Teenagers Who Cut: Adolescent Self-Injury
“Cutting is on my mind almost all the time, sometimes i feel i just wanna go ahead and get real crazy, end up in a mental hosp and fade away, being depressed and dark and lost sometimes.” Entry from Between Injury and Sanity, an Internet message board
The increasing number of stories in the mainstream press and the growing number of anecdotal reports by clinicians, therapists, and school counselors suggests that self-injury may be the “next teen disorder.” Self-injury is defined as deliberate, repetitive, impulsive, and harmful behavior without suicidal intent. Of the many types of self-injury, cutting is the most common (Box 1). Cutters will use razors, utility knives, scissors, needles, or broken glass to make repetitive slices on their arms, legs, or other body parts. Some burn themselves with cigarettes or lighters; others pull out their own hair. Although not usually a suicidal gesture, self-injury is statistically associated with suicide and can result in unanticipated severe harm or death.
Box 1. Typical Forms of Self-Injury
- Picking scabs or interfering with wound healing
- Burning or branding
- Punching self or objects
- Inserting objects in body openings
- Bruising or breaking bones
- Hair pulling
Self-injury is a complex behavior that results from a variety of factors, including the need to relieve anxiety, guilt, loneliness, alienation, or self-hatred; to relieve unpleasant thoughts or feelings; to release anger, tension, or emotional pain; to produce a sense of security or control; as a form of self-punishment; or to set boundaries with others. Adolescents who have difficulty talking about their feelings may show their emotional tension, physical discomfort, pain, and low self-esteem with self-injurious behaviors. Contrary to public opinion, self-injury is not typically a call for attention, as evidenced by the fact that many young people go to great lengths to hide their injuries. Many young people who self-injure say they do it because they normally feel “numb” and cutting helps them to “feel alive.” Others talk about the “sense of control” they may get from self-injury. See Box 2 for some common triggers reported by young people who practice self-injury.
Box 2. Self-reported Triggers of Self-Injury
- Knowledge that friends or acquaintances are cutting
- Difficulty expressing feelings
- Extreme emotional reactions to minor occurrences (anger or sorrow)
- Stressful family events (divorce, death, conflict)
- Loss of a friend, boyfriend/girlfriend, or social status
- Negative body image
- Lack of coping skills
Twenty years ago self-injury was considered a practice associated primarily with psychiatric illness and severe behavioral disorders. It emerged into a more public practice when celebrities such as the late Princess Diana, Johnny Depp, and Angelina Jolie publicly revealed their self-injury behaviors via the popular media. It is difficult to accurately estimate the current prevalence of injury among the general US adolescent population. Estimates range from 12% to 38% of young people, although recent studies reflect one-third to one-half of US adolescents have engaged in some form of self-injury.[5-7] However, data suggest that self-injury among young people is grossly underreported and misdiagnosed, in part because the behavior is often hidden or covered up.[7,8] The typical onset of self-harming acts is at puberty and young people are often introduced to it through peer groups and media outlets (eg, music, television, the Internet). The behaviors often last 5 to 10 years but can persist much longer without appropriate treatment.
Young people of all ethnicities, ages, and income levels intentionally hurt themselves, although self-injury is somewhat less common among Asians and Asian-Americans. Nearly 50% report physical and/or sexual abuse during childhood. As many as 90% say that they were discouraged from expressing emotions—particularly anger and sadness—as younger children. Other factors associated with self-abuse include a history of emotional neglect, low self-esteem, hypersensitivity to rejection, as well as childhood separation and loss. Although some teenagers may feel an emotional release following the act of harming themselves, others may feel hurt, anger, fear, and hate following the self-mutilating act. These teenagers may hide their scars, burns, and bruises because they are embarrassed, ashamed, or guilty about the behavior.
Influence of the Internet
One of the most influential factors in the lives, treatment, and recovery of adolescents who practice self-injury is the Internet. More than 80% of teenagers use the Internet and half of them log on daily. The Internet holds particular appeal for individuals who feel marginalized because the assurance of online anonymity is comforting to those struggling with shame, isolation, and distress. Adolescents who intentionally injure themselves are one such group, and is a practice around which many virtual communities have been built. More than 500 self-injury message boards have been identified and most are populated by females describing themselves between 12 and 20 years of age. On some self-injury boards, moderators are trained mental health professionals capable of offering feedback and insight as a part of the public exchange. Most often, however, moderators are “board monitors” with little or no training in mental health. The most common types of exchanges on the message boards are informal support and discussion of self-injury triggers, followed by personal information related to the addictive qualities of the self-injury practice, and ways to self-injure. A small percentage of the postings reinforce negative aspects of the behavior, such as how to cut better or deeper or how to obtain paraphernalia. Researchers warn that although the message boards give many isolated teenagers a safe place to share their intimate secrets, this virtual subculture reinforces self-injury behaviors and could create a “social contagion” effect.
Identifying Young People at Risk for Self-Injury
The majority of self-injuring adolescents are able to function within the community and to remain largely hidden within society. Therefore, it’s important that primary care clinicians and pediatric professionals learn to identify this phenomenon so as to offer appropriate assistance to young people who choose to seek professional help.
Self-injury crosses gender, racial, and socioeconomic lines, but there are some common warning signs:
- Unexplained frequent injury such as cuts and burns. Some people dismiss their scars as “roller blading accidents” or “cat scratches”
- Wearing long pants and sleeves in warm weather
- Poor functioning at work, school, or home
- Unexplained marks on body
- Secretive or elusive behavior
- Spending lengthy periods of time alone
If you suspect that a young patient is practicing self-harm behaviors, a complete history and physical can yield more clues. Questions during the review of systems should include “Do you have any rashes or sores? Have you done any cutting, piercing, or tattooing?” During the physical examination, look carefully at the forearms, hands, and sometimes the inner thighs, all places where cutting is common. The cutting usually results in linear markings, often in parallel lines. Other cuttings may represent lettering or symbols that are relevant to the teen. The newer lesions may be pink or red in various stages of healing. The older ones may leave scars, or even keloids. If there is evidence of self-injury during the physical examination, you can ask 1 or 2 questions such as “How often do you visit the Internet to get or share health information?” or “Have you ever visited a Web site to find out about or to talk about self-injury?”
Patients who deliberately hurt themselves are very challenging, with behaviors that may appear bizarre, disturbing, or inexplicable. Treatment can be time-consuming, complicated, and frustrating, making it difficult to make a meaningful connection with the patient.According to researchers at the Traumatic Stress Institute in Windsor, CT, there are some general principles for providing care to patients who have hurt themselves and require your care. Avoid expressing shock, disbelief, or horror. Try to remain low-key, dispassionate, and matter of fact. Because many of these patients have suffered trauma in the past, encounters with healthcare providers may open old wounds. Remaining direct, honest, and respectful will help open a dialogue with the patient that will allow you to ask questions and elicit feedback. In order to minimize triggering stimuli that might increase a patient’s distress, check out the patient’s comfort level with the surroundings, including noise levels, privacy, and perceived safety. Show the patient how to exit the room so that the patient will feel safe and in control. Healthcare clinicians are also encouraged to talk to adolescents about respecting and valuing their bodies. In many cases, referral to a mental health professional is required.
The effective treatment of self-injury is usually a combination of medication (often selective serotonin reuptake inhibitors), cognitive-behavioral therapy (CBT), and interpersonal therapy, supplemented by other treatment therapies.CBT helps individuals understand and manage their destructive thoughts and behaviors (to find a certified therapist in your area see the link at the end of this article). Contracts, journals, and behavior logs are useful tools for regaining self-control. Interpersonal therapy assists individuals in gaining insight and skills for the development and maintenance of relationships. Services for eating disorders, alcohol/substance abuse, trauma abuse, and family therapy should be readily available and integrated into treatment, depending on individual needs.
Some helpful ways for adolescents to avoid hurting themselves include learning to
- Accept reality and find ways to make the present moment more tolerable
- Identify feelings and talk them out rather than acting on them
- Distract themselves from feelings of self-harm (eg, counting to 10, waiting 15 minutes, saying “NO!” or “STOP!,” practicing breathing exercises, journaling, drawing, thinking about positive images, using ice and rubber bands)
- Stop, think, and evaluate the pros and cons of self-injury
- Soothe themselves in a positive non-injurious way
- Practice positive stress management
- Develop better social skills
If you have a patient who is engaging in self-injurious acts, remember that the majority of teens who cut themselves do not intend to inflict serious injury or to cause death. If the injury doesn’t appear to pose immediate medical risks, treat the injury, remain calm and nonjudgmental, and consider a referral to a mental health professional who has experience in this area.
National Association of CBT: Search for an NACBT Certified Therapist
Young People and Self-Harm: Key information resource for young people who self-harm and professionals working with them.
Psyke.org: Self-injury information and support
Youth Noise: Learning to cope with self-injury
S.A.F.E. Alternative: Self-Abuse Finally Ends
Jill Shuman, MS, ELS
Published on July 20, 2010
A version of this article appeared in print on November 13, 2008 on page 7 of the Primary Issues newsletter.
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