Pediatricians are most likely the first clinicians to discover that a teenager is engaging in self-harming behavior, and it’s their evaluation of the context and severity of the self-injury as well as their empathetic relationship with the patient that sets the stage for treatment.
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.
Based on the explanations we have offered, young people use NSSI to manage negative or empty feelings and to communicate suffering when they lack the ability to apply more effective solutions. Therefore, it makes sense that rates of self-injury are highest in those with troubling emotions, complex or stormy relationships, and poor coping skills.5
The Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, mentioned NSSI only as a symptom of borderline personality disorder (BPD), which in adults is defined as a pervasive pattern of unstable relationships, self-identity, and emotion, accompanied by impulsivity.7 Thus, NSSI in adolescence was considered a marker of severe and potentially lifelong illness. However, research suggests that NSSI often occurs independently of BPD; for example, in patients with depression or substance abuse or even in those with no other diagnosable psychopathology.5,8 Therefore, NSSI is now recognized as a distinct condition in the DSM-5.4 Future research will likely define subtypes of NSSI, some of which are more likely to persist into adulthood than others.
Estimates of the prevalence of self-injury vary according to assessment methodology and by whether or not nonfatal suicide attempts are included in the count. However, self-injury is accepted to be especially common in teenagers. Rates in community samples average around 18% as compared with 6% in the adult population.1,9 Rates are comparable in North America, Europe, Australia, and Asia, indicating that NSSI is an international phenomenon.1 Although NSSI has been traditionally associated with girls and women, more recently studies suggest there may not be a gender difference in prevalence.10
By definition, NSSI is self-injury carried out without the wish to die. In the moment, people who engage in this type of self-injury are not exhibiting suicidal behavior. On the contrary, they often use NSSI as a way to make being alive more bearable. Nevertheless, NSSI is a risk factor for later suicide attempts.
As a recent review article highlights, individuals who engage in NSSI are more likely to think about suicide and to actually attempt killing themselves.11 Nonsuicidal self-injury that occurs more frequently and in more severe forms is also a strong predictor of suicidal behavior. In a clinical sample of depressed teenagers, NSSI predicted future suicide attempts just as strongly as past suicide attempts.12 This link between NSSI and suicide held up even when the reviewers controlled for demographic differences, psychosocial conditions, and comorbid psychopathologies.
It remains unclear whether NSSI leads directly to suicidal behavior or if unbearable feelings lead to both. Regardless, adolescents who engage in NSSI should be assessed for immediate suicide risk as part of their clinical evaluation, even if suicide is not necessarily the sole or central focus.
Teenagers turn to self-injury as a solution to problems for various reasons, including genetics, temperament, or particular stressors. Thus, self-injury might be the sign of a relatively healthy teenager under extreme duress, or of a generally vulnerable teenager under more mild circumstances. For example:
CASE 1:Consider a teenager whose boyfriend breaks up with her just 2 weeks after her best friend moves to another city. She has experienced some mild anxiety for years but is usually able to keep it in check. She does well in school and enjoys her guitar lessons. Today, however, she feels sad and alone, certain that she will never be happy again. With her boyfriend and her best friend gone, there is no one who will understand how she is feeling. She knows of a friend who cuts herself. While in the shower after school, she superficially cuts her wrist with the blade from her shaving razor. The pain helps her “snap out of it,” and by the time her mother comes home from work she is able to tell her that she is feeling sad.
CASE 2:More concerning is the teenager who has been in treatment for attention deficit disorder since elementary school. He used to be able to keep up with his schoolwork, thanks to medication and help from teachers, but now that high school has started he is overwhelmed. He is afraid that his new friends will make fun of him if they find out that he has a learning disability, and he is ashamed to ask for more support. He stops turning in his homework on time and daydreams and doodles in class. He feels dumb, pathetic, and anxious about all the work that he has not done. He and his parents have started fighting about his slipping grades. He spends more and more time alone in his room playing video games. He is not sleeping well. He starts thinking that it would be better if he just did not wake up in the morning. While sitting in class, he rubs the skin of his forearm hard with an eraser until it blisters and bleeds. This calms him down enough so that he can get through the hour without running out of class or yelling at the teacher.
CASE 3: At the most severe end of the spectrum is the teenager who has been cutting and burning herself almost every day for months. It feels as if everyone in the world is against her. She used to have friends, but they are frustrated that she is not getting better. They are sick of her sending text messages in the middle of the night asking for help. She just cannot seem to get a handle on her mood, which swings from angry to sad and back again for reasons she cannot explain. Cutting herself is like hitting a “reset” button and helps her stay calm, but it only lasts until her next text message goes unanswered. Her parents are at their wits’ end, and she is fairly sure that if they could get rid of her, they would. She feels terribly guilty about being such a mess and also furious when they will not let her go out with the new guy she met. The next time her mother takes away the car keys, she walks into the kitchen and puts her hand on the stove. The pain feels like appropriate punishment for being such a bad person, but her mother still does not seem to understand just how bad she makes her feel. Later that night she sneaks out of the house, calls her new “boyfriend,” and has sex with him. She comes home before anyone is awake, thinks about killing herself, and looks for her razor.
As these vignettes illustrate, teenagers have different problems that they are trying to solve, and some are more or less well equipped to do so. It is the pediatrician’s job to evaluate the context and severity of self-injury to set the stage for successful further treatment.
When evaluating a teenager who engages in NSSI, it is important to first establish a general relationship with the patient by asking about school, home life, friendships, and activities. Then, a pediatrician can ease into asking about NSSI (Table 1). A good first question is “What does your self-injury help you with?” This is the same as simply asking “Why do you self-injure?” but the former question is less likely to be perceived as accusatory. Phrased in this way, the question demonstrates an understanding of the use of NSSI as a solution or self-treatment. Thus, it can open the door to a more specific discussion of psychiatric symptoms (depression, anger, anxiety) and interpersonal stressors (strained relationships with parents, breakups, loss of friendships).
Another approach is to ask the patient to remember a specific instance of self-injury. Helpful questions can include: “Do you remember how you were feeling before you injured yourself? How did that change after you injured yourself? How do you feel about it now?” Try to create a place that is nonjudgmental and safe.
Next, a pediatrician should try to gain information on the patient’s mood and the logistics of self-injury: “How do you do it? What instrument do you use? How often do you do it? What part of your body is involved?” The doctor should also provide factual medical information that can help minimize complications and additional injury. For example, physicians can counsel patients about the risks of blood-borne illnesses and ensure tetanus vaccinations are up to date.
Self-injury is a sign that a teenager is both experiencing uncomfortable feelings and is ill equipped to manage them. Therefore, the general practitioner should ask about other dangerous behaviors that, like self-injury, tend to be used to cope with stress. Disordered eating, substance abuse, and risky sexual activity are all associated with self-injury and can have independent medical consequences that warrant evaluation.5 Normalizing the experience can help teenagers talk about behaviors that they believe might get them into trouble. Try asking “Do you do anything else to make yourself feel better that might be risky in the long run?” or “Has your stress gotten so bad that you have turned to drugs or alcohol to try to escape?”
Of note, although many practitioners used to take for granted that teenagers who engage in NSSI had experienced childhood abuse, recent research has indicated that the relationship is much more modest.13 Many who have been abused do not go on to self-injure and many who self-injure have never been abused. Nevertheless, abuse does happen, both inside and outside the home, and the office of a trusted physician may be a good place to talk about it. A helpful first way to inquire is to ask “Has anyone hurt you-physically or mentally-in a way that is still affecting you?” In addition to screening for abuse by adults, the practitioner should specifically ask about bullying, which is often overlooked and can be severe.
Finally, although we have shown that NSSI should not be confounded with suicidal behavior, it is critical to evaluate for suicide risk. This is an area where it is helpful to be matter-of-fact, with progression from the general to the specific: “Have things ever gotten so bad that you thought you might be better off dead? Have you thought about killing yourself? Are you thinking of killing yourself now? Do you have a plan for how you might do it?” The word “kill,” although jarring, is chosen to be distinct from the word “hurt.”
For the sake of building an alliance, and of doing a complete evaluation, it is essential to also ask about what is going well for the patient. Is there a friend who is particularly supportive? Is there a class at which the patient excels? Does the patient have an artistic or musical talent? These relationships and skills are the basis for some level of self-esteem. They can be drawn on in therapy to help the teenager to get better and also to provide a picture of someone who is more than just a “self-injurer.”
Many teenagers will ask if what they reveal can be kept secret. Although conversations between physicians and their patients are generally confidential, when safety is at stake a patient’s parents will need to be informed. In the case of NSSI, this means the answer to that question is often “no.” It is important to explain to teenagers that their safety is your primary concern and that you will do what it takes to preserve it.
You can offer to help them tell their parents about the problem, and to mediate what is likely to be an emotionally charged conversation. You can also assure them that you will not talk to their parents without their knowledge. It is important that parents or legal guardians be informed so that they can support and participate in treatment. Most teenagers who are talking about NSSI for the first time are embarking on a lengthy road involving many encounters with healthcare professionals. It may be expedient in the short term, but it is most certainly damaging in the long term to promise confidentiality that you cannot or should not deliver.
Currently, the US Food and Drug Administration has not approved any medication for the specific treatment of self-injury. Patients who additionally suffer from depression and/or anxiety may benefit from the pharmacologic treatments of those conditions. Researchers have also suggested that NSSI works to control negative emotions via the endogenous opioid system.14 This raises the possibility that the opioid antagonist naltrexone (ReVia) might be effective in the treatment of NSSI, perhaps by blocking reward pathways and preventing positive reinforcement. Although helpful to treat associated disorders such as depression, medication is not a treatment for NSSI.
Different types of therapy for the treatment of NSSI have in common the necessity for consistent therapeutic contact for a relatively long time. Practically speaking, a teenager who self-injures warrants a referral to a mental health professional (Table 2). How and with what urgency the referral is made depends on the risk to the particular patient in question. Teenagers who are more fragile, more isolated, less successful, and who have families with fewer resources will require referral more urgently to a mental health clinician than others who are not at such high risk.
Any patient who is at imminent risk for suicide should be evaluated immediately by a crisis team or in an emergency department. He or she may require inpatient hospitalization to ensure safety in the short term. The inpatient team should then assist the pediatrician and the family in establishing longer-term outpatient mental health care.
Thus far, treatment for self-injury has been considered in the context of treatment for BPD. Perhaps with the development of the DSM-5’s new diagnosis, trials of treatments specifically designed for NSSI will come. The good news is that there are several empirically validated psychosocial treatments for BPD and its symptoms, including NSSI. These include transference-focused psychotherapy, mentalization-based psychotherapy, and dialectical behavior therapy, as well as manual-assisted cognitive-behavioral therapy.5 These therapies differ in theoretical underpinnings, method of application, and emphasis of treatment, but all provide the patient with the opportunity to acquire new skills for the management of ways to solve the problems of emotional distress and interpersonal conflict.
The goal of the pediatrician’s care is to establish a safe doctor-patient relationship, which will help the patient accept services and participate actively in treatment. Given the disturbing nature of self-injury and the frequent assumption that those who self-injure are “just manipulating” those around them, it can be difficult for the pediatrician to reach the respectful and nonjudgmental stance that is most effective in building a safe, trusting relationship. A better understanding of why teenagers self-injure and what can be done to help them get better is a first step in creating a comfortable, empathetic relationship. This work is difficult-but rewarding.
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Dr Brickell is a resident in child and adolescent psychiatry, Massachusetts General Hospital/McLean Hospital, Boston. Dr Jellinek is professor of psychiatry and pediatrics, Harvard Medical School, and chief clinical officer, Partners HealthCare System, Boston, Massachusetts. He is also an editorial advisory board member for Contemporary Pediatrics. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.