Handling young patients who cut themselves

Two psychiatrists answer questions about diagnosing and treating these fragile youngsters. You’ll be surprised how effective intervention can be.

Self-harm—sometimes called self-injury, self-mutilation, or cutting—is defined as deliberate injury to one’s own body without suicidal intent. In addition to cutting or scratching one’s skin with razors, knives, scissors, needles, or broken glass, self-harm can include biting, hitting, or bruising oneself; picking or pulling at skin or hair; or burning oneself with lighted cigarettes.

Accurate statistics on self-injury are hard to come by since most self-injurers hide their wounds. Experts in the field, however, believe that about 1% of the population exhibits self-injurious behavior. Although the incidence appears to be highest among adolescent girls and young women, people from all walks of life harm themselves. Some of the best-known include actors Johnny Depp and Angelina Jolie, Princess Diana, and the late American biologist and sex researcher Alfred Kinsey. Self-harm is found in people of all ethnic and racial backgrounds.

To help primary-care clinicians spot and help patients with this disorder, The Clinical Advisor spoke with two experts, Blaise Aguirre, MD, and Brian D. Smith, MD. Dr. Aguirre is medical director of the Adolescent Dialectical Behavioral Therapy Center at McLean Hospital in Belmont, Mass. He is also coauthor of Helping Your Troubled Teen: Learn to Recognize, Understand, and Address the Destructive Behavior of Today’s Teens and Preteens (Beverly, Mass.: Fair Winds Press, 2007). Dr. Smith is assistant professor of psychiatry at Michigan State University in East Lansing.

Q: What are the signs that a person is engaging in self-harm?
Dr. Aguirre: Obvious signs include scars, generally on the extremities. If a person is hiding scars, she or he may be cutting the chest or breasts and thighs. People engaged in self-harm may also pick at scabs or have wounds that don’t heal (Figure 1). Some kids who are cutting themselves collect X-Acto knives or razor blades. Often, kids who harm themselves feel isolated and spend a lot of time on the computer studying self-harm bulletin boards and entering virtual chat rooms.
Dr. Smith: Some cutters wear long sleeves or long pants even when such clothes are not appropriate for the weather.

Q: What kind of person engages in self-harm?
Dr. Aguirre: There are two broad types—young people who are interested in doing what other kids are doing—frequently they try it one time, find it extremely painful, and never do it again—and others who are emotionally very intense and do it either to numb themselves or to release themselves from numbness.
Dr. Smith: A lot of people who engage in self-harm aren’t good at expressing themselves verbally; it’s often seen in people who lack effective coping skills.

Q: Where on the body are scratches, cuts, and burns usually made?
Dr. Aguirre: People sometimes target a specific body part (Figure 2). One young woman, aged 13 years, who was well-endowed, hated her breasts. A neighborhood man had molested her, and she burned her breasts with a poker.
Dr. Smith: The forearm opposite the dominant hand and the inner thighs and abdomen are also popular locations.

Q: At what age does the disorder usually begin?
Dr. Aguirre: I typically see kids aged 13 or 14 years, but some as young as 10 or 11. There have even been kids who have engaged in head-banging since age 2 or 3.

Q: Are there specific risk factors?
Dr. Aguirre: People who have been emotionally, physically, or sexually abused are at elevated risk. Interestingly, self-injury is common only to the Western world—it is not found in developing countries. Once you start introducing Western ideals of beauty and behavior, self-harm occurs. I spoke with a therapist in black South Africa who told me self-harm was unheard of until Western beauty magazines were allowed into the country. Interestingly, a recently published study found that Asian Americans are less likely to engage in repetitive self-harm than their white counterparts (Pediatrics. 2006;117:1939-1948).

Q: Since kids typically hide their injuries from parents, should clinicians do a full body exam of all teens?
Dr. Aguirre: This is a good idea, especially if a child’s grades are slipping and she has been fighting with her parents. But the child has to agree to the exam.

Q: Is there a connection to other risk-taking behaviors such as drug use?
Dr. Aguirre: There can certainly be a connection to drug use. Rough sex and promiscuity may also be involved. Thrill-seeking by skipping school, spending money impulsively — acts that put people at risk for failing in life — can also coexist.
Dr. Smith: People who drink or use drugs are more impulsive. Inhibitions are lowered, and they’re not thinking in advance about the aftermath of their actions.

Q: What are the correlations between cutting and eating disorders?
Dr. Aguirre: There is a higher incidence of self-harm in kids with eating disorders. Engaging in self-harm is an attempt at control, and it’s also about an intense, immediate need. In contrast, eating disorders develop gradually and may take the form of restricting food intake over a period of weeks, for example.

Q: Can patients outgrow self-destructive behavior?
Dr. Smith: Sometimes—particularly if they know it can cause discord between them and their parents and friends— especially friends who used to cut themselves.

Q: What’s the likelihood that cutting will lead to suicide?
Dr. Aguirre: I’ve never encountered an adolescent who cut to kill himself. Self-injurers just want to relieve their emotional pain.

Q: Unless the wounds are deep or cause excessive bleeding, parents may choose to take young patients to clinicians instead of emergency departments.
Is there anything special clinicians can do to help these patients?
Dr. Aguirre: It is important to realize that youngsters do not engage in this behavior to make the clinician’s life difficult—they do it because they don’t know any other way of coping. Treatment without blame is key. If a kid is in a car accident, it was an accident. When you can see self-harm through a more compassionate lens, you can be more careful suturing and caring for wounds.

Q: What’s the best way to encourage youngsters to seek treatment, especially when they may hide scars and deny harming themselves?
Dr. Smith: Ask at-risk patients directly about it and respond non-judgmentally. Avoid an extreme reaction; try to determine if they view self-harm as a problem. Find out the function of self-injury for that person, and ask about the antecedents.

Q: What are the most effective treatments?
Dr. Aguirre: The single best treatment is dialectical behavioral therapy (DBT), an arm of cognitive behavioral therapy. DBT has been around since the early 1990s, and it deals specifically with self-injurious and suicidal behaviors. DBT validates that these patients suffer a tremendous amount of pain and teaches them how to recognize what happens before they self-injure—having a fight with a parent, for example. DBT also teaches new patterns of thinking and offers patients other self-soothing techniques to help regulate stress.

The focus of a number of studies, DBT is showing amazing results in helping patients recover from self-harm. Research has shown, for example, that DBT often leads to a marked improvement in emotion management, interpersonal relations, and reduced use of emergency medical services. Some studies have found that 80%-90% of those who undergo DBT recover. For more information about the therapy, visit the following Web sites: faculty.washington.edu/linehan, www.southbaydbt.com/dbt.php, and www.selfinjury.com/referrals.htm (this Web site features an up-to-date therapist referral list), all accessed July 12, 2007.

Group and individual psychotherapy can also be helpful for some patients. Drugs are often prescribed based on specific target symptoms. Antidepressants and mood stabilizers may help patients who exhibit depressed or labile moods. Antipsychotic agents may also be used when there are severe distortions in thinking.

Q: When should someone be referred to a mental-health specialist? Dr. Smith: If a person identifies herself as a cutter, she should be referred—especially if there are multiple episodes or episodes are escalating in intensity.

Q: Are cutting scars permanent, or should the clinician refer the patient to a plastic surgeon once the scars are healed?
Dr. Aguirre: It depends. One kid carved his body from head to toe and the cuts formed very thick scars. Another cut herself multiple times but you have to look carefully to see it. Some people use a much finer blade so there’s less scarring. None of the kids I’ve seen requested plastic surgery. Some cover up their scars but don’t want to get rid of them—they are a reminder that they’ve been through hell and came out okay.
Dr. Smith: Some patients actually enjoy their scars. Some like to take care of their wounds and watch them heal. It’s a reminder of what happened. Scars can serve as a reminder that they don’t want to cut anymore.

These interviews were conducted by Christine Sparta, a medical writer in West New York, N.J.

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