Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation. However, in being alert to these behaviors and comfortable learning more about them from your patients, you can become a critical source of support, education, and sometimes very needed referrals for your patients and their families.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
While NSSI is theoretically distinct from suicide in that it is not intended to end one’s life but rather to relieve anxiety – emotional distress – its relationship to suicide is more complex than this distinction would suggest. Suicide is the second leading cause of death among 15- to 29-year-olds worldwide (WHO, 2014), and as many as 8% of U.S. adolescents will attempt suicide. But the rate of suicide attempts jumps among those with NSSI. In a community sample of adolescents with NSSI, 20% have attempted suicide. And in samples of adolescent psychiatric inpatients with repetitive NSSI, 70% have attempted suicide once, and 55% have made multiple attempts ( Psychiatry Res. 2006 Sep 30;144:65-72 ). In one large study that included a clinical population of adolescents and community samples of adolescents, young adults, and adults, the researchers assessed suicide attempts, suicidal ideation, NSSI, anxiety, depression, borderline personality disorder, and level of impulsivity. In their statistical analysis, only suicidal ideation and NSSI had a significant and unique relationship with attempted suicide. In many of the studies, the risk of suicide attempt was highest during the period immediately following a recurrent episode of NSSI. There is enough evidence that this may be a distinct disorder with its own risks and possibly treatments, that it is formally defined as NSSI disorder (with at least five episodes of self-injury in the past 12 months) in DSM 5 as a condition for further study.
So what does this information mean for the pediatrician? Self-injury is often a behavior that teenagers keep secret, typically cutting or scratching themselves on a part of the body that is easily covered (thighs, abdomen, upper arms). A routine physical exam, though, will easily reveal the multiple healing cuts or scratches typical of those with recurrent NSSI. Gentle but forthright questions can shift this topic from shameful to manageable. The multiple injuries and the particular pattern indicate NSSI, and you might ask your patients when they started injuring themselves, what the circumstances were, and how often it happens. Also ask: Who else knows? Are any of their friends cutting themselves? When was the last time they did it? If it is a behavior that they tried impulsively in a setting of intense emotions, or after hearing about it from friends, it may be relatively benign or at the earliest stages of becoming a more entrenched behavior. It may be worthwhile to screen for suicidal thoughts, substance abuse, depression, or anxiety disorders, and try to connect them with a therapist or a counselor at school to learn skills to better manage stress.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.