Kim J. Masters, MD

Although self-harm behaviors such as burning or cutting are common among adolescents, they are a source of concern for parents and friends, and challenging to treat. Treatments have focused on distracting stimuli such as ice or the sting of a rubber band snapped on the wrist. Tattooing may be an alternative somatic strategy that can decrease self-harm and counter negative body image.^1,2

In a study of 423 individuals with body modification (tattoos and piercings), 27% admitted to cutting themselves during childhood.³ This study’s authors concluded that these practices became a substitute for self-harm, helped patients overcome traumatic experiences, and improved satisfaction with body image.

In line with these observations, we decided to offer temporary tattooing to residents in our 60-bed child and adolescent treatment center. Patients were age 6 to 20 and 70% were female. We received consent from all patients’ guardians after explaining the temporary, nontoxic nature of the ink or decals.

Our first trials were with adolescent females with a history of cutting, but we offered temporary tattooing to all patients within a few months. Overall, 7 females and 3 males, all of whom had an axis I mood disorder, participated in temporary tattooing as an alternative to self-harm. We noted borderline personality traits in female patients who engaged in severe self-harm. Patients either drew on themselves or, with therapist supervision, “tattooed” other patients using self-selected designs.

One older teenage girl used cutting to manage flashbacks of sexual abuse from a family member. She had multiple scars from the cutting despite outpatient, hospital, and residential treatment over several years without symptom improvement. After 1 year of tattooing, her cutting episodes decreased from several times per month to once every 3 months. She also reported an improvement in positive perception of her body image from 0 on a 1-to-10 scale on admission to 5 at 1 year.

A younger teenage female without visible scars used cutting to manage feelings of being ugly associated with memories of sexual abuse. She reported that over 3 months, drawing tattoos improved her feelings about her body from 0/10 to 4/10, and she no longer reported thoughts of cutting or self-harm. Over 3 months, a male teenager without scars who cut himself when distressed about female relationships instead used tattoos to draw his conflicted feelings on his arm.

Tattoo designs included:

• flowers, vines, and roses
• patients’ psychological issues
• 2 faces for a patient dealing with internal and external relationship conflicts
• 2 flags to represent melding different cultures
• 2 hearts fused to represent issues with the intensities of love
• foreign words to indicate secrecy and alienation
• fantasy daydreams reflected as unicorns and dolphins.

Patients’ conversations with their therapists about the tattoos enabled detailed discussions about abuse, body image, and relationships.

Parents and some of our staff initially were concerned that temporary tattoos would increase self-harm or high-risk behaviors. This did not occur, perhaps because patients felt the designs helped them visually express feelings and conflicts.

Our clinical experience indicates that temporary tattooing may be a method of discussing and altering self-harm behaviors and negative body image in adolescent inpatients. Further evaluation of this strategy is warranted.

Disclosure

Dr. Masters reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Although self-harm behaviors such as burning or cutting are common among adolescents, they are a source of concern for parents and friends, and challenging to treat. Treatments have focused on distracting stimuli such as ice or the sting of a rubber band snapped on the wrist. Tattooing may be an alternative somatic strategy that can decrease self-harm and counter negative body image.^1,2

In a study of 423 individuals with body modification (tattoos and piercings), 27% admitted to cutting themselves during childhood.³ This study’s authors concluded that these practices became a substitute for self-harm, helped patients overcome traumatic experiences, and improved satisfaction with body image.

In line with these observations, we decided to offer temporary tattooing to residents in our 60-bed child and adolescent treatment center. Patients were age 6 to 20 and 70% were female. We received consent from all patients’ guardians after explaining the temporary, nontoxic nature of the ink or decals.

Our first trials were with adolescent females with a history of cutting, but we offered temporary tattooing to all patients within a few months. Overall, 7 females and 3 males, all of whom had an axis I mood disorder, participated in temporary tattooing as an alternative to self-harm. We noted borderline personality traits in female patients who engaged in severe self-harm. Patients either drew on themselves or, with therapist supervision, “tattooed” other patients using self-selected designs.

One older teenage girl used cutting to manage flashbacks of sexual abuse from a family member. She had multiple scars from the cutting despite outpatient, hospital, and residential treatment over several years without symptom improvement. After 1 year of tattooing, her cutting episodes decreased from several times per month to once every 3 months. She also reported an improvement in positive perception of her body image from 0 on a 1-to-10 scale on admission to 5 at 1 year.

A younger teenage female without visible scars used cutting to manage feelings of being ugly associated with memories of sexual abuse. She reported that over 3 months, drawing tattoos improved her feelings about her body from 0/10 to 4/10, and she no longer reported thoughts of cutting or self-harm. Over 3 months, a male teenager without scars who cut himself when distressed about female relationships instead used tattoos to draw his conflicted feelings on his arm.

Tattoo designs included:

• flowers, vines, and roses
• patients’ psychological issues
• 2 faces for a patient dealing with internal and external relationship conflicts
• 2 flags to represent melding different cultures
• 2 hearts fused to represent issues with the intensities of love
• foreign words to indicate secrecy and alienation
• fantasy daydreams reflected as unicorns and dolphins.

Patients’ conversations with their therapists about the tattoos enabled detailed discussions about abuse, body image, and relationships.

Parents and some of our staff initially were concerned that temporary tattoos would increase self-harm or high-risk behaviors. This did not occur, perhaps because patients felt the designs helped them visually express feelings and conflicts.

Our clinical experience indicates that temporary tattooing may be a method of discussing and altering self-harm behaviors and negative body image in adolescent inpatients. Further evaluation of this strategy is warranted.

Disclosure

Dr. Masters reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Although self-harm behaviors such as burning or cutting are common among adolescents, they are a source of concern for parents and friends, and challenging to treat. Treatments have focused on distracting stimuli such as ice or the sting of a rubber band snapped on the wrist. Tattooing may be an alternative somatic strategy that can decrease self-harm and counter negative body image.^1,2

In a study of 423 individuals with body modification (tattoos and piercings), 27% admitted to cutting themselves during childhood.³ This study’s authors concluded that these practices became a substitute for self-harm, helped patients overcome traumatic experiences, and improved satisfaction with body image.

In line with these observations, we decided to offer temporary tattooing to residents in our 60-bed child and adolescent treatment center. Patients were age 6 to 20 and 70% were female. We received consent from all patients’ guardians after explaining the temporary, nontoxic nature of the ink or decals.

Our first trials were with adolescent females with a history of cutting, but we offered temporary tattooing to all patients within a few months. Overall, 7 females and 3 males, all of whom had an axis I mood disorder, participated in temporary tattooing as an alternative to self-harm. We noted borderline personality traits in female patients who engaged in severe self-harm. Patients either drew on themselves or, with therapist supervision, “tattooed” other patients using self-selected designs.

One older teenage girl used cutting to manage flashbacks of sexual abuse from a family member. She had multiple scars from the cutting despite outpatient, hospital, and residential treatment over several years without symptom improvement. After 1 year of tattooing, her cutting episodes decreased from several times per month to once every 3 months. She also reported an improvement in positive perception of her body image from 0 on a 1-to-10 scale on admission to 5 at 1 year.

A younger teenage female without visible scars used cutting to manage feelings of being ugly associated with memories of sexual abuse. She reported that over 3 months, drawing tattoos improved her feelings about her body from 0/10 to 4/10, and she no longer reported thoughts of cutting or self-harm. Over 3 months, a male teenager without scars who cut himself when distressed about female relationships instead used tattoos to draw his conflicted feelings on his arm.

Tattoo designs included:

• flowers, vines, and roses
• patients’ psychological issues
• 2 faces for a patient dealing with internal and external relationship conflicts
• 2 flags to represent melding different cultures
• 2 hearts fused to represent issues with the intensities of love
• foreign words to indicate secrecy and alienation
• fantasy daydreams reflected as unicorns and dolphins.

Patients’ conversations with their therapists about the tattoos enabled detailed discussions about abuse, body image, and relationships.

Parents and some of our staff initially were concerned that temporary tattoos would increase self-harm or high-risk behaviors. This did not occur, perhaps because patients felt the designs helped them visually express feelings and conflicts.

Our clinical experience indicates that temporary tattooing may be a method of discussing and altering self-harm behaviors and negative body image in adolescent inpatients. Further evaluation of this strategy is warranted.

Disclosure

Dr. Masters reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Orlistat is an FDA-approved anorexic agent for adults and adolescents that interferes with gastrointestinal lipase and prevents the absorption of 30% of dietary fat. Some clinical trials have failed to show significant weight reduction with orlistat,^1,2 but in our adolescent residential psychiatric treatment center:

• 15 patients (13 girls and 2 boys) lost an average 17.9 lbs over 4 months
  
• one patient lost 100 lbs over 8 months.
  

In a naturalistic observation, we offered orlistat plus dietary counseling to all teenage patients with a body mass index (BMI) >25 kg/m². Gastrointestinal (GI) side effects, such as odoriferous loose stools and fat-stained and occasionally soiled underwear, are common.

Factors contributing to weight loss

Motivation. Most of our patients gained weight while being treated with psychiatric medications, particularly mood stabilizers and atypical antipsychotics. These were continued during orlistat use.

Larger waist sizes and exaggerated facial and body features diminished our overweight patients’ self-respect and made them targets of bullying and rejection. Weight loss helped reverse these negative factors. Peers often supported these changes by including the teens in their circle of friends. Self-esteem, maturity, and motivation for personal growth were reflected in the teens’ social and psychotherapeutic encounters.

Overweight. Weight loss was statistically significant in teens with BMI >25 kg/m². Average pre-orlistat weight was 193 lbs and BMI 33 kg/m². Average BMI loss was 4.3 kg/m² (median loss 3.7 kg/m², standard deviation ±4.08). Although we did not treat patients with initial BMI

Diet, dosing, and activity. Our patients began a low-fat, 1,800-calorie diet in 3 meals and 2 snacks per day. They also received a daily supplement with vitamins A, D, E, and K to prevent deficiencies from the loss of fat-soluble vitamins.

Orlistat, 120 mg tid, was dispensed before meals, which enhanced awareness of healthy food choices because high-fat foods caused GI side effects.

As patients lost weight, they became more interested in exercise, and tolerance for physical activity improved.

Monitoring and support. Nursing staff weighed the teenagers weekly. Patients also had twice-monthly psychiatric assessments of orlistat’s impact on their medical, psychiatric, and psychopharmacologic status. The teens’ primary concerns included the amount of weight loss and GI side effects.

Summary. Under these conditions, orlistat may be an effective weight loss medication that can enhance self-esteem in motivated, overweight teenagers with psychiatric comorbidities.

Orlistat is an FDA-approved anorexic agent for adults and adolescents that interferes with gastrointestinal lipase and prevents the absorption of 30% of dietary fat. Some clinical trials have failed to show significant weight reduction with orlistat,^1,2 but in our adolescent residential psychiatric treatment center:

• 15 patients (13 girls and 2 boys) lost an average 17.9 lbs over 4 months
  
• one patient lost 100 lbs over 8 months.
  

In a naturalistic observation, we offered orlistat plus dietary counseling to all teenage patients with a body mass index (BMI) >25 kg/m². Gastrointestinal (GI) side effects, such as odoriferous loose stools and fat-stained and occasionally soiled underwear, are common.

Factors contributing to weight loss

Motivation. Most of our patients gained weight while being treated with psychiatric medications, particularly mood stabilizers and atypical antipsychotics. These were continued during orlistat use.

Larger waist sizes and exaggerated facial and body features diminished our overweight patients’ self-respect and made them targets of bullying and rejection. Weight loss helped reverse these negative factors. Peers often supported these changes by including the teens in their circle of friends. Self-esteem, maturity, and motivation for personal growth were reflected in the teens’ social and psychotherapeutic encounters.

Overweight. Weight loss was statistically significant in teens with BMI >25 kg/m². Average pre-orlistat weight was 193 lbs and BMI 33 kg/m². Average BMI loss was 4.3 kg/m² (median loss 3.7 kg/m², standard deviation ±4.08). Although we did not treat patients with initial BMI

Diet, dosing, and activity. Our patients began a low-fat, 1,800-calorie diet in 3 meals and 2 snacks per day. They also received a daily supplement with vitamins A, D, E, and K to prevent deficiencies from the loss of fat-soluble vitamins.

Orlistat, 120 mg tid, was dispensed before meals, which enhanced awareness of healthy food choices because high-fat foods caused GI side effects.

As patients lost weight, they became more interested in exercise, and tolerance for physical activity improved.

Monitoring and support. Nursing staff weighed the teenagers weekly. Patients also had twice-monthly psychiatric assessments of orlistat’s impact on their medical, psychiatric, and psychopharmacologic status. The teens’ primary concerns included the amount of weight loss and GI side effects.

Summary. Under these conditions, orlistat may be an effective weight loss medication that can enhance self-esteem in motivated, overweight teenagers with psychiatric comorbidities.

Orlistat is an FDA-approved anorexic agent for adults and adolescents that interferes with gastrointestinal lipase and prevents the absorption of 30% of dietary fat. Some clinical trials have failed to show significant weight reduction with orlistat,^1,2 but in our adolescent residential psychiatric treatment center:

• 15 patients (13 girls and 2 boys) lost an average 17.9 lbs over 4 months
  
• one patient lost 100 lbs over 8 months.
  

In a naturalistic observation, we offered orlistat plus dietary counseling to all teenage patients with a body mass index (BMI) >25 kg/m². Gastrointestinal (GI) side effects, such as odoriferous loose stools and fat-stained and occasionally soiled underwear, are common.

Factors contributing to weight loss

Motivation. Most of our patients gained weight while being treated with psychiatric medications, particularly mood stabilizers and atypical antipsychotics. These were continued during orlistat use.

Larger waist sizes and exaggerated facial and body features diminished our overweight patients’ self-respect and made them targets of bullying and rejection. Weight loss helped reverse these negative factors. Peers often supported these changes by including the teens in their circle of friends. Self-esteem, maturity, and motivation for personal growth were reflected in the teens’ social and psychotherapeutic encounters.

Overweight. Weight loss was statistically significant in teens with BMI >25 kg/m². Average pre-orlistat weight was 193 lbs and BMI 33 kg/m². Average BMI loss was 4.3 kg/m² (median loss 3.7 kg/m², standard deviation ±4.08). Although we did not treat patients with initial BMI

Diet, dosing, and activity. Our patients began a low-fat, 1,800-calorie diet in 3 meals and 2 snacks per day. They also received a daily supplement with vitamins A, D, E, and K to prevent deficiencies from the loss of fat-soluble vitamins.

Orlistat, 120 mg tid, was dispensed before meals, which enhanced awareness of healthy food choices because high-fat foods caused GI side effects.

As patients lost weight, they became more interested in exercise, and tolerance for physical activity improved.

Monitoring and support. Nursing staff weighed the teenagers weekly. Patients also had twice-monthly psychiatric assessments of orlistat’s impact on their medical, psychiatric, and psychopharmacologic status. The teens’ primary concerns included the amount of weight loss and GI side effects.

Summary. Under these conditions, orlistat may be an effective weight loss medication that can enhance self-esteem in motivated, overweight teenagers with psychiatric comorbidities.