What Makes People Cut Themselves?

Razor blades come in packs of ten or one hundred. You always buy the ten pack, because there's no way you'll need a hundred, you think. You're not going to be doing this that long. There's something in your chest, in your blood, that wants out, something you can feel itching for release. The tension is unbearable, or else you wouldn't be doing this. It's not like you're some kind of freak.

Razor blades are beautiful, in their way; there's a starkness to them, a simplicity of line and shape and function that is pleasing. You pick one from your box of ten, feel the weight of it in your hand. Maybe test the edge with your fingertip; a single drop of blood, the color and luminosity of a Burmese ruby, beads up, smears rust-colored across the steel.

You draw the razor blade across your skin, watching your flesh open up, watching all your pain and anxiety and frustration bleed out.

Crash course: Freud believed the human subconscious was broken into three parts: the ego, the superego, and the id.

The ego is "I"—it is the basic working unit of your waking mind. The superego is the imposition on the ego of all societal influence—everything your parents or your preacher ever told you about right and wrong lives in the superego. And the id is the ego's antagonist, the seat of all primal urges. When your mother tells you that you can't have any more candy (it'll rot your teeth), the id wants. That. Candy. When the police tell you that you have to stop for red lights, not to do so is a crime, the id has your foot itching to press down on the accelerator.

The id's desires are broken into two conflicting forces: Eros, the life force; and Thanatos, the death force. (Thanatos, like Eros, was a god in Greek and Roman mythology. Thanatos was the iron-hearted god of death, and generally a guy that no one wanted to party with.) The life force is what wants all those things that tend toward life (meaning, as you may suspect if you are even casually familiar with that horny old goat, Sigmund, sex). Eros is the desire for sex, for propagation, for babies. Thanatos, the death drive, is the opposite. Thanatos craves destruction.  In normal psyches, Thanatos is simply a counterbalance to Eros, and centers mostly on the human realization that all things, including themselves, will one day die. In abnormal psyches, like those of people who have undergone trauma or are plagued by mental illness, Thanatos takes on a life of its own.

Expressions of the death drive can take two forms: external or internal. External expressions of Thanatos involve harming others, or destroying things outside of one's self: murder, fire setting, etc. Internally-focused expressions of Thanatos involve things like suicide.

Suicide is the most dramatic form of self-destruction. Suicide rates are highest among patients with mood disorders; suicide rates among patients with bipolar disorder are 30 times higher than the national average, with as many as one in five patients suffering from bipolar disorder dying by their own hand.

Self-destruction is also evident in behaviors like habitual drug and alcohol use, and binging and purging behaviors in patients with eating disorders. Even with its staggering suicide rates, bipolar disorder is second in overall mortality rates among mental illnesses, falling behind eating disorders. Though the aim of anorexia is not to end one's life, death is often the outcome, with anorexics within certain populations more than 12 times as likely to die from their disease than from any other cause.

But drugs, alcohol, and starvation are slow forms of self-destruction. The keenest is a group of behaviors called self-injury, or SI.  SI is just what it sounds like: purposeful injury of the self. The most popular form of SI is cutting, although there are many other alternatives, from beating and burning to trichotillomania, in which patients compulsively pull out their own hair.

What does the typical self-injurer look like?  She is a woman in her twenties or thirties.  She has been self-injuring since she was a teenager, and she most likely has a history of physical or sexual abuse and/or suffers from an eating disorder, a mood disorder, or borderline personality disorder. She is smart and well-educated. She probably discovered SI spontaneously, and has a favorite method, though the Internet has, like the pro-ana movement, created a community in which she can learn to be a better self-injurer. She is probably very good at hiding it.

I am the typical self-injurer. I am twenty-five, and have been self-injuring since the eighth grade. I have bipolar disorder. I am in graduate school. I discovered SI on my own, like you discover sex: like it's something new and magical you can't believe no one had thought of before.

I am excellent at hiding it.

Though new studies suggest that as many as 70 percent of self-injurers mix and match their methods of SI, about a third of self-injurers, like bomb makers, find their special formula and stay with it. The three big ones are cutting, beating, and burning.

All of these behaviors have historical roots, some coming into vogue for a spell and then petering out. Others have endured for hundreds, sometimes thousands of years. Self-injury is maladaptive; it is listed in the DSM-V (the current edition of the American Psychiatric Association's encyclopedia of how people are crazy). But the DSM changes with the times.

For instance: until 1973 and the publication of the DSM-II, homosexuality was listed as a mental defect. Hysteria, a ladies' malady that's most common symptom was women getting feisty, and which resulted in many a 19th century woman sent to the nuthouse when she became hard for her husband to handle, was removed from the DSM-III in 1980. I am not advocating for self-injury as a treatment for anything, and especially not as a hobby.

I just wonder—as I often do—whether the things that make us "crazy" are just crazy because people tell us they are. Throughout history, what we've known as facts have changed again and again. In the 17th century, we knew that the sun orbited the Earth. Whoops. Alchemy used to be a science. So did phrenology. Those turned out to be duds, too.

Cutting is by far the most common form of self-injury. When cutters cut, they use a razor, knife, or other sharp object to deliberately break the skin anywhere on the body—it's usually done on the forearm opposite the dominant hand or on the thighs, places which are easy to reach without contorting oneself into exotic positions.

For many years, bloodletting was a popular medical procedure, used to treat everything from scurvy to syphilis. (Other medieval syphilis cures include: arsenic, taken orally, and mercury, applied to the, er, trouble areas.) Bloodletting has its roots in medieval times, when all ills were blamed on an imbalance of humors. (For those of you who did not attend medieval medical school, humors were substances that fought for balance in your body.)

In cutting, blood is half the point. Bleeding is so important to the process of cutting that, in treatment, cutters are urged, instead of cutting themselves, to draw red lines on themselves with marker. Many self-injurers report pleasure in seeing a physical change in their bodies, a change they caused, be it blood or bruises or burns.

Blunt trauma is another form of self-injury. The most common type of blunt trauma SI is wrist banging, in which the self-injurer repeatedly hits the head of the ulna (the large bone on the outside of the wrist) on a solid object. This can cause bruising and broken bones. There is also head banging, in which self-injurers hit their head into a wall or other solid surface. Other forms of blunt trauma include injurers hitting themselves with their fists or objects like wire hangers.

Self-flagellation is a religious act that has been practiced since the 13th century. Monks would beat themselves with whips and knotted cords, often while chanting about what a good guy this God who invented whips and knotted cords was. Originally started as homage to events during Christ's Passion, self-flagellation evolved into a movement in which penitents revered suffering as the only way to guarantee a clean soul and passage to heaven.

Ironically, a study by Russian scientists in 2005 suggests that being whipped curbs depression, suicidal thoughts and actions, and addiction. It cites corresponding release of endorphins (feel-good neurotransmitters) as the culprit. Part of the peripheral nervous system, which governs the flight or fight response, endorphins are released during pain and excitement but also during sex and love. (And while eating chocolate.) Part of the pleasurable sensation you feel while spending time with your loved one or after orgasm is from endorphins.

Burning is another popular form of self-injury. Burning is done in a variety of different ways: with matches, an open flame, a hot object, chemicals, etc. The first time I self-injured, I burned myself with a hot glue gun, letting the molten glue stick to my skin until it had hardened and cooled enough to be removed. Matches are a popular tool for burning; the matches are lit, and held to the skin to extinguish. This method is relatively safe in the world of burning; there's less chance of anything catching fire from ambient flame.

Branding is the act of purposefully leaving a permanent mark on the flesh via application of an extremely hot object. Human branding was practiced during the years of slavery; contemporarily it is used by some tribes as a rite of passage. Human branding has also found popularity in BDSM ("bondage, discipline, sadomasochism") communities. Here, both the brand itself and the act of branding are found pleasurable.

For people who have never had the urge to do it, self-injury seems, well, crazy. Most people have a death drive that merely serves to balance out their life force; most people are too interested in self-preservation to entertain the idea of hurting themselves on purpose. Yet thousands of people, many of them children, regularly practice these behaviors. There must be a reason why.

There are multiple reasons. The first has to do with control. Self-injurers feel out of control in their environment. They feel out of control in the wake of the mental illness that lives inside them.  (Anorexia, especially, is characterized by its desire for control, for perfection—there is a very high comorbidity between anorexia and self-harm behaviors.) Self-injurers cannot control the pain they feel on the inside, so they control the pain they feel on the outside by deliberately causing it.

It's also a distraction. SI becomes a ritual, and rituals are soothing, especially when they can put blinders on you to the stressors in your life.  SI becomes a little project, something you do so you're not spending time with your depression or your anxiety or your abusive household.

I spoke to a few self-injurers about their experiences under the condition of anonymity.  I will refer to them by their first initial. T, a domestic abuse survivor who battles anxiety and depression, self-injured for 11 years—her method was cutting.  She says, "Whenever I did it, it made me feel almost like I'd accomplished something, for a little while.  I'd be concentrating really hard on the SI, and then it'd be done and I could wrap it up. That feeling wouldn't last long, though. Usually when the bandage fell off and I saw the SI site again, I'd start having the itch to do it again."

And we cannot forget the endorphins, the stars of the Russian whipping study. Here's the math: Pain causes endorphins. Endorphins make you feel better, if only for a moment. Pain makes you feel better.

Self-injury is a coping strategy, but it's not a healthy coping strategy. How do self-injurers stop self-injuring?

Some self-injurers stop on their own. They either leave the situation that was causing them such stress in the first place, or they simply grow out of the behavior. T says, "When I stopped SIing, it wasn't for any particular reason. Possibly, I had a little more room in my life to just be depressed instead of anxious and depressed at the same time."

Others need help to stop.  There are therapies to counteract the urge to self-injury.  Drugs are usually the first line of defense, with SSRIs (a kind of antidepressant) as the preferred treatment, and low-dose mood stabilizers used for more stubborn cases.  Sometimes medication is enough, but some self-injurers may require ongoing psychotherapy, in which patients are taught aversion therapies and healthy ways to manage their negative feelings.

There are even specialized in-patient rehabilitation programs. Unfortunately, there are very few studies on SI as a whole and less information still about things like recidivism rates, so there's no real way to make sure these things are effective long-term options.

And stopping the behavior doesn't mean that the scars—both literal and figurative—from the disease are gone. L is a paralegal with a young son who self-injured for ten years. Her methods were cutting, bruising, and scratching.  She says, "It's been eight years since the last [time I self-injured]. Thinking back, I mostly just miss it."  It's like AA—no matter how many days of clean living you have behind you, the urge is always there.

I'd be lying if I said that my mind has completely written off SI as a solution. Sometimes I'll be overwhelmed by negative emotion and the thought is there, like a reflex: Self-injury could help you with this. You will feel much better. Do it. I don't know if that will ever go away.

As we've discussed, there are a lot of "slow" forms of self-destruction. There are a lot of human behaviors that negatively affect our health and our lives. T says, "The period in which I SI'd overlapped to a certain extent with the period in which I started doing other things that are detrimental to my health, and I am still doing them every day."

People drink too much, smoke too much, eat too much. They do drugs; they drive too fast.  What makes those behaviors personality traits, and SI pathological? We know it isn't just the passage of time, since it has been going on for centuries, long before there were cars to drive too fast. What makes one a quirk, and one a disease?  Is self-injury just suicide by increments?