By Gail Fernandez, MD
Child Psychiatrist
Most parents believe that the transition from child to pre-teen to adolescent is fraught with behavioral and emotional challenges due to a variety of causes – hormones, peer influences, and rebelliousness to name a few. However, the vast majority of children transition through adolescence relatively unscathed and go on to live happy and productive lives. The individuals who struggle during adolescence often have underlying psychiatric disorders and are experiencing stressful environments such as family, social, health, or academic issues.
Self-injurious behavior is one maladaptive behavior that has increased in frequency in adolescents. Self-injury, “cutting,” or “self-cutting” is defined as purposeful self-harm without the intent of suicide. Cutting is usually accomplished with sharp objects (razor blades, knives, or broken glass for example) but can also include burning oneself (using fire or through friction such as rubbing an eraser repeatedly on the skin), self-biting, pinching, or punching. It is almost always a repetitive behavior, and contrary to popular belief, it is not usually an attention-seeking behavior. Research has shown that the location of the self-injury is usually in areas that are hidden by clothing such as the arms, abdomen, inner thighs, feet, genitals, and torso (especially near the breasts in females).
Self-injury occurs in both males and females, and although it is more commonly observed in females some studies indicate that it occurs equally in both sexes. Research also indicates that being a member of a sexual minority group is a risk factor for self-injury. Females who describe themselves as bisexual are more likely to self-injure. It is present in all socioeconomic classes, but is more common in ethnic minorities. Studies regarding the prevalence of self-injury are limited, but it appears to range between 4% and 38% with a 17% lifetime prevalence rate for one episode and about 10% for repetitive self-injury. Self-injury can begin as early as age seven, but the most common age at which self-injury begins is twelve to fifteen. Once an individual starts to self-injure, the duration of the behavior is variable and can last for several years.
Teens Cutting – There are many reasons adolescents turn to self-injury. Examples include:
- To distract from and/or control severe depression, anger, or anxiety by causing physical pain
- To relieve stress or pressure
- To trigger physical pain when an individual feels “numb”
- Because they enjoy causing wounds, the sight of blood, or to feel pain
- To avoid suicidal behaviors or as a substitute for suicide
- As a reaction to physical abuse, sexual abuse, or neglect
While many individuals who self-injury also attempt suicide, 60% report no history of suicidal ideation or attempts. This indicates that self-injury is a different phenomenon than suicidal behavior. Recent literature suggests that self-injury has an addictive quality and that once someone develops a pattern of using self-injury to manage their emotions, it is difficult to control. Two researchers, Grossman and Siever, have postulated “the addiction theory” The addiction theory suggest that self-injurious acts may solicit involvement of the endogenous opioid system (EOS) which regulates both pain perception and levels of endogenous endorphins which occur as a result of injury. Studies also show that there is a “contagious” quality to self-injury as well, which means that it can increase in frequency for those individuals in proximity to a self-injurer. Keep in mind, however, that many adolescents keep their self-injury hidden.
Teens Cutting – Treatment Options
The treatment of self-injury is complex; there is no simple solution. The most important first step is to identify the problem. Self-injury is often discovered after the child or adolescent has been evaluated or treated for emotional problems. However, it can be identified by watching for any unexplained cuts, marks, or burns. Also, look for individuals wearing long sleeves or clothing that hides the body especially in the wrong season or if it is out of character for the individual. One should also be concerned if the adolescent is found with sharp objects such as razor blades or broken glass and cannot explain the reason. Since many individuals with self-injury have psychiatric disorders, any signs or symptoms of depression, mood swings, or deterioration in functioning should be a cause for concern.
Once self-injury is discovered, the second step is to have the adolescent evaluated by a psychologist or psychiatrist. If the adolescent has an underlying psychiatric disorder, appropriate treatment with medications (if indicated) and/or therapy is warranted.
There is no medication that has shown to be a primary treatment for self-injury. It is important not to panic or over-react if self-injury is discovered, but to recognize it as a maladaptive coping strategy that is, unfortunately, effective in managing distressing emotions. If the approach towards self-injury is critical and punitive it can actually cause an increase in the behavior.
The goal of treatment is to find a more effective method of processing emotions and to help the adolescent realize that the self-injury is a temporary “fix” rather than an actual solution. Developing improved communication skills, coping strategies to deal with stress and distress and to remove any unintentional triggers are important goals of therapy. If there are other stressors, such as family conflict, family therapy may be indicated. It is also important to identify other stressors, such as school issues (bullying or academic problems), drug and/or alcohol abuse, and trauma (such as sexual assault). If identified, these issues must be addressed directly.
Group therapy may also be useful for those adolescents who have difficulties with social skills and communication. For severe and chronic self-injurers some areas of the country have specialized outpatient or residential programs. For parents, it is often useful to remove any sharp or tempting objects from the home to reduce the temptation.
With patience and proper treatment, many adolescents will succeed in overcoming self-injury and will go on to happy and successful lives.
