Table 4.

Summary of emotional reactions and impacts of viewing and sharing videos and images.

Impact of image or video		Findings reported
Anger or hostility		Spoof advertisement on Twitter for stick-on self-harm scars evoked reactions of anger and frustration [34] Some hostile comments about an uploader of self-harm content (57/864, 6.6%) were found in comments of YouTube videos [28] A small percentage of comments of self-harm–related Instagram posts were coded as abuse (450/6651, 6.77%) [31]
Other emotions		The reaction from viewing self-harm photographs varied considerably between informants and may be dependent on the individuals’ state of mind when they are viewed. A wide range of feelings were covered in responses, including being sad, sick, and shocked. Reactions such as depression, grief, and concern for themselves were stated [39] Common reactions reported after viewing a suicide prevention video included sadness, surprise, shock, and feeling overwhelmed. Almost 40% of participants indicated that they were most affected by the real, personal stories of family and friends of those who had taken their own lives (particularly the impact of suicide on the lives of the people left behind) or individuals who had survived a suicide attempt [40]
Ambivalence		Dramatic responses are not always reported when viewing self-injury photos, with some reporting it can be done to pass time [39]
Exacerbation of self-harm urges or behavior
	Triggering	Nearly 3 quarters of interview participants reported that imagery (notably photographs) was the primary reason for their utilization of the internet, due to a powerful physical reaction that triggered the desire to self-harm. Reliance on the image as a trigger had led to images assuming a vital role within their ritualistic practice with “sessions” often commencing with retrieval of a web-based image. The power of the image primarily centered on their ability to “bring back memories” of previous self-harm or the ease with which they allowed the individual to envisage how others experience the act. Participants also reported looking at images deliberately to trigger more severe self-harm [9] Participants often discussed the triggering role of images. Many stated that whether an image would trigger an act depended on mood at the time. It was commonly expressed that photographs of flesh, open wounds with blood are more triggering than pictures of scars and healing wounds [38] About one-third of participants describe the outcome of viewing photographs as triggering, with “bluntly gruesome” photographs described as the most triggering content [39]
	Competition	Participants spoke of being inspired to recreate certain sets of practices presented by particular images. Discussion was characterized by a sense of competition with individuals desiring to emulate the depicted self-harm while chiding themselves when they failed to engage with more sophisticated and severe techniques [9]
	Imitation	Pictures depicting wounds generated around twice as many comments from users than pictures not depicting wounds. There was also a significant association between wound grade and number of comments [31]. Time-related analyses did not support any effects of contagion or reinforcement [31,37] Participants reported that a lack of moderation on Tumblr and the freedom to view and share the most stark and severe images had led to normalization and exacerbation of self-harm. One participant stated that their self-harm had escalated from little gashes to severe injuries and cutting through arteries [9]
Reduction in self-harm urges
	Calming	Participants reported self-harm photographs as providing a sense of vicarious relief and of viewing photos to calm themselves when feeling triggered [38]. Reactions to self-harm images were described as comforting or calming in nearly half of statements [39]
	Use as a deterrent	Some participants stated that self-harm photographs of severe injuries acted as a deterrent of self-harm. Participants reported using this as a pre-emptive strategy to avoid more severe self-injury [38]. One participant described viewing of severe injuries as making them feel nauseated, serving as a strategy to avoid more severe self-harm [38]
	Emotional outlet	Content creation, particularly artistic or creative content, was described as an emotional outlet to disclose negative emotions, distress, and aspects of the self otherwise difficult to express. This was reported, at times, to reduce self-harm urges by acting as a distraction or alternative to self-harm [38] Some participants reported that looking at content helped them reflect on their experience, make sense of it, and potentially avoid further episodes. Creation of content was reported to reduce self-harm urges serving as a creative alternative [38]. Participants reported viewing images made them feel less alone helping to curb NSSIa urges. Feelings of relief were reported with photographs reducing urges to self-harm.
Connection with others
	Empathy	Empathetic comments made up 23.49% (1562/6651) of comments on Instagram posts [31]. Many participants spoke of feeling empathy with content creators when viewing images related to self-harm. Several participants also addressed the internet as their only source of support or connection where they could receive empathetic reactions and emotional support [38]. Empathy and sympathy were common reactions to a suicide prevention video [40]
	Solidarity and reduction in loneliness	Participants reported the viewing of photographs as comforting, as they made them feel less alone [38,39]. Participants describe feeling less alone in their battle as a motivation for sharing images [39]
	Giving and receiving help	The motivation to support like-minded people was often described as going hand in hand with a desire for help [38] Warnings asking user to stop behavior were present in 11.58% (770/6651) comments on Instagram posts, as were offers of help (462/6651, 6.95%) [31] A total of 51.0% (127/249) of interactive Tumblr posts involve seeking or providing advice, of which 40.9% (52/127) provided positive support or advice (eg, encouragement in stopping self-harm) and 25.1% (32/127) provided potentially harmful advice (eg, advising how to secretly engage in self-harm), with 13.4% (17/127) suggesting professional help or therapy [32] An equal number of comments on YouTube videos asked for help or offered help (23/1150, 2.00%), and a small number encouraged the uploader to seek help (21/1150, 1.82%) [28] Participants who watched a suicide prevention video expressed a higher awareness of the need to watch for signs of depression to be able to help friends and the need to take immediate action, take depression seriously, and talk openly about suicide [40] A total of 9.09% (249/2739) of Tumblr posts involved directly interacting with another user. Of these, 47.0% (117/249) provided emotional support or reassuring messages to one another [32]
Feedback or discussion of creative content		Creators of creative content expected constructive criticism from their viewers to improve their artistic skill, and positive feelings were reported when content received comments or was reblogged [38] High levels of feedback were given or received for video content. Feedback included admiration of video quality (191/869, 22.0%) and the video message (148/869, 17.0%) and validation and admiration for the individual who uploaded the video (134/869, 15.4%) [28]. Very few Instagram comments complimented the wound or image (33/6651, 0.50%) [31]

^aNonsuicidal self-injury.