Search This Blog

Wednesday, December 14, 2011

Why do teens cut (self harm)?

      Deliberate Self-Harm (DSH) is the latest term used to describe a set of behaviors, including: cutting, needle-sticking, rubbing against rough surfaces, severe scratching, burning, hitting or banging limbs, and interfering with wound healing. These behaviors are not performed with the intent to die (commit suicide) and they are rarely life-threatening or medically severe.

Getting teens to stop cutting behavior too quickly may
make them more likely to engage in suicidal behavior.
Learning new ways to express feelings and cope with
strong feelings takes time. Caregivers need to be patient.
   All the labels for this behavior are meant to describe the same behaviors. NSSI (non-suicidal self-injury) is another more recent clinical term that emphasizes the importance of understanding that these behaviors are not to be confused with suicide. A careful evaluation by a licensed mental health professional is necessary in order to determine suicide risk. While DSH itself is not done with suicide intent, persons who engage in DSH are at greater risk of suicide than the general population. But there are many risk factors and protective factors for suicide, so a full assessmen is necessary. Many teens and adults have probably been hospitalized unnecessarily in response to DSH. The costs of inpatient hospitalization are high and so it is something that should not been taken lightly (social, mental & emotional, and financial).
 Subscribe in a reader

     The prevalence of DSH has increased this decade. In two studies from 2006 and 2007, mental health researchers found that 40-80% of adolescent psychiatric patients reported a history of self-harm, and 20% of adults reported a history of self-harm. Current estimates put nation-wide prevalence between 4% of all adults. Rates between men and women are quite similar, but are higher in white persons over minorities. Adolescents have the highest rates (13-23% depending upon the sample size of the study).  Most persons who self-injure do so using mulitple methods. Also, most persons who self-injure do so only 1-3 times and very few continue self-harm after that (keep in mind that these are self-reports).

The age of onset is between 12w and 14 years old
with the most common forms of self-harm being
cutting, scratching, hitting, banging, and burning.

     At one time, DSH was limited to Borderline Personality Disorder, however, research in the last 10 years has clearly shown that self-harm is not associated with any specific mental health diagnosis; teens who cut may suffer from depression, anxiety, "emerging" personality disorders, or other disorders. In adults, DSH does remain highly correlated with Borderline Personality Disorder, but it is also associated with several other personality disorders; this is probably because DSH is not a core symptom of any one mental health disorder, but it is currently only listed as a criteria for Borderline Personality Disorder.

     There are several reasons that people engage in self-harm, by their own reports, including, in order of frequency: (1) the desire to regulate or alleviate intense and overwhelming negative emotions or feelings; (2) self-punishment (expressing anger at self); and (3) for a small number of persons, they may self-injure to influence others, to interrupt depresonalization or dissociation, to cope with suicidal thoughts, to bond with friends, or to feel excited.

In reviewing dozens of studies, researchers found
that about 50% of persons who DSH do so to 
punish themselves.This means that many self-injurers 
engage in self-harm for two or more reasons.

     Currently, there are no medications available to treat the behavior of self-harm. In other words, the FDA has no approved any medications for treating it, and there is no research indicating that any medications work for it. Medications that reduce the intensity of emotional reactions may help; however, some psychotropics like SSRI's are a risk factor for self-harm and suicide ideation and behavior. The option to try medications should be weighed against the pros and cons of using drugs to treat mental health problems. Since most persons who engage in DSH will not continue the behavior, medications may not be necessary for this problem alone.

      Even for those who do continue engaging in DSH, medication will not teach them how to regulate their moods, cope with self-anger and relationship problems, tolerate negative emotional states, and cope with other problems that lead to self-harm behaviors. Like most mental health problems, medications probably are not appropriate either because they foster dependence, often work no better than a placebo, and can have very negative short and long-term side effects as well as mild to severe withdrawal syndromes.

     Some studies indicate that psychotherapy can reduce DSH. However, not just any type of therapy. Specifically, therapies that include the following components seem to help alleviate DSH, however, more research is needed in order to find the most effective psychotherapies for helping teens and adults end self-harm.

Psychotherapy should include:
(1) functional assessment
(2) emotional intelligence & regulation
(3) problem solving
(4) physical exercise

     Studies on psychotherapy are limited. It does appear that person who engage in DSH more frequently or continusoulsy may experience greater, immediate relief from the behavior. This wouldn't come as a surprise since behavior tends to be repeated with reinforcement and usually will not continue if it is not reinforced. So, behavioral interventions may help teens reduce DSH, too. 


    I suspect that the authoritarian parenting-style may be a risk factor for DSH as well as an avoidant temperament on the part of the teen, or significant temperamental differences between child and parent (volatile v. avoidant). Also, parents who are dismissive of a child's feelings or prevent them from venting their feelings ("don't talk back to me, that's disrespectful), may be a factor in the formation of the problem as teens may never feel safe venting strong emotions and instead "bottle them up."  In this scenario, children may be unable to learn through day-to-day experience how to regulate their moods simply because they don't get the practice they need in an environment of patience and tolerance by the parents.

   Since self-anger is accounts for so much of self-harm, demands on children to be exceptional may lead to increased anxiety and guilt. Perfectionistic thinking may also contribute to the problem and some parents may unwittingly reinforce this trait.

     I have seen self harm lead to permanent scarring and infections (e.g., MRSA or sepsis), so a harm-reduction attitude is probably a worthwhile. When working with teens, it may be best to involve the family if self-harm behaviors are present. Parents can help monitor for the behavior and reinforce techniques that the teen learns in therapy. This is probably especially true for teens with substance abuse problems, psychosis, or impulsivity since they may be at even higher risk of significant complications from self-harm.

     There are no prevention programs for DSH in Illinois. Prevention interventions by schools or parents for teens may help reduce the incidence of self-harm.  Education about DSH at age 12 is probably early enough. Graphic images are not necessary (there's no value in shock therapies regardless of how often you see them advertised or promoted and they may actually traumatize teens).  However, teaching children and teens about behaviors that are conducive to alleviating anxiety or other intense emotions as well emotional regulation/intelligence may help. 

Sources for information contained in this posting include:
   Klonsky, E. David & Jennifer J. Muehlenkamp, Self-Injury: A research review for the practitioner, Journal of Clinical Psychology, Volume 63, Issue 11, pages 1045-1056, November, 2007. Wiley Periodicals, Inc., A Wiley Company.
   Mikolajczak, Moira, K.V. Petrides & Jane Hurry, Adolescents choosing self-harm as an emotion regulation strategy: The protective role of trait emotional intelligence, British Journal of Clinical Psychology, Volue 48, Issue  2, pages 181-193, June 2009. 
   Klonsky, E. David, Nonsuicidal Self-Injury, Corsini Encyclopedia of Psychology, Januare 30, 2010. 
   Ourgrin, Dennis & Saquib Latif, Specific Psychological Treatment Versus Treatment as Usual in Adolescents with Self-Harm, Crisis: The Journal of Crisis Intervention and Suicide Prevention, Volue 32, November 2, 2011. 

Mental Health Advice Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

No comments:

Post a Comment