Defining exactly a phenomenon such as self-harm, which appears to be growing enormously, is very complex and presupposes one flexibility in the categorization which often makes the evaluation criteria uneven. As in all good frameworks, we start from a first coarse but effective division: theself harm culturally recognized and encouraged and the deviant or pathological one. 

Tearing hair or blood scratching are perfectly acceptable self-harm manifestations in the context of severe mourning in certain cultures and may be part of a shared ritual (Rossi Monti 2014). In the same way, tattooing the body, getting pierced in more or less orthodox points, surgically modifying one's somatic features, using sadomasochistic erotic practices, can be perfectly understandable and accepted within certain limits. Inflicting cuts, burns, bruises or deliberately stabbing yourself is considerable pathological.

Where's the discrimination between normality and pathology when it comes to self-harm?

Each path that leads to self-harm can be studied and investigated in depth and certainly has some uniqueness. However, not all aspects of the phenomenon are absolutely personal and unrepeatable and this allows us to shape an organization using a differential approach which allows us to highlight the discrepancies between culturally shared self-injurious phenomena and those resulting from discomfort or psychic suffering (Deviant Self-harm).

Today DSM 5 inserts "non-suicidal self-harm" in the chapter relating to conditions that require further studies and proposes borderline personality disorder as the first differential diagnosis.

But we come to the typing that is currently recognized as the most complete, that is the one elaborated by Favazza (1996) in the second edition of his book "Bodies under Sieges" (Corpi Sotto Attacco), currently considered the reference text on the phenomenon. The American psychiatrist theorizes three major categories: major self-harm, stereotyped self-harm and superficial / moderate self-harm.

• Major self-harm: is the least frequent one more serious from the point of view of the incidence of the gesture on the target body. This first category includes mutilation and ablation gestures such as enucleation of the eye, amputation of an ear, removal of a testicle. Usually these gestures are not premeditated and the patients who perform them cannot give plausible explanations; when they are given they are always denoted by little adherence to reality. The explanations concern type issues religious tourism o sexual: the need to purify oneself, identification with Christ who suffers (Rossi Monti), malignant influences or the desire to be a woman, the fear of homosexuality, the attempt to control overwhelming sexual impulses. Major self-harm is associated with psychotic pictures but it can also be triggered by states of acute substance intoxication.
  
  
• Stereotypical self-harm: includes a series of repetitive and manneristic self-injurious actions like banging and shaking your head, scratching your skin and eyes, tearing your hair and biting your hands. These events are almost always linked to paintings by serious pathological incidence, psychiatric o neurological. Acute psychotic patients, schizophrenics, autists and people with severe mental retardation suffer especially from non-inclusive care settings (institutionalized patients). Understanding and interpreting the gestures is almost always impossible, it is as if these patients reacted to an internal imperative instance.
  
  
• Superficial / moderate self-harm: Characterized by the lesser gravity of the pipes, it includes typical actions such as: burning, piercing, pinching, scratching, tearing hair, teasing old wounds in a state of healing, carefully obtaining controlled cuts in various parts of the body. Those who use the practice of cutting are called "cutters". Within this category it is possible to make a further categorization by analyzing the specificity of the pipelines. We can detect compulsive behavior (trichotillomania, eating nails to live meat, skinning skin), episodic conduct e repetitive conduct (the most common are cutting and burning the skin). These behaviors are present in numerous pathological pictures: personality disorders, dissociative disorder, post-traumatic stress disorder, eating disorders. I am generally episodic behavior but they can become repetitive if they turn into one strategy to cope with certain internal emotional states or if they meet the needs of identification with a group or a sub-culture of belonging. Episodic or compulsive superficial / moderate self-injury is generally among the symptoms of some specific pathologies, repetitive self-injury is instead leading the authors to configure it as a separate disorder. The description of these three categories allows to ascribe to each of them a prevalent problem.

While for greater self-harm and stereotyped self-injury we can refer to psychotic pictures and some clear syndromes, in superficial / moderate self-harm we certainly refer to the Borderline Personality Disorder.

Perspective inversion

In some religions, self-harm acts represent basic rites of passage, just think of circumcision or flogging during traditional ceremonies.

So let's try to make a clear change of perspective, embracing aanthropological perspective: the young Dinka of Sudan engrave bull horns on their forehead, as a sign of gratitude to the cattle, the main source of livelihood of this ethnic group. The Nuer decree the passage from puberty to adulthood with five scarifications on the chest as forming the letter V. The Mursi of Ethiopia are known for scarifications and white paints on the body, as well as for the female labial incision, and the insertion of a terracotta saucer between the two flaps of skin separated by incision. These practices which are to an objective, self-damaging analysis, they are part of what the culture of belonging approves or even encourages.

It is not necessary to direct our curiosity beyond national borders to have significant and very particular examples of rites centered on self-injurious acts. To date, it is sufficient to visit Verbicaro, a town of 3.061 inhabitants in the province of Cosenza, located in the Pollino National Park, during Easter Holy Week to see the ritual of the "Battenti Rossi" in the dialect i Vattienti, proud self-flagellants of Southern Italy.

So how to answer the question we asked ourselves at the beginning of this short article? A clear answer is not possible but we can say that context analysis remains the most important clinical tool.

Contextualizing it is always the best way to approach structured, organic but also updated knowledge.

Joseph Scurci

* Notes on the author:
Giuseppe Scurci, Clinical Psychologist, founding partner and Secretary General of Psy + Onlus. Specialized in Psychodynamic Psychotherapy at the European Research Institute in Psychoanalytic Psychotherapy (IREP), under the guidance of Prof. Edmond Gillièron.