Cutting: Putting the pieces together

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. 

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. 

Cutting, otherwise known as nonsuicidal self-injury (NSSI), is a frightening and complex disorder that is prevalent among adolescents, but poorly understood. Typically, pediatricians see distraught parents who, unaware that their children were even depressed, have discovered that they engage in self-harming activities. Quick answers are needed, and with most psychology services being overwhelmed, an immediate evaluation is unlikely. Therefore, it is important to have a clear understanding and resources available to help defuse the situation.

For most, it is hard to understand why young people would want to inflict bodily harm on themselves. The questions that always arise are, was this a suicide attempt? Or, was it a cry for help? Well, the answer to both is quite surprisingly "no," at least in the majority of cases.

Cutting, or NSSI, is an unhealthy reaction to anxiety, pain, frustration, or stress. It is an impulsive behavior that is not necessarily associated with intent to die.

A 2007 study showed that 46% of 633 9th and 10th graders admitted to a least one episode of cutting, burning, scratching, or hitting themselves in response to emotional stress (Psychol. Med. 2007;37:1183-92).

The prevalence of NSSI among adolescents is reported to be 14%-15% and declines to 4% by adulthood (J. Youth Adolesc. 2002;31:67-77). There is no significant gender difference, but the method of self-harm for females tends to be cutting, whereas males are more likely to hit or burn themselves.

So why do people want to inflect pain on themselves? Well, there is a physiologic basis for the most common reason, which is termed affect regulation. Although not completely understood, it is believed that by eliciting pain, endorphins are released, and there is an immediate relief of anxiety, pain, or stress. Most "cutters" report infrequent episodes, but some do become addicted to the sensation, and the episodes increase.

Another reason for cutting is self-punishment. Young people who suffer from low self-esteem, or self-degradation, may use self-harm to express anger toward themselves.

A surprising finding was that interpersonal influence was one of the least common reasons given for self-harm. It is not a common method for a "cry for help" or attention as is a suicide attempt. People who cut are looking for an immediate relief from the emotional stress they are feeling. In fact, many are very secretive about this behavior, and it usually goes unnoticed for several months to years.

Although NSSI can occur independently of any psychological dysfunction, it has been found to have a comorbidity with borderline personality disorder (BPD), anxiety, and depression. All of these disorders are associated with negative emotional stress. Sexual abuse and self-harm are associated because they have the same psychological risk factors but not a cause and effect relationship with NSSI (J. Clin. Psychol. 2007;63:1045-56).

One of the biggest risk factors for suicide is the frequency of the cutting. Addiction to the behavior resulting in daily or weekly episodes does significantly increase the risk of a suicide attempt. Therefore, anyone who presents with a history of cutting should have a Suicide Risk Assessment completed.

First-line treatment for nonsuicidal self-harm is psychotherapy, for example, cognitive-behavioral therapy. Pharmacotherapy of comorbid conditions such as depression and anxiety can be helpful in reducing symptoms, and therefore reducing episodes.

Understanding the psychology behind self-harm will be very helpful in educating and calming families through this difficult situation. Being able to direct the patient to the appropriate resources will expedite evaluation and treatment. Such resources include www.selfinjury.com, www.helpguide.org/mental/self_injury.htm, and www.selfinjury.bctr.cornell.edu.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].