"You have so much pain inside yourself that you try to hurt yourself on the outside."

The late Princess Diana's words shocked the world four years ago when she admitted in a television interview that she intentionally cut her arms and legs. At last, self-injury-the practice of deliberately cutting, burning, scratching or otherwise destroying body tissue-was out of the closet.

Since then, mental health experts and authors who've examined the phenomenon have called the condition everything from "the addiction of the '90s" to a widespread epidemic. With an estimated 2 million sufferers in the United States alone and more seeking treatment than ever before, doctors are finally beginning to unravel the mystery of self-abuse. The majority of self-injurers are white females, and they're likely to suffer from other compulsive disorders, such as eating disorders or alcoholism. "Most begin self-abusing during puberty, a chaotic, confusing time when emotions run high and self-esteem runs low," says Karen Conterio, administrative director of SAFE Alternatives in Berwyn, IL, the only inpatient treatment center exclusively for self-injurers in the United States.

To many, what's puzzling about self-abuse is the contradiction: Self-injurers hurt themselves in order to feel better. Experts say that when people who self-abuse become emotionally overwhelmed, a self-inflicted injury breaks the tension, allowing them to focus on something other than the emotion they're feeling. "It's a coping technique they develop early in childhood," says Wendy Lader, Ph.D., clinical director of SAFE Alternatives and, along with Conterio, co-author of Bodily Harm: The Breakthrough Healing Program for Self-Injurers (Hyperion, 1998). Somewhere along the way, self-abusers are taught that certain emotions, such as anger, sadness or fear, are wrong or bad, so they stifle their feelings. Without an outlet for expressing those emotions, they turn to self-abuse as a release or to punish themselves for having those feelings. For some, the physical pain immediately dulls overwhelming emotions. For others, a deliberate cut or burn summons the sense of being alive. They say the feeling of pain is a welcome change from feeling numb and empty.

Many experts, including Lader, say such injuries may cause the release of endorphins, the body's naturally occurring opiates. Much like a trauma victim, self-abusers experience a kind of physiological shock response to highly emotional situations, and self-injury is the most immediate means of relief. Like any addictive behavior, over time, most sufferers hurt themselves more often and more severely to achieve the same sense of relief. At the same time, a cycle of shame and self-hatred begins. Sufferers feel guilty for having the urge to self-injure, but they're compelled to hurt themselves to relieve those intense emotions, which leads to more guilt and shame for being unable to control the urge. "There's a drive behind self-injury. People who self-injure feel the need to do it more and more in order to handle uncomfortable, intense emotions," says Lader.

A big part of the treatment process at SAFE Alternatives is "unlearning" those coping skills by keeping an impulse-control log, a journal of sorts for self-abusers to work through the urge to injure themselves. "We teach them that the urge to self-injure is a clue that they're avoiding something bigger-an emotion, a feeling, a fear," says Lader. "If they can identify the emotion and face it by feeling, talking or writing about it, they're less likely to act on that impulse to hurt themselves."

Signs of a self-injurer:

Wearing long-sleeves or pants in warm weather
Explaining frequent minor injuries as accidents or cat scratches
Withdrawn, depressed behavior
Inability to express emotions
Difficulty handling intense feelings
Answer true or false to the following questions to find out if you're suffering from self-abuse:

I often obsess about self-injury.
I sometimes can't explain where my injuries come from.
I get anxious when my wounds start to heal.
I often believe that if I don't self-injure, I'll go crazy.
No one can hurt me more than I can hurt myself.
I can't imagine life without self-injury.
If I stop self-injuring, my parents win.
I often self-injure as a way to punish myself.
I often self-injure to show others how I feel.
I often believe that if I don't self-injure I'll explode.
I almost always carry something with me that I can use to self-harm.

-Source: Bodily Harm: The Breakthrough Healing Program for Self-Injurers (Hyperion, 1999). Colleen Rush

Resources:

SAFE Alternatives Program
(800) DONT CUT (366-8288)
www.selfinjury.com

The Cutting Edge, a self-injury newsletter
P.O. Box 20819
Cleveland, OH 44120

Bodies Under Siege by Armando Favazza (Johns Hopkins Univ. Press, 1996).

A Bright, Red Scream by Marilee Strong (Penguin USA, 1999)

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