Every year, pediatricians care for adolescents who hurt themselves deliberately, in ways that include cutting, burning, abrading, and hitting. Roughly 1 in 6 teenagers has tried self-harm at least once.1 The majority of teenagers do so only mildly or occasionally, but approximately 5% hurt themselves in serious and persistent ways.2,3 Collectively, these actions are referred to as self-injurious behavior (SIB), which is defined as the deliberate, direct destruction of body tissues. Notably, most teenagers who engage in SIB do so without the intent to kill themselves. Clinicians and researchers thus often speak of nonsuicidal self-injury (NSSI), the focus of this article.4
A pediatrician is likely the first clinician to discover that a teenager has been self-harming. Wounds or scars may be uncovered during a routine physical examination, or a panicked parent may call for an urgent evaluation of a son or daughter. The first clinical encounter can be difficult for everyone: Parents often experience guilt, betrayal, or outrage; the adolescent may feel exposed and ashamed; the pediatrician might respond with frustration or just incomprehension. The first clinical encounter is also critical for setting the stage for successful treatment. As a 15-year-old patient with a history of self-injury stated during a therapy session, “I hate it when people freak out. It makes me feel disgusting, and then I don’t want to talk.”
The goal of this article is to introduce the phenomenon of NSSI, including information on who self-injures and why. In terms of treatment, a variety of effective and evidence-based interventions for self-injury are available, but most require specific training and are implemented over a lengthy period of time, usually by psychiatrists.5 Therefore, this discussion focuses on the preliminary evaluation of NSSI, with an emphasis for primary care physicians on how to present a supportive and nonjudgmental stance that can facilitate further assessment.
It is intuitive to classify self-injury as a problem and to assume that once the behavior has stopped the patient will feel better. However, studies show that the most common function of self-injury is to manage a range of negative emotions or to create feeling where there is only numbness or emptiness.6 In other words, the problem for the patient is feeling unbearably sad, anxious, ashamed, or lonely—or not feeling anything at all. Self-injury is a solution that, in the short term, can be incredibly effective at easing intolerable emotions.
In this type of situation, NSSI provides relief immediately and independently of any response from the outside world. Adolescents do not start self-injuring “just to get attention.” In fact, many teenagers self-injure in secret for months or years before they are discovered, and rather than seeking attention will take active steps to hide their behavior. Once discovered, the behavior can take on a whole new dimension. Depending on the reaction they get from those around them, teenagers who have few emotional skills may quickly learn to use NSSI as a way to affect others.
For example, if a teenager starts cutting herself because she feels lonely and cannot bear it, and her family responds by rushing to express love and support, it is likely that she will start hurting herself every time she needs affection. Or, if a teenager is miserable at school and is allowed to stay home every time he starts hitting himself, he may continue hitting himself whenever things get particularly tense at school. Not surprisingly, then, adolescents in community samples report using NSSI as a means of influencing people and of communicating distress.3
As these examples suggest, NSSI can work to avoid something unpleasant or to provoke a reaction, even if it is a negative one. Therefore, many practitioners may dismiss adolescents who self-injure as manipulative. However, it is normal to want attention. Everyone tries to minimize suffering and to maximize pleasure. The problem is that the self-harming adolescent may not know how to ask for help in a direct or effective way. Self-injury is a temporary and blundering solution to a failure to communicate or to have critical needs met.
Far from being the master manipulators that some may make them out to be, teenagers who cut or hit themselves are often trying to manage their emotions and their relationships without really knowing how. Simply put, in our experience, many adolescents who self-injure do so because they do not know what else to do. This is an important underpinning of many of the treatments for NSSI, which aim to teach alternative problem-solving methods.