*Trigger Warning for self-harm and psychosis experiences*
Having struggled with self-harm since I was 13, I have done a lot of thinking about the topic. Why do we self-harm? What are the benefits? And what are the disadvantages? These are all great questions, but what I want to draw our attention to is actually a phenomenon that I’ve been pondering over, which is self-harm in psychosis. My first experience with psychosis was when I was 21, long after my first experience with self-harm, and the interaction between psychosis and self-harm intrigued me. In particular, what is the connection between them, and what are the similarities and differences between self-harm by itself and self-harm in psychosis?
Below are personal descriptions of experiences of self-harm and psychosis from myself and Natasha:
Self-harm by itself
“I kind of hate to acknowledge it but I know I’ve attempted to use self-harm in a manipulative way, but not trying to hurt anyone else — even though it did sometimes. I think it was more a means of self-preservation, trying to reach out for help in the only way that made sense in the moment.” – Natasha
“There were definitely times when I felt so overwhelmed with feelings that I just needed to hurt myself to let the feelings out. I needed the numbness that I knew would follow. Again, it seemed like self-preservation, a bad coping mechanism. These were always times when I was alone and “knew” in some way that that was just how it had to be. It was a very private act, the one that gave me the most shame afterward. In retrospect, it was really just a trade-off of emotions from ones I couldn’t handle to ones I felt like I could.” – Natasha
“When I’m under a lot of stress or anxiety from situations in life, I tend to get the urge to self harm. It feels like an itch that has to be scratched, an aching sort of longing for that quick relief. I know that self-harm isn’t the healthiest option, but sometimes the urges can overwhelm rational thinking, emotional mind takes over and eggs me on to perform the self-destructive act. At these times, I often feel like there’s another side of me, which I named Eris, whom I struggle to control. Eris is the one causing me to slam my arm into the edge of the desk, the one un-taping my knife and ultimately digging the blade into my arm. It feels like a tug-of-war between Eris and I, I try to fight back, and she retaliates even harder. In the end, if she wins, I feel that wave of immediate relief, grounding me back to the present, painful emotions temporarily stunted. However, not long after, I will feel the guilt slowly creeping in, and causing a second wave of unwanted emotions.” – Anne
Self-harm in psychosis
“I remember one time specifically where it felt like there was another presence in the room trying to make me follow through with a suicide plan. It might have been just two parts of myself struggling between dying and not dying. Either way, I thought the only way out was to cut myself, like it was some sort of compromise. After I self-harmed it felt like the fog cleared and it was just my regular pain of depression.” – Natasha
“When I strongly believed that in order to save humanity from self-destruction, I had to sacrifice myself, it led me to a handful of self-harming behaviours. I abstained of any oral intake of food and drinks, except for water, believing that I needed to go through this “purification” process before ultimately sacrificing myself. There was also a lot of internal and external pressure from these audible thoughts that would tell me “It’s your fault, you have to fix this.” I kept seeing images of me with my wrists cut open and bleeding. I needed to “let my essence out”, was what I kept thinking, and that led me to attempt to cut open the veins in my arm. I was convinced that it would be how I would die and therefore save humanity.” – Anne
“I feel that when my mind is “in psychosis” the act of self-harm comes from a more definitive place. I need to perform this act, in order to achieve what my brain at the time deems to be the saving grace for humanity. There is no question as to whether or not should I self harm, there is no struggle between my two selves to refrain from harming, it is simply what I must do. Whereas when I’m not “in psychosis”, there is a fight within me, and a rational voice arguing against self-harm, subconsciously I know the healthier choice.” – Anne
“This makes me wonder about the myriad of psychotic experiences and how it interacts with anything else a person is going through. For me it was always depression, so it felt like there was a ghost in the room. It makes so much sense at the time, and then I look back and get a different perspective of what was happening. “Emotional ghost” is the only way I know how to describe it right now. Like it was definitely not me, but I’m not entirely sure what is was… It was, by my current standards, a different reality. As opposed to non-psychosis self-harm, which I can recognize because it uses features of my daily life. I think a lot of people might look at these experiences and be like “yeah, obviously you were psychotic then and not the other time” but I kind of feel like it’s more of a grey area.” – Natasha
Some themes I notice in our comparison, is that self-harm itself, can serve a purpose of getting rid of overwhelming emotions and coping with distress. It can be a form of communication, when it seems impossible to communicate. It can be a means to staying alive. There seems to be a rationalization attached to this form of self-harm, wherein the reason to self-harm is for “self-preservation” of sorts.
Whereas in psychosis, self-harm can be roughly divided into two components. One is delusion/hallucination driven self-harm, and the other is much like non-psychosis self-harm, where the act is to diminish or resolve the distress of the psychosis itself. Delusion/hallucinations can increase the risk and severity of self-harm, because oftentimes the self-harm comes from strong convictions that one must perform the act (e.g. “emotional ghost” making my friend follow through with suicide) otherwise face consequences (e.g. humanity will self-destruct if I don’t cut open my veins). The other aspect of self-harm in psychosis is using self-harm to gain control over psychosis, to distract from and eliminate distressing experiences of psychosis such as hearing voices, seeing visions and having unusual beliefs (e.g. cutting to make the “emotional ghost” go away).
Whether we’re in psychosis or not, self-harm seems to have a common purpose of decreasing or eliminating negative internal experiences. In these instances, self-harm is not usually related to the desire to die, and can be referred to as non-suicidal self-injury (NSSI). The goal is to regulate emotions, handle overwhelming experiences and feel better. When we are in psychosis though, self-harm can step into a more risky territory, increasing the chances of severely harming oneself, leading to intentional or unintentional death.
According to a meta analysis by Challis et al.(2013), about 1 in 5 people experiencing first episode psychosis have a history of deliberate self-harm, and 1 in 10 people will engage in deliberate self-harm during their first-episode of psychosis and there is a persistent risk of deliberate self-harm in the period after initial treatment of psychosis. However, there is very limited literature on the relationship between the two, and how to approach it. This points to the prevalence of the issue, and brings to light how much more research needs to be put into this area. I’m just in the beginning stages of understanding the interaction between my self-harm and my psychosis, and I hope with time and experience, I can better predict and prevent either from re-occurring.