Self-Injury Should Not Be Ignored
By Barbara Smith, M.D.
A: In recent years there appears to be a dramatic increase in the number of younger and older adolescents who engage in self-injurious behavior. Twenty years ago this type of behavior was not seen nearly as often and was primarily associated with a personality disorder. Some adolescents may self-mutilate to express their individuality, to take risks, to be accepted by their peers or to reject parental values and expectations. Others, however, may engage in self-injurious behavior because of feelings of worthlessness, hopelessness, anger, desperation and even to seek attention. Different forms of self-injury may include: carving, cutting, scratching, marking, picking scabs or interfering with wound healing, burning/abrasions, branding, punching self/objects, infecting oneself, biting oneself, breaking bones and mutilation of body parts. Contrary to popular belief, tattoos and body piercing are not considered forms of self-injurious behavior. This is because they are performed by someone else in a social context and are primarily designed to beautify the body. However, teenagers who allow piercings to become infected and then pick at the wounds or secretly pierce or tattoo their own bodies to relieve anxiety or "feel better" are engaging in self-injury.
Self-injury is defined as deliberate, repetitive, impulsive and non-lethal harming of one's body. This behavior is not intended to be life threatening; however, it should be taken very seriously and not written off as normal adolescent behavior or just going through a phase! Young people who engage in self-injurious behavior almost always have low self-esteem. Now we are more aware that self-harm can be a symptom of a number of psychiatric disorders such as depression, anxiety, mood disorders, eating disorders, personality disorders, substance dependence and developmental disorders. Some young children will exhibit self-injurious behavior from time to time, but often grow out of it. Children who have been abandoned or abused, as well as children with autism and/or mental retardation may also exhibit these behaviors.
Who engages in self-injurious behavior and why? As mentioned earlier, young people who self-mutilate almost always have low self-esteem. These adolescents may have difficulty talking about their feelings and engage in self-injurious behavior to "relieve" their emotional tension, physical discomfort, pain and low self-esteem. This becomes a coping strategy. It manages overwhelming thoughts and feelings by short-circuiting them or creating a competing stimulus. In the event of negative feelings such as rage or despair, tension builds, and it is theorized that the young person begins to dissociate or "zone out." At that point, they can detach from themselves and hurt the body without experiencing any real pain. Perhaps, most importantly, the body responds to the trauma of injury by releasing endorphins, which allows the teenager to feel "high," euphoric" and "relieved." They then don't feel the pain, and there is an initial improvement in mood. This important physiologic mechanism may well explain the addictive quality of self-injurious behavior — that a chemical change in the brain "hardwires" the desire or need to self injure. The effects of peer pressure can also influence adolescents to injure themselves.
So, what can parents and you as a professional do about self-injurious behavior in young people?
• Any self-mutilation should always be taken seriously and never ignored.
• It is imperative that family and others talk openly about self-injurious behavior when they suspect it is occurring.
• Talk with young people about respecting and valuing their bodies.
• Serve as a role model by not engaging in acts of harm.
• Talking non-judgmentally about the behavior helps reduce the shame and secrecy that surrounds self-harm.
Evaluation by a mental health professional is very important in identifying and treating the underlying causes of self-mutilation. Someone trained in dealing with this behavior can work with the individual on safe, alternative ways to communicate, self-soothe and cope with emotional tension. There are also cognitive behavioral techniques that a therapist can work with the individual on, i.e. helping the individual learn concrete methods to distract themselves from feelings of self-harm, practicing breathing exercises, journaling, drawing, thinking about positive images, etc. In addition, medication for the associated depression, anxiety or other psychiatric disorder is imperative in many cases. This will allow the person to be more emotionally available for the therapy that should accompany the medication. Dr. Barbara Smith is a family psychiatrist with a private practice in Greensboro.