The Link Between Depression and Self-harm

What are Depressive Disorders?

Depressive disorders, often referred to as “depression”, fall under the category of Mood or Affective Disorders, and affect about 5% of the world population (WHO, 2013), and 5.25% of the Indian population (B.A. et al., 2019). Depressive disorders have been classified in the International Classification of Diseases- 10 (ICD 10) into the following types (WHO, 2004):

• Depressive episode: A single episode of mild, moderate or severe depressive symptoms for a period of more than 14 days.
• Recurrent depressive disorder: Repeated depressive episodes
• Persistent depressive disorder: includes Major Depressive Disorder lasting for more than 2 years or Dysthymia (chronic depression of mood, lasting at least several years) 

However, the characteristic features of these disorders include the following symptoms (WHO, 2004):

• Lowered mood
• Fatigue or reduction in energy levels
• Decrease in activity
• Reduced capacity for enjoyment, interest, and concentration (including libido)
• Diminished/increased sleep and disturbed appetite
• Reduced self-esteem and self-confidence
• Ideas of guilt and worthlessness
• Psychomotor retardation (slowing down of physical movements and thought processes)
• Agitation
• Weight loss

In terms of experience, depression can be understood as a mood state that involves a sense of hopelessness, helplessness and loss of control, which may be considered endless. It is common to lose one’s sense of self-worth and start feeling isolated from those around, which may lead to feelings of numbness or difficulty feeling and regulating emotions. It can be experienced as paralysing, intense, and can severely affect functionality, making it difficult to cope with day-to-day life (Parker et al., 2015).

Depression can be debilitating, and some features of depression, notably lowered self-esteem, hopelessness, and difficulty regulating emotions, can link it to another concern, which is being researched and linked to depression: self-harm, or Non Suicidal Self Injury (NSSI) (Lei et al., 2024).

Self-harm or Non Suicidal Self Injury (NSSI)

Self-harm or NSSI can be understood as intentionally and repeatedly causing the destruction of body tissue in the absence of suicidal intent (Lei et al., 2024). This may be done by cutting, biting, burning skin, pulling hair, whipping, headbanding, scratching, pinching, etc. It differs from Deliberate Self-Harm (DSH) in the sense that it occurs without suicidal intent, whereas DSH is a broader term that applies to self-harm with and without suicidal intent (Bordalo & Carvalho, 2022).

Experiencing distress to the extent of harming oneself can be a very painful experience, and requires understanding and treatment to be resolved. To understand what may motivate the urge to harm oneself, a few contributing factors have been listed below. What is important to note is the overlap between the factors leading to NSSI, and the link that they may have with the experience of depression.

• Emotional dysregulation: As mentioned above, difficulty regulating emotions (seen in depression and other disorders in the form of overwhelming emotions or numbness) can lead to coping strategies that may involve self-harm, which may provide relief in the short-term, but may be detrimental to mental and physical health in the long run (Brereton & McGlinchey, 2019).
• Experiential avoidance: Emotions such as guilt, shame, loneliness, emptiness, and self-hatred can lead to rash decision-making and difficulty seeking out social support. Experiential avoidance (EA) refers to the tendency to avoid and escape emotional pain through experiences that are intense so that distress is suppressed. Unwanted thoughts, memories and somatic sensations are avoided through behaviours such as self-harm. One perspective is that the neural overlap between physical and emotional pain in the brain allows for this. The relief following self-harm may be perceived by the brain as a reduction in emotional pain, and this leads to short-term relief. This leads to a self-perpetuating cycle where the self-harm behaviour is rewarded through avoidance of the emotional pain (Nielsen et al., 2016). 
• Self-punishment: The self-criticism and worthlessness characteristic of depression may lead to a belief that one is a bad person, and self-harm then becomes a way to punish the self, especially when guilt and shame occur. This is particularly the case when the person engages in behaviours that they do not approve of, such as overeating. NSSI thus offers temporary relief and a sense of tangible punishment (Stanicke, 2021).
• Emotional numbness: The inability to “feel something” can lead to physical and emotional numbness, where people find themselves misaligned with their bodies and physical experiences. This may leave one confused and perplexed, leading to the urge to “feel anything”. Self-harm may become a way of involving the body in this experience and increasing one’s sense of reality (Horne & Csipke, 2009).

Control: An interesting perspective is one where people may feel the need to be in control of their own bodies in order to cope with feelings of alienation from those around them. Overwhelming and helplessness may be dealt with by an attempt to “take control” of their bodies (Stanicke et al., 2018).

The Link between Depression and Self-Harm

While the features of depression may be indicators for self-harm, research has shown links that go beyond just this. For instance, there is research, although limited, suggesting that self-harm can become a risk factor leading to depression. While it offers temporary relief, self-harm maintains the cycle of shame, rumination, guilt, regret and isolation. Moreover, it can also lead to strong responses from those around, in the case of adolescents, for instance, that may lead to disruptions in relationships and lowered social support (Lundh et al., 2011).

Moreover, depression and self-harm may create a “vicious cycle” through a system where the challenges of depression may feed the need to self-harm, and one’s feelings towards oneself (regarding the self-harm) reinforce the depressive symptoms. Thus, along with sadness, self-harm becomes a way to cope with negative self-image (Lundh et al., 2011). 

What is the best Treatment Approach?

Since depression and self-harm are both debilitating and distressing conditions, both require attention and treatment in a timely manner. For treatment, the self-harm is addressed as a priority, and any suicidal thoughts (if present) are addressed and resolved through medication, increasing social support, and ongoing therapy or counselling. 

A common treatment approach used to address self-harm is the Dialectical Behavioural Therapy approach developed by Marsha Linehan. It involves using certain strategies to learn how to tolerate distress and crisis episodes through various methods. They are closely linked to learning how to manage bodily sensations and using physiological techniques such as:

• Temperature: Using cold water or ice- dipping the face in water, holding ice, using a washcloth.
• Intense exercise to release stored energy.
• Paced breathing: Deep belly breathing, or breathing patterns such as 4-7-8.
• Paired muscle relaxation: Tensing and relaxing the muscle groups for 2-3 seconds while deep breathing.

Over the course of individual and/or group (skills training) therapy sessions, DBT focuses on achieving an equilibrium between change and self-acceptance. It uses cognitive, behavioural, and client-centred approaches to therapy to work on one’s thoughts, feelings, and self-esteem in close alliance with a trained therapist. It aims to achieve emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness, all of which are effective in dealing with self-harm urges and show a decrease in depressive symptoms (even in the presence of suicidality) in the long term (Saito et al., 2020; Meygoni & Ahadi, 2012; Feldman et al., 2009; Junkes et al., 2024).

If you or anyone you know is struggling with depression, self-harm, or both, it may be crucial to intervene in a timely manner. Consulting a psychiatrist and a therapist may be the first step, since a combination of medication and psychotherapy is understood to be the most effective in treating mental health concerns.

Navigate Your Emotions with Expert Help

Recovery starts with a conversation. Let’s start yours today.

Book a Free Call

FREQUENTLY ASKED QUESTIONS

1. What’s the difference between self-harm (NSSI) and deliberate self-harm (DSH)?

Self-harm or Non-Suicidal Self-Injury (NSSI) means intentionally hurting yourself without wanting to die, like cutting or burning. Deliberate Self-Harm (DSH) is a broader term that includes all self-injury, whether or not there’s suicidal intent. So, NSSI is a specific type of DSH, focused on non-suicidal actions.

2. How common is depression, and what does it feel like?

Depression affects about 5% of people worldwide, including in India. It causes persistent low mood, tiredness, and loss of interest in activities. People often experience changes in sleep, appetite, concentration, and feelings of worthlessness or guilt.

3. Why do people with depression sometimes hurt themselves?

People with depression may self-harm to cope with overwhelming feelings or emotional numbness. It can also be a way to punish themselves or regain control when life feels chaotic. Self-harm often provides temporary relief from intense emotional pain.

4. How do depression and self-harm feed into each other?

Depression can lead to self-harm as a way to manage difficult feelings. However, self-harm often causes shame and guilt afterward, which worsens depression. This creates a cycle where each problem feeds and intensifies the other.

5. What is Dialectical Behavioral Therapy (DBT), and how can it help?

DBT is a therapy that helps people balance accepting themselves and making positive changes. It teaches skills like mindfulness, distress tolerance, and emotional regulation. Techniques include breathing exercises and using cold water to calm intense emotions.

6. Can self-harm cause depression, or does depression always come first?

Depression often leads to self-harm, but self-harm can also increase feelings of shame and isolation, contributing to depression. The relationship is two-way, with each condition potentially triggering or worsening the other.

7. What should someone do if they or a loved one is struggling with depression and self-harm?

It’s important to seek professional help quickly by seeing a psychiatrist and therapist. Treatment usually combines medication and therapy, like DBT. Addressing self-harm and suicidal thoughts early is crucial for safety and recovery.