Self-Injurious Behavior

Introduction

It is estimated that one to two million people in the United States intentionally and repeatedly bruise, cut, burn, mark, scratch, and mutilate different parts of their own bodies.1 This estimate represents only the adolescents and adults who actually seek help for the behavior. Since the wounds inflicted are not intended to be life-threatening, often do not require medical attention, and are frequently dismissed as "accidental," clinicians and researchers believe that many people engage in acts of self-inflicted violence who are never treated or included in mental health statistics. In recent years, however, there appears to be a dramatic increase in the number of younger and older adolescents who engage in self-injurious behavior (SIB).2 Family members and friends are justifiably confused, angry, and frightened by the idea of a teenager deliberately and repeatedly hurting his or her own body.

Adolescents who self-harm experience tremendous tension and anxiety before the act along with an intense preoccupation with thoughts of injuring themselves. Many people report that the impulse to injure is irresistible and cannot be thwarted. The teenager may feel little or no pain as the cut, burn or scratch is inflicted. There can be feelings of gratification, relief, comfort, and even arousal after the act of self-harm. Despite the fact that many teens are psychologically invested in the behavior and feel helpless to stop, self-injurious behavior can be reduced and eventually extinguished. Often, a combination of individual and family therapy, self-help strategies, selfinjurious behavior substitutes, medication, and the use of community resources and support groups can help individuals re-claim a healthy sense of control over their bodies.

Case Vignettes

When Debbie turned 12 years old, she began to menstruate and to become physically mature. Instead of feeling excited by these normal developmental changes, she remembered feeling extremely anxious and angry. Several months later, she began to secretly scratch her inner thighs and chest in response to these feelings, and as a way to manage them. She would either use her fingernail or a pen cap, and would scratch "just deep enough to make it bleed and leave behind a mark." Debbie realized that the behavior increased whenever a family member commented on her physical development or when she got her menstrual period. For 17-year-old Charlie, his father's promotion at work meant another move to a new neighborhood and school. These relocations were always challenging and anxiety-producing. Charlie described his parents as "workaholics" who chose to work long hours. Charlie was frequently alone in his new house and had a difficult time making new friends. As a way to "feel better and handle stress," Charlie made small cuts on his forearms with a razorblade and burned himself with a lighter. In addition, Charlie picked at wounds until they became infected. He reported that he was "unable to let the wounds heal."

Symptoms of self-injurious behavior

Adolescents who engage in selfinjurious behavior are performing deliberate and repetitive acts of physical harm to their own bodies.3 The behavior is usually done secretly and privately. It may be planned and ritualistically performed or it may occur impulsively and without forethought. The most common manifestation of self-injury is cutting and slashing.4 Although most self-harmers have a preferred method, many teenagers who habitually hurt themselves do so in a variety of ways. Other common forms of self-injurious behavior include: burning the skin; limb-hitting and bruising; head-banging; picking at wounds; peeling the skin; deep biting; severe skin scratching; nail and cuticle biting; pulling out hair; bone breaking; swallowing sharp objects; and inserting sharp objects or toxic liquids into the body. The most targeted body parts are the upper limbs.

Adolescents may use razorblades, scissors, and knives to cut the skin, and cigarettes, lighters, and matches to burn themselves. They can also take seemingly benign objects such as paperclips, pen caps, jewelry, fingernails, and nail clippers, and turn them into self-harming tools.