut, and ultimately cutting, which effectively relieves the discomfort. Here, cutting is not destructive but rather an attempt to reduce suffering 78
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and elicit interpersonal engagement. This model echoes the descriptions of cutting episodes in early literature (Chaney, 2012; Channing, 1878; Emerson, 1913) and parallels the diagnostic description of NSSI in DSM-5. The literature that identified the prototypical cutter as young and female ignored male cutters (Graff and Mallin, 1967; Grunebaum and Klerman, 1967; McKerracher et al., 1968; Nelson and Grunebaum, 1971; Rosenthal et al., 1972). In a study of 21 “wrist slashers” admitted to the Institute of the Pennsylvania Hospital in 1964, the one male patient was excluded because the authors “felt he was atypical” (Graff and Mallin, 1967). In a 1972 study of patients with history of wrist cutting admitted to Mount Sinai Psychiatric Institute, 24 women were included but the 11 male patients with histories of cutting were excluded because “the findings were so different than those of the women” (Rosenthal et al., 1972). This exclusion of men was contested in at least one article published in 1971 by psychiatrist William Clendenin. He compared the characteristics of male wrist cutters with female wrist cutters identified from St. Louis police reports filed between 1968 and 1969. There were 65 total cutters, 40% of whom were men, asking, “Why is it that the literature has so ignored men?” (Clendenin and Murphy, 1971). The finding that 40% of wrist cutters were men was replicated in a 1970 study of wrist cutters admitted to the emergency department at Yale-New Haven Hospital (Weissman, 1975). A review of all published cases (that included individual-level data) of low-lethality, repetitive self-harm between 1960 and 1980 found that, of the 56 individual cases identified, 27 were men and 29 were women (Pattison and Kahan, 1983). However, some mid–20th-century epidemiological studies of cutting did find that this behavior was more frequent in women than men (Dorpat and Boswell, 1963; Phillips and Alkan, 1961). For example, a study of the demographic characteristics of “self-mutilators” in a New York state hospital found that, for every 1 man who self-injured, 2.81 women did (Phillips and Alkan, 1961). Part of the contemporary criticism (Gilman, 2012, 2013) of the clinical portrayal of NSSI is that it inaccurately portrays women as more likely to self-injure than men. However, it should be noted that DSM-5 makes no mention of sex in the diagnostic criteria for NSSI. Late–20th-century psychiatrists sought to refine and systemize the nomenclature of self-harm. The 1980 DSM-III mentions self-harm only as a possible symptom of borderline personality disorder. The behavior was first suggested as a separate diagnostic category that should be included in the DSM in 1983, when E. Mansell Pattison, a psychiatrist at the Medical College of Georgia, termed it deliberate self-harm syndrome (Pattison and Kahan, 1983). Pattison argued that deliberate self-harm syndrome should be included as a separate diagnosis because research showed no consistent association between self-harm and a specific personality disorder or axis I disorder. Marsha Linehan, PhD, the founder of dialectical behavioral therapy for borderline personality disorder, outlined the debate in a 1986 article, concluding that individuals who make serious suicide attempts and those who self-injure without the intent to die represent two separate but overlapping populations (Linehan, 1986). In 1987, Armando Favazza, a cultural psychiatrist, published the first edition of his book, Bodies Under Siege: Selfmutilation and Body Modification, outlining the long history of self-harm in its various forms (Favazza, 1996). He later defined selfmutilation as “the deliberate destruction or alteration of body tissue without conscious suicidal intent” (Favazza, 1989). In 1990, Favazza proposed that the term repetitive self-mutilation be included as an axis I disorder. He defined this as a syndrome of repetitive burning or cutting in response to psychological or environmental stress (Favazza and Rosenthal, 1990). Despite an ongoing debate in the clinical literature about how to classify self-harm, it was again included in the 1994 DSM-IVonly as a possible symptom of borderline personality disorder. Making a near-identical argument to Pattison, Jennifer Muehlenkamp suggested the term deliberate self-injury syndrome for inclusion in © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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DSM-5 in 2005 (Muehlenkamp, 2005). Furthering these arguments, David Shaffer, a psychiatrist at Columbia University, formally proposed that the term nonsuicidal self-injury be included as a DSM-5 disorder in 2009 (Shaffer and Jacobson, 2009). He argued, much as earlier psychiatrists did (Deas, 1896; Favazza, 1989; Menninger, 1938; Pattison and Kahan, 1983), that it is important to distinguish selfinjurious acts associated with suicidal intent from those without suicidal intent because the risk profile and treatment are different and that inconsistent terminology makes research difficult. This definition of NSSI is much more specific than other definitions of the same term, NSSI. For example, in the 2009 book Understanding Nonsuicidal Self-injury, Nock and Favazza define NSSI more broadly as “the direct, deliberate destruction of one's own body tissue in the absence of suicidal intent” (Nock and Favazza, 2009). This definition of NSSI includes many forms of selfharm from tattooing to self-enucleation and castration that DSM-5's definition explicitly excludes. Ultimately, NSSI, as Shaffer defined on the basis of review of published studies, was included in the appendix of DSM-5 as a condition for further study. Of note, DSM-5 includes another form of repetitive skin injury: excoriation (skin-picking) disorder, which is included in the larger diagnostic category of obsessive-compulsive disorders. Unlike the diagnostic criteria of NSSI, its definition does not include motive, intent, or mood. Instead, it is defined behaviorally by recurrent engagement in the self-injurious activity with repeated attempts to stop or decrease the behavior, leading to significant distress or impairment. In DSMIV-TR, skin-picking could fall under the rubric of impulse control disorder not otherwise specified or stereotypic movement disorder. DSM-5 is the first time skin-picking has been included as a stand-alone diagnostic category (APA, 2013; Grant et al., 2012; Stein et al., 2010). This disorder was first identified as “neurotic excoriation” by the dermatologist Erasmus Wilson in 1875 and was followed by many case reports in the early dermatology literature. H. G. Adamson, a British dermatologist, wrote about three cases in 1909. All were young women who repetitively induced superficial skin eruptions although denied that the injuries were self-inflicted. He attributed this behavior to neurotic individuals “anxious to attract sympathy” (Adamson, 1909). Some early dermatologists distinguished between two types of neurotic excoriation: “one produced in ‘hysterical’ young people without obvious reason… and the other in which great [skin] irritation was sought to be relieved by determined tearing with the nail” (Anonymous, 1910). Other dermatologists thought that the two classes of individuals who presented with self-induced skin eruptions were either “true malingers,” in which the artifact was produced consciously for the sake of gain or freedom from work, or hysterics, in which the individual was either “devoid of reason” or desired attention (Pernet, 1915). Despite the historical interest of dermatologists in the motive behind skin-picking, the DSM-5 criteria for excoriation (skin-picking) disorder does not address this explicitly. Contemporary clinical literature argues that negative affects can trigger skin-picking (much like negative affects are a trigger for NSSI) (Grant et al., 2012; Stein et al., 2010). Curiously, DSM-5 does not adequately address the considerable overlap between excoriation (skin-picking) disorder and NSSI.
CONCLUSIONS NSSI is not simply a modern social construction. Shifting boundaries around socially acceptable behavior do not negate the possibility of a core constellation of problematic symptoms across different cultures and times. That said, it is misguided to claim that NSSI describes a transhistorical illness. More simply, Western psychiatrists have contended with this uniquely troubling set of behaviors—namely, repetitive nonlethal self-harm—since at least the mid-19th century. The same set of behaviors described in the contemporary DSM-5 definition of NSSI can also be identified in clinical psychiatric literature from the mid-19th century. Over time, psychiatrists have used various terms for
Historical Perspective on Self-Harm
self-harm interchangeably, but careful review of the historical record demonstrates that early psychiatrists did not view all forms of self-harm as one in the same. Mid–19th-century alienists differentiated between types of self-harm, commenting on whether self-injurers were suicidal or psychotic, and noted the degree of self-harm and the frequency with which the individual self-injured. These observations confirm that these are clinically meaningful differences that laid the groundwork for the crystallization of the subcategory NSSI. These same distinctions are found in NSSI, which includes only minor or moderate self-injury inflicted without suicidal intent and in the absence of psychotic symptoms. The creation of the diagnostic criteria of NSSI does not imply that other forms of self-harm are not possible or problematic. However, it does imply that other forms of self-harm may require a different clinical approach. For example, enucleation in a person experiencing auditory hallucinations and religious delusions would be excluded from NSSI because it is a one-time act and suggestive of a psychotic disorder. Presenting NSSI as a social construct that is only a threat to society (and not the individual) misses the opportunity to acknowledge the very real suffering of many individuals who repetitively self-injure and seek help from mental health professionals. Presenting NSSI as a relative category that completely evaporates when exposed to the lens of social context is as misleading as presenting NSSI as an essential transhistorical category entirely uninfluenced by its historical context. This is a false dichotomy: social influences and historical changes are the inescapable contexts for both patients and historians, but these contexts can enhance and not erase an attempt to understand and delineate syndromes of individual psychic suffering.
ACKNOWLEDGMENTS The author thanks Dr Daria Colombo, MD, for her mentorship throughout this project and Dr George Makari, MD, for his instruction in the history of psychiatry and editorial comments on this paper.
DISCLOSURES The author declares no conflict of interest. REFERENCES Adam J (1883) Cases of self-mutilation by the insane. Br J Psychiatry. 29:213–219. Adam J (1892) Self-mutilation. In Tuke DH (Ed), A dictionary of psychological medicine (pp 1147–1152). London: J&A Churchill. Adamson HG (1909) Two cases of neurotic excoriation. Proc R Soc Med. 2:67–71. Adler P, Adler P (2011) The tender cut: Inside the hidden world of self-injury. New York: New York University Press. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: America Psychiatric Publishing. Anonymous (1910) Dermatologic section. Br J Dermatol. 22:13–26. Blandford GF (1871) Insanity and its treatment: Lectures on the treatment, medical and legal, of insane patients. Philadelphia: HC. Lea. Brushfield TN (1880) On medical certificates of insanity. Lancet. 638–641, 711–713, 830–832. Chaney S (2012) Anaesthetic bodies and the absence of feeling: Pain and selfmutilation in later nineteenth-century psychiatry. 19: Interdisciplinary Studies In The Long Nineteenth Century, 0(15). Accessed December 30, 2014 from http:// www.19.bbk.ac.uk/index.php/19/article/view/646. Channing W (1878) Case of Helen Miller: Self-mutilation—Tracheotomy. J Insanity. 34:368–378. Clendenin WW, Murphy GE (1971) Wrist cutting: New epidemiological findings. Arch Gen Psychiatry. 25:465–469.
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Defining and Refining Self-Harm A Historical Perspective on Nonsuicidal Self-Injury Cara Angelotta, MD Abstract: Nonsuicidal self-injury (NSSI) is a newly proposed diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Some contemporary historiography dismisses NSSI as a fiction of modern psychiatry. Although the exact definition and psychological meaning attributed to self-harm has not been static over history, there is a clear thread that connects Western asylum psychiatrists' thinking about self-harm to the current standalone diagnostic category of NSSI. Nineteenth-century psychiatrists identified a clinically meaningful difference between self-harm with and without the intent to die, between self-injurers who were psychotic and those who were not, and between self-injurers who made a single, serious mutilation and those who repetitively self-injured without causing permanent bodily damage. These same distinctions are apparent in the definition of NSSI. Thus, NSSI is a formalization of long-held observations about a category of people who repetitively self-injure without suicidal intent. Key Words: Cutting, nonsuicidal self-injury, self-harm, psychiatric diagnosis, DSM (J Nerv Ment Dis 2015;203: 75–80)
T
he poorly defined border between mental health and mental illness complicates psychiatric diagnosis. Despite the vulnerability of psychiatric diagnosis to prevailing social mores, psychiatrists have long recognized that it is still necessary. In 1900, George Savage, a British asylum psychiatrist, wrote, “Great difficulty is found in distinguishing the normal and the abnormal reaction of the individual to his circumstances, and hence also in arranging and classifying such reactions. Classification… is, and for the present must be, provisional, and meanwhile rest mainly upon consideration of custom and convenience” (Savage, 1900). Over time, psychiatrists have increasingly categorized psychiatric illnesses, splicing out disorder subtypes from broader categories in an effort to tailor treatments. The first standardized psychiatric nosology, The Statistical Manual for the Use of Institutions for the Insane, contained 22 categories of mental illness. Now, with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), in 2013, the diagnostic bible contains just more than 300 diagnostic categories (Hyman, 2007; Kawa and Giordano, 2012; Spiegel, 2005). Self-harm occupies the fuzzy border between normal and abnormal behavior, making it particularly difficult to categorize. The exact bounds of this border have shifted over time with changing cultural norms. Nonetheless, psychiatrists have slowly carved out self-harm into several specific subtypes since at least the mid-19th century. The classification challenge presented by repetitive, nonlethal self-harm is reflected in the numerous terms for it in the historical literature including self-mutilation, focal suicide, parasuicide, suicide gesture, wristDeWitt Wallace Institute for the History of Psychiatry and Department of Psychiatry, Cornell University New York Presbyterian Hospital, New York, NY. Send reprint requests to Cara Angelotta, MD, DeWitt Wallace Institute for the History of Psychiatry and Department of Psychiatry, Cornell University New York Presbyterian Hospital, 525 East 68th St, Box 140, New York, NY 10065. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20302–0075 DOI: 10.1097/NMD.0000000000000243
cutting syndrome, delicate self-cutting, deliberate self-harm, selfinjury, and self-injurious behavior. Currently, DSM-5 includes several types of repetitive, nonlethal self-injurious behavior: nonsuicidal selfinjury (NSSI), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and suicidal behavior disorder. In addition to these subtypes of self-harm, there are repetitive self-injurious behaviors that DSM-5 classifies as symptomatic of a more global disorder (e.g., head banging in autism). NSSI was included in the DSM for the first time with the publication of the fifth edition in 2013, in which it is listed as a condition for further study in the appendix (American Psychiatric Association [APA], 2013). According to the DSM-5 definition, NSSI can be diagnosed when, on at least 5 days during the course of a year, an individual has engaged in intentional self-inflicted damage to the surface of the body with the expectation that the injury will not lead to death. Typically, the intended purpose is to reduce a negative feeling state or to resolve an interpersonal difficulty. Often the behavior is associated with a sense of urgency and preoccupation followed by relief. Psychosis precludes a diagnosis of NSSI. This definition of NSSI distills what has been learned from many decades of Western psychiatric thought about the broader category of individuals who self-injure. A careful review of the history of the diagnostic category NSSI demonstrates a thread connecting early Western asylum psychiatrists' observations about individuals who repetitively self-injured to the current definition of NSSI. Early psychiatrists were interested in clarifying many of the same features of self-harm as psychiatrists today: suicidal intent, extent of injury, the absence or presence of psychosis, and frequency of injury. Precisely that early psychiatrists differentiated patients on the basis of the same symptoms and signs that cluster together in the modern NSSI diagnosis suggests that NSSI likely represents a historically persistent diagnostic phenomenon. It is not simply an invention of modern psychiatry. Review of the historical record will show that early observations laid the groundwork for formalization of the NSSI category.
CONTEMPORARY HISTORIOGRAPHY OF SELF-HARM Current literature on the history of self-harm comes from a wide range of academic disciplines, including the history of medicine, sociology, feminist theory, as well as psychiatric observation and research (Adler and Adler, 2011; Chaney, 2012; Favazza, 2009; Nock and Favazza, 2009; Shaffer and Jacobson, 2009; Strong, 1998; Walsh and Rosen, 1988). Most recently, Sander Gilman wrote about the history of self-harm (Gilman, 2012, 2013). He says that the existing literature falsely presents NSSI as a transhistorical category. “The idea that there is a standard empirically observable category with its own autonomous history is a fantasy of the present.” He argues that self-harm is a social construct that results from “moral panic” about how to define aberrant behavior that threatens societal norms. In his view, psychiatric diagnosis of NSSI is a means of social control by doctors. He writes “The line [between pathological and normal] in 2013 runs between cutting and piercing.” Here, Gilman suggests that the significant difference between ear piercing and wrist slashing is simply that one is deemed socially acceptable and the other is not.
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This argument neglects that many self-injurers, both historically and at present, report significant suffering and seek psychiatric help to find other ways to cope with psychic pain. The effect is to collapse all forms of self-harm, from tattooing and preventative mastectomy to self-castration and serious suicide attempt, into one category. The implication that separating out different forms of self-harm is a contemporary and unhelpful phenomenon is in stark contrast to the long history of clinical writing about self-harm, which differentiates subtypes of selfharm as early as the mid-19th century. I will argue that there is a clear thread that connects the current conception of NSSI to early asylum psychiatrists' observations about self-injurious behavior. NSSI did not appear out of nowhere. NSSI as a separate diagnosable illness evolved from a long history of mental health professionals attempting to understand how to help a subcategory of individuals who self-injure repetitively without the intent to die. A careful review of the literature shows that there is striking consistency between the self-injurious behavior of this subgroup and the contemporary definition of NSSI, rather than the radical difference Gilman claims. By tracing the evolution of the category of NSSI, we see that it is not a new entity but a carving out of a subtype of self-harm that has long been considered a uniquely troubling clinical problem.
HISTORICAL DEVELOPMENT OF THE NSSI CATEGORY The first description of self-harm as a clinical entity is often attributed to the 20th-century psychiatrist Karl Menninger (Adler and Adler, 2011; Muehlenkamp, 2005; Shaffer and Jacobson, 2009). However, self-harm without suicidal intent appeared in the psychiatric literature much earlier than Menninger's writing. The clinical difference between self-harm with and without suicidal intent was articulated frequently in the 19th-century clinical literature. Mid–19th-century asylum records included case reports of individuals with self-injurious behavior that clearly lacked suicidal intent (Chaney, 2012). Admission papers to Bethlem Royal Hospital asylum asked whether a patient was “disposed to suicide, or otherwise to self-injury” as early as 1844. This, as Sarah Chaney argues, implies separate but related categories of mental symptoms. She proposes that alienists in the later 19th century may have distinguished between self-harm with and without suicidal intent to protect both the asylum's reputation from accusations of medical neglect and to the protect the patient and family from the legal and religious ramifications of a suicide attempt, which was criminalized in midcentury Britain. Medical trainees at the time were taught to make the distinction between self-harm with and without suicidal intent. For example, G. Fielding Blandford, MD, in lectures delivered at the School of St. George's Hospital and published in 1871, differentiated between “those who try in every way to put an end to themselves” and those who “will damage or mutilate … part of their bodies” (Blandford, 1871). The distinction was widely held to be an important component of a thorough psychiatric evaluation. In a three-part 1880 series on how to write a proper medical certificate of insanity for asylum admission published, T. N. Brushfield, a British asylum superintendent, proposed that all certificates should indicate “whether dangerous to self—from non-suicidal motives, or from suicidal motives” (Brushfield, 1880). He said that it is a mistake to classify nonsuicidal acts as suicidal, “These acts [without suicidal motive] are generally termed suicidal in certificates of insanity, but the difference between the two is a very wide one.” Brushfield gives the example of a woman who developed depression with auditory hallucinations after her child died, saying that the voices told her to cut off her hands because the bible says “it was better to lose the left hand or the right eye than be cast into hell.” This woman was documented to be suicidal in the medical certificate because she cut off her left hand at the wrist, “but her motive for doing this was a non-suicidal one.” Distinguishing self-harm based on suicidal intent was not isolated to psychiatrists. George Gould and Walter Pyle, both American ophthalmologists, published a book in 1896 on medical curiosities that 76
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included a chapter on self-mutilation. They divided cases of selfmutilation into three categories: those inflicted “in a moment of temporary insanity from hallucinations or melancholia; with suicidal intent; and in a religious frenzy or emotion” (Gould and Pyle, 1896). Here again, distinguishing between self-harm with intent to die and without intent to die implies that physicians viewed these as separate but related subcategories of self-harm. Asylum psychiatrists also distinguished between nonsuicidal selfharm in insane individuals versus nonpsychotic individuals. James Adam, a Scottish asylum superintendent, wrote about cases of self-harm motivated by delusion or auditory hallucinations compared with cases in which no psychotic symptoms were present (Adam, 1883, 1892). He notes that nonsuicidal self-harm may be the “direct result of hallucination or delusion affecting the special sense.” In an entry on “Self Mutilation” in A Dictionary of Psychological Medicine published in 1892, Adam shares multiple case examples of self-harm in psychotic individuals, including the story of a 45-year-old woman admitted to Crichton Royal Institution in October 1875. The patient “hears voices commanding her to do the [self-mutilation] act” and “if her hands were allowed to be free for one moment, she would gouge out her eyes with her fingers, pull out her tongue, or do something else equally dreadful.” He contrasts cases of self-mutilation motivated by delusion or hallucination with cases of self-mutilation “compatible with reputed sanity.” His examples in noninsane individuals were of people who self-injured but blamed either others or medical illness. Much like Adam, and in a surprisingly contemporary-sounding observation, Savage, the British alienist, delineated a murky continuum between sane and insane. He wrote, “there are very many persons who are of unsound mind but who have no right to be treated as lunatics… Sanity after all is only a relative term” (Savage, 1906). Savage includes self-mutilators as a subtype of hysterical patients who inhabit this “borderland” between sane and insane. Borderland inhabitants include a girl who self-injured repetitively with pins and another who repetitively damaged the surface of her skin with liquor potassae, a caustic irritant. It is clear that 19th-century psychiatrists encountered cases of patients who self-injured with no evidence of psychotic symptoms. This is a defining feature of the modern NSSI construct, which precludes psychosis. Nineteenth-century psychiatrists also distinguished types of selfharm on the basis of the degree of physical injury and whether the injury was inflicted once or repetitively. Blandford thought that the degree of physical injury delineated between acts motivated by suicidal impulse or delusions from less concerning acts. He defined minor selfmutilations as face or hand picking, nail biting, and hair plucking, which “are common among nervous people who are not insane” (Blandford, 1871). In the 1892 dictionary entry on self-mutilation, Adam wrote, “In going round the wards of almost any asylum for the insane cases are continually encountered of what may be described as minor self-mutilations. A patient is met with here and there who inflicts severe punishment upon his own head or body with his clenched fists, causing extensive ecchymosis or even wounding. Another, again, in a maniacal or excited state, will cause self-injury or laceration by dashing himself against walls, or by throwing himself upon the ground. Some of these injuries are undoubtedly self-inflicted for supposed sin or other cause, but a large proportion of the minor mutilations, such as biting the nails into the quick, picking the skin of the face, or head, or hands, arms or body, with finger-nails, needles, pins, glass &c., into sores more or less extensive, are self-inflicted by patients in a state of dementia who do not reflect or reason upon what they are doing, and the mischievous propensities probably arise simply from nervous, fidgety, restless habits, generating a desire to be doing something, or possibly in some cases originating in an irritable state of the skin” (Adam, 1892). Peter Deas, the long-time medical superintendent of the Wonford House Hospital for the Insane at Exeter, also noted a clinically meaningful difference between serious and more minor self-harm. In an 1896 article on the use and limitations of mechanical restraint, he wrote, “I have had many cases of self-mutilation not distinctly suicidal, such as © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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exhibit habits of flesh-picking, biting the fingers, or biting other parts of the body, pulling out hair, or eating rubbish” (Deas, 1896). Henry Rayner, a British asylum psychiatrist, wrote in a 1900 textbook on diseases of women that self-mutilation even without suicidal intent can result in accidental death (Rayner, 1900). These examples show that early psychiatrists linked the degree of physical injury to the degree of mental impairment of the individual, with insane patients more likely to cause grave, permanent damage and neurotic patients more likely to cause minor, reversible damage. In addition to consistently identifying nonsuicidal self-harm as a clinical problem, 19th-century psychiatrists described the behavior pattern of repetitive, nonlethal self-injurious episodes. In 1878, Walter Channing, a psychiatrist at the New York State Asylum for Insane Criminals, published a detailed case report of Helen Miller, a 30-yearold German Jewish woman, imprisoned at Sing Sing for grand larceny (Channing, 1878). She “cut up” in order to be transferred to the asylum, where she resided for 3 years and cut repetitively, usually with windowpane glass or wood splinters. Each episode was set in motion by a depressed or angry feeling state, usually in the context of an interpersonal difficulty with staff or co-patients, which was then relieved by the act of self-harm. For example, in one episode, Miller “again became ‘discouraged’ to use her own word” and then “being enraged because she was refused opium, cut her arms to avenge her wrongs.” A few weeks later, she cut her forearms again when she felt that the staff and other patients were “down on her.” She was preoccupied with urges to cut, “struggling with all her might to control her actions… remissions would last only a short time to be succeeded by doubts, suspicion, jealousy of all about her, and final despondency.” Here, Channing describes Miller's behavioral pattern and motivation for self-harm, foreshadowing the same pattern found in the DSM-5 diagnosis of NSSI. Asylum psychiatrists proposed varied motives for self-harm. Some of the Royal Hospital Asylum psychiatrists equated self-harm with hysteria. For example, Edith Mary Ellen Blyth, a 30-year-old woman, was admitted to the asylum in 1893 when a doctor discovered that the “apparent skin disease” for which she had seen more than 20 doctors was actually self-inflicted. Blyth repeatedly cut herself with scissors then rubbed ammonia into the wounds, saying that she felt an “uncontrollable impulse” to do so. Her doctors considered her symptoms to be hysterical and manipulative, discharging her uncured after 8 months. There are several references among the Bethlem case reports to individuals who cut because they felt that bleeding relieved “pressure” or “distress” (Chaney, 2012). In 1892, Adam wrote, “some additional light may be thrown upon the obscurity which surrounds the whole subject [of self-harm], by an endeavour to trace some of the motives which have prompted to the commission of the acts at various periods of history, and under various religious conditions” (Adam, 1892). He goes on the catalogue cases of self-mutilation without suicidal intent, organized by various motives. Monastic flagellations exemplified “self-torture as an expiation for sin.” Another possible motive for self-harm was “remorse, self-hatred.” Here, Adam refers to the first-known written reference to repetitive self-harm (Favazza, 2009), the story of the Gadarene madman in the Gospel of Mark. This demon-possessed madman spent “night and day … in the mountains and in the tombs, crying out and cutting himself with stones.” For Adam, the madman's cutting represents “a blind rage against himself as the true author of his evil.” Citing the example of a Roman who burned himself to show that “no amount of pain could subdue his spirit,” Adam thought that an individual may engage in self-harm “simply to show endurance of pain and strength of will.” Malingering also motives self-harm “the convict, if opportunity serves him, will mutilate, or even dismember, himself to avoid the performance of his allotted task, or to excite sympathy.” Many of the Bethlem alienists' and Adam's motives for self-harm—attention, manipulation, and relief of psychic suffering—are also found in the contemporary NSSI definition.
Historical Perspective on Self-Harm
The first psychoanalytic case report of repetitive, nonlethal selfharm in a nonpsychotic individual was published in 1913 by L. E. Emerson, PhD (Emerson, 1913). The patient, Miss A, a 23-year-old factory worker who was sexually abused by her uncle, displayed a set of behaviors and symptoms parallel to the current criteria for NSSI. She began cutting intentionally after she discovered that it relieved a headache and a “queer feeling” when she accidentally cut herself with a bread knife during a “scuffle” with her cousin, who was attempting to sexually assault her. Miss A clarified that she had no intention of killing herself , saying, “I sneered at my reflection in the glass and said something about nobody caring if I killed myself, much less if I only cut myself, so I drew the razor slowly across my wrist, and made a deep cut.” Usually she cut to obtain relief from a depressed or otherwise negative feeling, reporting that “when I had cut my arm, the bad feelings went away.” Sometimes she cut to resolve an interpersonal difficulty, for example, describing an episode of cutting brought on by a fight with her mother. She also cut at times to induce a positive feeling, “all week I had been conscious of a feeling of lost… oh I felt so bitter… I would not stand it. I took the razor, I thought a moment, then I opened my waist and cut over the left breast as deeply as the razor would go in, and then I laughed.” She reported frequently thinking about self-harm and being preoccupied with the act before engaging in it, saying, “I had tried hard to control myself ” and “at last I could not stand it any longer….” Similar to Helen Miller more than 40 years earlier, Miss A's words describing her motivations for nonlethal cutting parallel the reasons listed in the DSM-5 diagnosis of NSSI. Her analyst proposed a layered psychoanalytic model for understanding Miss A's behavior. Emerson noted the “multiplicity of motives” inherent in her case, including an inability to “bear mental anguish” because of childhood “psycho-sexual traumas,” a “strong component of masochism” as evidenced by taking pleasure in pain, a sadistic identification with the aggressor, and “sexual relief through symbolical masturbation [i.e. cutting].” He thought that his analysis of these layered motives allowed the patient to consciously consider them and thus allowed her to “believe in her own capacity.” Emerson deemed his treatment a tentative success, stating that Miss A had not cut in 14 months. The early 20th-century psychoanalytic literature presented multiple potential motivations for self-harm (Emerson, 1913, 1914; Houston, 1934; Lewis, 1928). In 1928, Nolan Lewis, an American psychoanalyst, theorized that “the universal castration complex” (i.e., fear of castration or wish to have a penis) motivated self-harm, wherein other body parts may be substituted for the genital organs (Lewis, 1928). W. R. Houston, an American psychiatrist and analyst, wrote in 1934 about a “simple village girl” who for 2 years mutilated skin with caustic potash “in order to gain consideration from her family.” He went on to theorize that self-harm of this type represents “a triumph of the desire for consideration [from others] over the instinct to bodily well-being” (Houston, 1934). Menninger first wrote about what he termed interchangeably focal suicide or partial suicide in a 1933 essay for the International Journal of Psychoanalysis. Menninger was not the first to comment on this condition but rather joined an ongoing dialogue. He wrote, “For, just as neurotic symptoms may be localized, as in conversion hysteria, or generalized as in major hysteria, so self-destruction may be focalized or generalized” (Menninger, 1933). He clarified this concept further in a 1935 essay on self-mutilation, writing, “In self-mutilation the self-destructive tendencies familiar to us in many clinical manifestations are directed upon a part of the body” (Menninger, 1935). These articles served as the foundation for his widely read 1938 book, Man Against Himself, exploring suicide and self-harm (Menninger, 1938). Referencing a Freudian theory about the death instinct, Menninger argued that each of us has “strong propensities towards self-destruction” that are usually outweighed by a stronger will to live. Partial or chronic self-destruction occurs when self-destructive impulses, made up of self-punitive, aggressive, and erotic components, are “partially but not completely neutralized” by the “life-instinct.” Much like his predecessors, Menninger explicitly describes subtypes
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within the larger category of self-harm. In addition to actual suicide, he delineates three types of self-harm: chronic suicide (defined as asceticism, martyrdom, neurotic invalidism, alcohol addiction, antisocial behavior, and psychosis), focal suicide (defined as self-mutilations, malingering, polysurgery, purposive accident, impotence, and frigidity), and organic suicide (defined as organic medical illness). He theorized in cases of focal suicide, “the suicidal impulse may be concentrated upon a part as a substitute for the whole.” In Menninger's view, selfharm is a mechanism to preserve life by substituting a partial suicide for actual suicide. He viewed this as a crude attempt at self-help, “It is as if a bargain had been struck between the instinctive and the repressing forces, and the symptom produced as a compromise.” Although not the first to do so (Chaney, 2012; Channing, 1878; Emerson, 1913), Menninger most clearly articulated a theory that self-harm is a mechanism to diffuse emotional pain. At the same time as Menninger flushed out psychoanalytic theories of self-harm, psychiatrists began systematically studying the epidemiology of suicide and self-harm (Moore, 1937; Piker, 1938; Siewers and Eugene, 1943). In 1937, Merrill Moore, MD, published a report on 1147 cases of attempted suicide treated at Boston City Hospital between 1915 and 1936 (Moore, 1937). He noted, and later research confirmed, that women were more likely than men to attempt suicide but less likely to die because women tended to choose less lethal means (e.g., poisoning) than men (e.g., firearms, hanging). In 1950, Herbert Hendin, a psychiatrist at Bellevue Hospital in New York City, published an article comparing 100 attempted suicides with New York City Department of Health figures on completed suicides for the same year (Hendin, 1950). He distinguished these attempts on the basis of suicidal intent, noting that “not all of those who attempt suicide have the same ‘wish to die.’” Like the earlier literature, he found that women were more likely than men to attempt suicide but less likely to die. He also found that women were more likely to make attempts with minimal intent to die compared with men. Buoyed by emerging epidemiological data, psychiatrists confirmed long-held clinical wisdom that “those who attempt and those who commit suicide represent two different groups of people or, expressed in the language of epidemiology, two different populations which overlap” (Stengel, 1960). Psychiatrists then began to systematically study the epidemiology of self-injurious behavior without suicidal intent (Dorpat and Boswell, 1963; Phillips and Alkan, 1961). Through a series of independent studies of patients admitted to psychiatric hospitals, this process identified—some would argue, created (Millard, 2013)—an archetype of the typical “cutter” as young and female (Gilman, 2012, 2013; Strong, 1998). Psychiatrists Henry Grunebaum and Gerald Klerman wrote the first of these articles in 1967 about patients admitted to Massachusetts Mental Health Center (Grunebaum and Klerman, 1967). On the basis of their clinical experience, they identified the prototypical “wrist-slasher” as female and “generally young, attractive, intelligent, even talented, and on the surface socially adept… They appear ‘normal’ except when periodically overwhelmed by inner emotional tensions.” The authors describe a continuum of suicidal intent in wrist slashers from “bona fide suicidal attempt” on one end to “merely ‘scratching’” for attention or manipulation on the other. “Patients for whom wrist slashing is predominantly a means of tension release and self-mutilation” occupied the middle of the continuum. Other authors in the 1960s and 1970s described nearly identical prototypes of the typical cutter—young, female, and cutting with the goal of relief of inner turmoil (Graff and Mallin, 1967; Grunebaum and Klerman, 1967; McKerracher et al., 1968; Nelson and Grunebaum, 1971; Rosenthal et al., 1972). In addition to identifying a prototypical cutter, this literature described a model of the typical selfinjurious episode. The episode is triggered by an interpersonal disappointment that leads to an increasing feeling of tension, an intense urge to cut, and ultimately cutting, which effectively relieves the discomfort. Here, cutting is not destructive but rather an attempt to reduce suffering 78
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and elicit interpersonal engagement. This model echoes the descriptions of cutting episodes in early literature (Chaney, 2012; Channing, 1878; Emerson, 1913) and parallels the diagnostic description of NSSI in DSM-5. The literature that identified the prototypical cutter as young and female ignored male cutters (Graff and Mallin, 1967; Grunebaum and Klerman, 1967; McKerracher et al., 1968; Nelson and Grunebaum, 1971; Rosenthal et al., 1972). In a study of 21 “wrist slashers” admitted to the Institute of the Pennsylvania Hospital in 1964, the one male patient was excluded because the authors “felt he was atypical” (Graff and Mallin, 1967). In a 1972 study of patients with history of wrist cutting admitted to Mount Sinai Psychiatric Institute, 24 women were included but the 11 male patients with histories of cutting were excluded because “the findings were so different than those of the women” (Rosenthal et al., 1972). This exclusion of men was contested in at least one article published in 1971 by psychiatrist William Clendenin. He compared the characteristics of male wrist cutters with female wrist cutters identified from St. Louis police reports filed between 1968 and 1969. There were 65 total cutters, 40% of whom were men, asking, “Why is it that the literature has so ignored men?” (Clendenin and Murphy, 1971). The finding that 40% of wrist cutters were men was replicated in a 1970 study of wrist cutters admitted to the emergency department at Yale-New Haven Hospital (Weissman, 1975). A review of all published cases (that included individual-level data) of low-lethality, repetitive self-harm between 1960 and 1980 found that, of the 56 individual cases identified, 27 were men and 29 were women (Pattison and Kahan, 1983). However, some mid–20th-century epidemiological studies of cutting did find that this behavior was more frequent in women than men (Dorpat and Boswell, 1963; Phillips and Alkan, 1961). For example, a study of the demographic characteristics of “self-mutilators” in a New York state hospital found that, for every 1 man who self-injured, 2.81 women did (Phillips and Alkan, 1961). Part of the contemporary criticism (Gilman, 2012, 2013) of the clinical portrayal of NSSI is that it inaccurately portrays women as more likely to self-injure than men. However, it should be noted that DSM-5 makes no mention of sex in the diagnostic criteria for NSSI. Late–20th-century psychiatrists sought to refine and systemize the nomenclature of self-harm. The 1980 DSM-III mentions self-harm only as a possible symptom of borderline personality disorder. The behavior was first suggested as a separate diagnostic category that should be included in the DSM in 1983, when E. Mansell Pattison, a psychiatrist at the Medical College of Georgia, termed it deliberate self-harm syndrome (Pattison and Kahan, 1983). Pattison argued that deliberate self-harm syndrome should be included as a separate diagnosis because research showed no consistent association between self-harm and a specific personality disorder or axis I disorder. Marsha Linehan, PhD, the founder of dialectical behavioral therapy for borderline personality disorder, outlined the debate in a 1986 article, concluding that individuals who make serious suicide attempts and those who self-injure without the intent to die represent two separate but overlapping populations (Linehan, 1986). In 1987, Armando Favazza, a cultural psychiatrist, published the first edition of his book, Bodies Under Siege: Selfmutilation and Body Modification, outlining the long history of self-harm in its various forms (Favazza, 1996). He later defined selfmutilation as “the deliberate destruction or alteration of body tissue without conscious suicidal intent” (Favazza, 1989). In 1990, Favazza proposed that the term repetitive self-mutilation be included as an axis I disorder. He defined this as a syndrome of repetitive burning or cutting in response to psychological or environmental stress (Favazza and Rosenthal, 1990). Despite an ongoing debate in the clinical literature about how to classify self-harm, it was again included in the 1994 DSM-IVonly as a possible symptom of borderline personality disorder. Making a near-identical argument to Pattison, Jennifer Muehlenkamp suggested the term deliberate self-injury syndrome for inclusion in © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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DSM-5 in 2005 (Muehlenkamp, 2005). Furthering these arguments, David Shaffer, a psychiatrist at Columbia University, formally proposed that the term nonsuicidal self-injury be included as a DSM-5 disorder in 2009 (Shaffer and Jacobson, 2009). He argued, much as earlier psychiatrists did (Deas, 1896; Favazza, 1989; Menninger, 1938; Pattison and Kahan, 1983), that it is important to distinguish selfinjurious acts associated with suicidal intent from those without suicidal intent because the risk profile and treatment are different and that inconsistent terminology makes research difficult. This definition of NSSI is much more specific than other definitions of the same term, NSSI. For example, in the 2009 book Understanding Nonsuicidal Self-injury, Nock and Favazza define NSSI more broadly as “the direct, deliberate destruction of one's own body tissue in the absence of suicidal intent” (Nock and Favazza, 2009). This definition of NSSI includes many forms of selfharm from tattooing to self-enucleation and castration that DSM-5's definition explicitly excludes. Ultimately, NSSI, as Shaffer defined on the basis of review of published studies, was included in the appendix of DSM-5 as a condition for further study. Of note, DSM-5 includes another form of repetitive skin injury: excoriation (skin-picking) disorder, which is included in the larger diagnostic category of obsessive-compulsive disorders. Unlike the diagnostic criteria of NSSI, its definition does not include motive, intent, or mood. Instead, it is defined behaviorally by recurrent engagement in the self-injurious activity with repeated attempts to stop or decrease the behavior, leading to significant distress or impairment. In DSMIV-TR, skin-picking could fall under the rubric of impulse control disorder not otherwise specified or stereotypic movement disorder. DSM-5 is the first time skin-picking has been included as a stand-alone diagnostic category (APA, 2013; Grant et al., 2012; Stein et al., 2010). This disorder was first identified as “neurotic excoriation” by the dermatologist Erasmus Wilson in 1875 and was followed by many case reports in the early dermatology literature. H. G. Adamson, a British dermatologist, wrote about three cases in 1909. All were young women who repetitively induced superficial skin eruptions although denied that the injuries were self-inflicted. He attributed this behavior to neurotic individuals “anxious to attract sympathy” (Adamson, 1909). Some early dermatologists distinguished between two types of neurotic excoriation: “one produced in ‘hysterical’ young people without obvious reason… and the other in which great [skin] irritation was sought to be relieved by determined tearing with the nail” (Anonymous, 1910). Other dermatologists thought that the two classes of individuals who presented with self-induced skin eruptions were either “true malingers,” in which the artifact was produced consciously for the sake of gain or freedom from work, or hysterics, in which the individual was either “devoid of reason” or desired attention (Pernet, 1915). Despite the historical interest of dermatologists in the motive behind skin-picking, the DSM-5 criteria for excoriation (skin-picking) disorder does not address this explicitly. Contemporary clinical literature argues that negative affects can trigger skin-picking (much like negative affects are a trigger for NSSI) (Grant et al., 2012; Stein et al., 2010). Curiously, DSM-5 does not adequately address the considerable overlap between excoriation (skin-picking) disorder and NSSI.
CONCLUSIONS NSSI is not simply a modern social construction. Shifting boundaries around socially acceptable behavior do not negate the possibility of a core constellation of problematic symptoms across different cultures and times. That said, it is misguided to claim that NSSI describes a transhistorical illness. More simply, Western psychiatrists have contended with this uniquely troubling set of behaviors—namely, repetitive nonlethal self-harm—since at least the mid-19th century. The same set of behaviors described in the contemporary DSM-5 definition of NSSI can also be identified in clinical psychiatric literature from the mid-19th century. Over time, psychiatrists have used various terms for
Historical Perspective on Self-Harm
self-harm interchangeably, but careful review of the historical record demonstrates that early psychiatrists did not view all forms of self-harm as one in the same. Mid–19th-century alienists differentiated between types of self-harm, commenting on whether self-injurers were suicidal or psychotic, and noted the degree of self-harm and the frequency with which the individual self-injured. These observations confirm that these are clinically meaningful differences that laid the groundwork for the crystallization of the subcategory NSSI. These same distinctions are found in NSSI, which includes only minor or moderate self-injury inflicted without suicidal intent and in the absence of psychotic symptoms. The creation of the diagnostic criteria of NSSI does not imply that other forms of self-harm are not possible or problematic. However, it does imply that other forms of self-harm may require a different clinical approach. For example, enucleation in a person experiencing auditory hallucinations and religious delusions would be excluded from NSSI because it is a one-time act and suggestive of a psychotic disorder. Presenting NSSI as a social construct that is only a threat to society (and not the individual) misses the opportunity to acknowledge the very real suffering of many individuals who repetitively self-injure and seek help from mental health professionals. Presenting NSSI as a relative category that completely evaporates when exposed to the lens of social context is as misleading as presenting NSSI as an essential transhistorical category entirely uninfluenced by its historical context. This is a false dichotomy: social influences and historical changes are the inescapable contexts for both patients and historians, but these contexts can enhance and not erase an attempt to understand and delineate syndromes of individual psychic suffering.
ACKNOWLEDGMENTS The author thanks Dr Daria Colombo, MD, for her mentorship throughout this project and Dr George Makari, MD, for his instruction in the history of psychiatry and editorial comments on this paper.
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