Patient Safety / Quality

Self-mutilation: The cutting truth

Whether or not you realize it, you may be caring for patients who mutilate themselves. Most people who engage in this behavior excel at hiding the signs of their injuries.

Self-mutilating behaviors include compulsively and repeatedly cutting or picking at the skin or damaging the body in other ways (such as by burning). The person may use knives, razor blades, paper clips, scissors, pens, or other sharp objects to inflict wounds in less visible areas, such as the arms, legs, abdomen, and breasts—all common sites of self-mutilation.

Unlike people who are suicidal, those who self-mutilate aren’t preoccupied with death and don’t intend to take their own lives. Instead, the mutilation is an act of control done to relieve emotional anxiety, stress, or pain or to numb intense emotions. Or, in some cases, the person is emotionally numb and uses self-mutilation as a way to feel emotions; the mutilation triggers endorphin release, which in turn causes a “high,” eases feelings of stress, and allows the person to feel again.

A growing body of knowledge

Self-mutilation is categorized as deliberately self-harming or self-injurious behaviors. Currently, no single diagnosis for self-mutilation exists, as this behavior is symptomatic of multiple disorders. In most cases, healthcare providers diagnose self-mutilating patients with “impulsive-control disorders not otherwise specified”—the classification provided by the Diagnostic and Statistical Manual of Mental Disorders (4th edition), Text Revision.

Until the 1990s, little formal information on self-injurious behaviors existed. Although such behavior has gained increasing publicity, it still isn’t considered a problem by most school and college administrators—or even by many healthcare pro­viders. One study of 2,000 elementary and secondary schools found that 75% of staff (including psychologists, social workers, nurses, nurse practitioners, special educators, principals, assistant principals, special services staff, student service workers, and teachers) viewed “cutting” as a minor problem.

But self-mutilation is not minor. In U.S. studies, 4% to 38% of adolescents reported engaging in self-harming behaviors. The cutting truth is that self-injury among adolescents is a serious problem—one that healthcare providers who work with adolescents need to stay alert for it.


Why do adolescents self-mutilate?

The rising incidence of self-mutilation may reflect the proliferation of high-stress conditions, such as domestic violence or upheaval, pressure to succeed academically, and peer pressure. Studies show adolescents begin this behavior to relieve stress. Many don’t remember how or when they started it, while others report the behavior began with less damaging means of stress relief, such as pinching themselves, and progressed to self-mutilation. Some adolescents learn this behavior from peers or siblings who engage in it and recommend it for stress relief.

The Internet (used by more than 80% of Americans ages 12 to 17) has increased awareness of self-mutilation. Studies of Internet posting boards over a 6-month period in 2004 found 3,000 postings with self-injurious behavior content. Some websites aim to give self-mutilators a safe environment in which to interact; others provide help for self-mutilating adolescents (www.kidshealth.org/teen/your_mind/mental_health/cutting.html and http://eqi.org/cutting1.htm#Notes%20about%20attention%20seeking).

Causes, comorbidities, and risk factors

Generally, self-mutilating behavior begins during adolescence, when poor coping skills can lead to maladaptive behaviors. Also, one in five adolescents has a mental, behavioral, or emotional problem. Disorders that may coexist with self-mutilation include depression, anxiety, substance abuse, eating disorders, kleptomania, borderline personality disorder, adjustment disorders, posttraumatic stress disorder, and mental retardation. (See Risk factors for self-mutilation by clicking on the pdf icon above.)

Behavioral red flags

Suspect self-mutilation in adolescents who:

  • wear long sleeves and long pants, even in warm weather
  • refuse to undress or take part in activities that require them to change clothes within view of others
  • have noticeable lacerations, burns, or scars, usually in a pattern.

No specific screening tool for self-mutilation exists. However, the American Medical Association has published recommendations that provide a framework for preventive health services for adolescents, called the Guidelines for Adolescent Preventive Services (GAPS) program. These recommendations include questionnaires and an algorithm healthcare providers can use to screen adolescents for suicide and depression (available at www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf). The questionnaires help healthcare providers initiate conversations with patients about self-harming behaviors.

If an adolescent has risk factors for depression and you suspect he or she might be self-mutilating, consider broaching the topic by mentioning that some adolescents who are depressed will cut, pick, or burn themselves to relieve their pain. Then ask, “Is this something that might happen with you?”

We have developed our own screening tool for quick assessment of adolescent self-harming behaviors. (See Assessing adolescents for self-mutilation by clicking on pdf icon above.) We recommend that in addition to using our tool or the GAPS questionnaires, you should conduct a complete assessment of the patient’s skin, noting cuts or scars that could have been inflicted by sharp objects or by picking at or burning oneself.

Treatment: Trust, therapy, medication, education

Treatment for self-injury is a lengthy endeavor requiring a multidisciplinary approach by a team that includes a psychiatrist or psychiatric nurse practitioner, psychologist, therapist, school counselor, and school nurse. The team must gain the adolescent’s trust by showing congruence, consistency, empathy, and genuineness. It should focus on stressors that may originate in the home, school, or peers, with the goal of creating a safe environment for adolescents to deal with these issues. Stress-reduction therapies commonly include individual therapy, family therapy, group therapy, and music therapy.

Building trust

When caring for a self-mutilating adolescent, maintain a nurturing attitude while acknowledging the patient’s inner pain. Give continuous encouragement and positive feedback. Take care not to place blame on the patient or the parents, as this can cause a breakdown in trust. Clear the air about causes and risk factors for self-mutilation, emphasizing that no one is at fault.

Contact child services only if you suspect abuse or neglect. Otherwise, the patient and parents may grow mistrustful. Forcibly committing the patient to a treatment facility also jeopardizes trust. A self-mutilating patient should be hospitalized only under certain conditions, which should be discussed with the adolescent and parents. Valid reasons for hospitalization include nonadherence with outpatient care, lack of parental involvement, a deep and serious physical wound, verbalization of suicidal intent, and psychosis.

Remember that maintaining confidentiality is especially important when caring for adolescents. Breaching confidentiality can breed distrust. Don’t discuss the patient’s care outside the treatment team unless a threat of injury to the self or others exists. Be familiar with confidentiality rules and regulation, and inform the patient and parents of these.

Improving the patient’s coping skills

Adolescents self-mutilate in an effort to reduce uncomfortable feelings, so teaching them better ways to cope with stress is a crucial part of treatment. Treatment includes teaching patients assertiveness and communication skills to help them express their feelings and needs verbally, which allows them to find their voices and release their feelings in appropriate ways.

Medications

Medications may be used if the patient’s stress stems from an underlying disorder, such as depression. Selective serotonin reuptake inhibitors, such as citalopram (Celexa), are first-line drugs for treating childhood and adolescent anxiety or depression; however, the Food and Drug Administration hasn’t approved them for all ages. Before drug therapy begins, the child should be screened for bipolar disorder and suicidality. After drug initiation, the patient should be monitored for suicidality by a psychiatric provider, especially during the first 2 months.

If your patient is receiving drugs, assess previous medication use (including over-the-counter medications and herbal supplements as well as prescription medications and street drugs). Conduct a thorough dietary assessment, as the effects of foods and beverages with high sugar or caffeine content can mimic signs and symptoms of anxiety disorders. Urge the patient to reduce or eliminate substances and foods that can contribute to his or her self-mutilating behaviors.

Knowledge is power

Learn as much as you can about risk factors for and signs of self-mutilation so you can identify patients who are hurting themselves. Become familiar with how self-mutilation is treated. If you suspect self-mutilation, remain nonjudgmental, and show concern in an effort to build trust from the first encounter. To help prevent self-mutilation, teach the patient about healthy coping techniques. Gaining knowledge about self-mutilation can help you brighten a child’s future.

Selected references

Derouin A, Bravender T. Living on the edge: the current phenomenon of self-mutilation in adolescents. MCN Am J Matern Child Nurs. 2004;29(1):12-19.

Favazza A. Self-injurious behaviors in college students. Pediatrics. 2006;117(6):2283-2284.

Lenhart A, Madden M, Hitlin P. Teens and technology: youth are leading the transition to a fully wired and mobile nation. http://www.pewinternet.org/~/media/Files/Reports/2005/PIP_Teens_Tech_July2005web.pdf.pdf. Accessed June 17, 2009.

Romer D, McIntosh M. Roles and perspectives of school mental health professionals in promoting adolescent mental health. In: Evans D, Fow E, Gur R, et al, eds. Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don’t Know. New York, NY: Oxford University Press; 2005:597-615.

Whitlock J, Powers J, Eckenrode J. The virtual cutting edge: the internet and adolescent self-injury. Dev Psychol. 2006;42(3):407-417.

Kimberly A. Williams and Katherine Bydalek are assistant professors at the University of South Alabama in Mobile.

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