The Atlanta Journal-Constitution
Getting a handle on self-harm
Habitual self-harm, over time, is a predictor for higher suicide risk, studies suggest.
The sensations surged up from somewhere inside, like poison through a syringe: a mix of sadness, anxiety, and shame that would overwhelm anyone, especially a teenager.
“I had this Popsicle stick and carved it into sharp point and scratched myself,” Joan, a high school student in New York City, said recently; she asked that her last name be omitted for privacy. “I’m not even sure where the idea came from. I just knew it was something people did. I remember crying a lot and thinking, ‘Why did I just do that?’ I was kind of scared of myself.”
She felt relief as the swarm of distress dissolved, and she began to cut herself regularly, at first with a knife, then razor blades, cutting her wrists, forearms and eventually much of her body. “I would do it for five to 15 minutes,” she said, “and afterward I didn’t have that terrible feeling. I could go on with my day.”
Self-injury, particularly among adolescent girls, has become so prevalent so quickly that scientists and therapists are struggling to catch up. About 1 in 5 adolescents reports having harmed himself or herself to soothe emotional pain at least once, according to a review of three dozen surveys in nearly a dozen countries, including the United States, Canada and Britain. Habitual self-harm, over time, is a predictor for higher suicide risk, studies suggest.
But there are very few dedicated research centers for self-harm and even fewer clinics specializing in treatment. When youngsters who injure themselves seek help, they are often met with alarm, misunderstanding and overreaction. The apparent epidemic levels of the behavior have exposed a structural weakness of psychiatric care: Because self-injury is considered a “symptom” and not a stand-alone diagnosis like depression, the testing of treatments has been haphazard, and therapists have little evidence to draw on.
In the past few years, psychiatric researchers have begun to knit together the motives, underlying biology and social triggers of self-harm. The story thus far gives parents — tens of million worldwide — some insight into what is at work when they see a child with scars or burns. And it allows for the evaluation of tailored treatments: In one newly published trial, researchers in New York found that self-injury can be reduced with a specialized form of talk therapy that was invented to treat what’s known as borderline personality disorder.
“It used to be that this kind of behavior was confined to the very severely impaired, people with histories of sexual abuse, with major body alienation,” said Barent Walsh, a psychologist who was one of the first therapists to focus on self-injury, at the Bridge program in Marlbor
ough, Massachusetts, now a part of Open Sky Community Services. “Then, suddenly, it morphed into the general population, to the point where it was affecting successful kids with money. That’s when the research funding started to flow.”
Joan was 13 when the cutting began. Now 16, she had greatly curtailed this routine in the past few months, she said: “But I still do it, like, every week or so.”
Whether this method of self-soothing is an epidemic of the social media age is still a matter of scientific debate. No surveys asking about selfharm were conducted before the mid-1980s.
In the 1990s, the idea of self-injury and its underlying psychic misery began to enter popular culture. Princess Diana talked about it, in an interview; so did actors Johnny Depp and Angelina Jolie. A popular 2010 music video by Pink contained vivid scenes of cutting. By then, dozens of online forums were providing community, support and understanding to those who self-injured — and also, some experts say, often reinforcing the behavior, as a badge of membership in a special club.
Among current American college students, a privileged group by definition, about 1 in 5 reports having inflicted self-harm on purpose to ease emotional pain at least once, according to surveys done at 10 universities by Janis Whitlock, director of the Cornell Research Program for SelfInjury and Recovery. The first episode occurs around age 15, on average, she said, but a large number of people who self-harm started later, at age 17 or 18.
Few people who self-harm once stop there, said Whitlock, an author of “Healing Self-Injury: A Guide for Parents.” “About three in four continue, and the frequency tends to go up and down, as people go in and out of various stages. It’s absolutely crazy-making for parents because it’s hard to know what’s happening.”
This pattern becomes, for about 20% of people who engage in it, a full-blown addiction, as powerful as an opiate habit. “Something about it was so grounding, and it was always there for me,” said Nancy Dupill, 32, who cut herself regularly for more than a decade before winding down the habit, in therapy; she now works as a peer specialist for adolescents in central Massachusetts. “I got to the point where I cut myself a lot, and when I came out of it, I couldn’t remember things that happened, like what set it off in the first place.”
In psychiatry, self-injury is considered a symptom, not a stand-alone disorder. As a result, people who habitually injure themselves often receive an underlying diagnosis, like depression, attention-deficit disorder, posttraumatic stress, borderline personality, bipolar or some combination, which may change from doctor to doctor.
“I was diagnosed with bipolar, borderline, depression,” Dupill said. She didn’t think the labels fit her very well, and “some of the drugs they put me on caused me to panic and harm myself badly.” She considered the surges of anxiety and distress she felt, and sometimes still feels, as a post-traumatic reaction to a chaotic childhood.
If a diagnosis fits, experts say, treatment should integrate it. In a paper this summer, a team led by Theodore Beauchaine of Ohio State University argued that preadolescent girls with a history of family trauma and attention-deficit disorder are at extremely high risk for later self-injury, and treating the ADHD as well as the traumatic stress would be a powerful prevention strategy and could reduce sui- cide risk.