Free Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis by Christine Montross

progressed, they became calmer and calmer.
    So what is it about self-mutilation that has the power to produce calm in a certain cohort of human and nonhuman primates alike?
    From a scientific standpoint, self-injurious behavior is difficult to study. The ethics of scientific research prevent studies from being conducted in which human subjects are knowingly harmed, and rightly so. However, this means that we cannot, for example, observe cutters as they are cutting themselves in order to assess the physiological and psychological responses their actions evoke. Instead researchers must rely on patients’ self-reporting—a notoriously inexact source of data—or devise experiments that attempt to replicate the effects of cutting without in fact causing harm.
    In 1995 the
Journal of Abnormal Psychology
published a paper by Janet Haines and her colleagues entitled “The Psychophysiology of Self-Mutilation,” which aimed to do precisely that. In the paper, Haines lists the reported factors that give rise to the negative emotions that most commonly prompt self-injury as “interpersonal conflict, rejection, separation, or abandonment,” which may be “threatened, real, or imagined.” Indeed, nearly all of Lauren’s admissions cited predisposing events that could be interpreted through this lens. A terminally ill uncle or a sister’s hepatitis diagnosis could signal pending abandonment via illness or death. A fight with a neighbor raised the specter of both interpersonal conflict and personal rejection. Similarly, when Lauren’s doctors and nurses grew frustrated by her behavior and impatient with her care, she would perceive this as yet another rejection. In the self-fulfilling prophecy of projective identification, her own actions poured fuel on the fire of her worst fears.
    Haines describes a generalized sequence of events that typically occur before, during, and after self-injury. This sequence has been repeatedly described by self-injurers and their clinicians, and it begins with the rise of negative emotions. As the emotions swell, they reach a point where the self-injurer can no longer tolerate the intensity of the feelings. It is at this point that a phenomenon called dissociation is thought to occur. Haines writes that as the negative feelings become increasingly intolerable, “many self-mutilators report feeling numb, withdrawn, and unreal” and begin to engage in the act of harming themselves. As the wound is inflicted, it typically does not cause pain until “minutes, hours, or even days after the injury,” regardless of its severity. Haines postulates that this anesthesia is likely a physiological one, “mediated by an increase in endogenous opiates . . . caused by the extreme stress reaction prior to cutting.” In other words, according to her theory, the body may release its own morphinelike substances twice: first in response to the stress and then in response to the injury. Not only would this double response mute pain, it also could contribute to the addictive properties of self-injury, reinforcing the impulse to turn to self-harm in moments of distress.
    Haines wanted to explore exactly what happens in the body and mind during episodes of self-injury. In order to do this, she gathered groups of “mutilators” and “nonmutilators” and read them personalized scripts of various events they had experienced and described, including one event, such as an argument with a significant other, that was meant to evoke a degree of psychic distress. Then both groups were read a script that guided them through images of self-harm. Various physiological measurements associated with tension, such as pulse and respiratory rate, were taken throughout the experiments. The results showed that the subjects with a history of self-injurious behavior became calmer—both by their own self-assessment and by the measured bodily responses—during the self-mutilation imagery. Essentially, the mere act of imagining they