Many therapists have encountered teens that have harmed themselves, but denied suicidal intent. Recent studies have found that one-third to one-half of teens in the U.S. have engaged in some type of self-harm. Self-harming behavior is a considerable problem for therapists, not only because of the obvious danger of the client harming himself/herself, but also because of the difficulties in ascertaining whether the teen was trying to commit suicide.
Self-injury intended to inflict pain on oneself most commonly includes the following:
- Banging walls
- Breaking bones
- Ingesting toxic substances
- Interfering with healing of wounds
- Punching objects to induce pain
Self-injury typically begins in mid-adolescence. Adolescents who injure themselves are often impulsive, engaging in self-injury with less than an hour of planning. They commonly report feeling minimal or no pain. Once started, self-harm seems to acquire addictive characteristics and can be quite difficult for the teenager to discontinue. While some studies indicate that self-injury is more frequent in females than males, other studies indicate that there are no consistent gender differences.
Self-injury frequently occurs in teens that, at other times, have contemplated or attempted suicide. Thus, there is a significant risk of suicide and suicide attempts among young people that engage in self-injury. One recent study found that 70 percent of adolescents engaging in self-injury had made at least one suicide attempt – and 55 percent had multiple attempts. However, the non-suicidal and suicidal cases serve distinctly different purposes. Some clients report that they hurt themselves in order to stop suicidal ideation, or to stop themselves from actually attempting suicide. Consequently, self-injury without suicidal intent may be a morbid form of self-help.
Until recently, self-injury was seen as primarily associated with the following three specific psychiatric diagnostic categories: developmental disabilities, eating disorders, and borderline personality disorder (BPD). Self-injury occurs in roughly 15 percent of kids with developmental disabilities, especially profound and severe mental retardation. Among adult females, self-injury accompanies up to 35 percent of those diagnosed with anorexia nervosa, bulimia nervosa, and other eating disorders; girls with anorexia nervosa also tend to engage in self-injury more than those without the eating disorder. Repetitive self-injury is so common among people with BPD that BPD is the only clinical diagnosis in the DSM for which self-harm, whether suicidal or non-suicidal, is a symptom. However, no studies have examined the prevalence of self-injury among boys or girls exhibiting borderline personality symptoms.
Recent research calls into question the assumption that teen self-injury is primarily limited to young people with developmental disabilities, eating disorders, or borderline personality disorder. Psychiatric conditions that are specifically associated with self-injury in teens include internalizing disorders (e.g., depression, posttraumatic stress disorder, generalized anxiety), externalizing disorders (e.g., conduct disorder, oppositional defiant disorder), and substance abuse disorders. There is a strong link between self-injury and maltreatment in early childhood, especially sexual abuse.
About 50% of young people who engage in self-injury may not meet criteria for depression, anxiety, eating disorder, substance use disorder, or other major psychiatric disorders. In fact, self-injury appears to be a common psychiatric symptom found in a variety of disorders, as well as being found in teens without a specific psychiatric diagnosis. It seems more useful to understand self-injury in functional terms rather than as a distinct diagnosis, because a separate diagnostic category is not well supported by current research findings.
Some teens who engage in self-injury have elevated rates of emotional reactivity, intensity, and hyper-arousal. Interpersonal processes associated with self-injury include increased use of avoidant behavior and decreased emotional expressivity. Adolescents who self-injure are more likely to report being bullied by peers and experience discomfort regarding their sexual identity. A recent study also found an association with Goth subculture and self-harming behavior among adolescents. Knowledge of self-injury in peers is a risk factor for self-injury due to an apparent “copy cat” effect, and there has been an increase in publicity about this behavior. A variety of internet websites and chat rooms provide information – and even encourage self-harming behavior.
The major purpose of self-injury appears to be affect regulation and management of distressing thoughts. For example, in one study of high school kids, 55 percent of those who engaged in self-injury indicated their reason for self-injury was, “I wanted to get my mind off my problems,” while 45 percent asserted, “It helped me to release tension or stress and relax.” When a child feels overwhelmed by negative feelings, self-injury can be an effective, although harmful, strategy to stop or reduce these negative thoughts and emotions.
Adolescents that engage in self-injury demonstrate higher levels of physiological arousal during a stressful task compared with teens without self-injury. This finding is consistent with primate research. For example, monkeys engaging in self-harm (usually self-biting) have a blunted cortisol response to mild stress when compared with controls. After experiencing a stress-induced escalation in heart rate, these monkeys appear to use self-injury as a coping strategy to decrease arousal. In turn, the self-injury is associated with a rapid decrease in heart rate.
Self-injury may also regulate emotions by increasing the affective experience. The teen may have the subjective experience of being emotionally “numb” or “empty” or feeling disconnected with others. Self-injury may help the young person to gain a sense of control, to feel excitement, or to stop dissociative experiences. Self-injury may also give the teen the experience of being “real.”
Self-injury may serve interpersonal functions for the teen. It may elicit positive reinforcement in the form of attention from others (although many who injure themselves do so in private and do not tell others). Self-injury may also help the teen to avoid difficult situations. The threat of self-injury may cause parents to decrease interpersonal pressure or to stop attempting to get the child to complete his or her homework, chores, or other tasks.
Self-harm in the teenage years has only recently been recognized as a commonly occurring phenomenon. Consequently, there are few randomized, controlled trials for the specific treatment of self-injury. In grown-ups, the therapeutic intervention with the most research demonstrating efficacy in reducing self-harming behavior is dialectical behavioral therapy (DBT). DBT uses a combination of individual and group therapy to teach skills in emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self-management. The intensive treatment requires the therapist to be on call for these clients at all times. DBT has been adapted for teens with features of borderline personality disorder, with the additional expectation that the group therapist is on call at all times for the mom and dad of the client. The clinical and financial demands of DBT have led to applications of less intensive treatments to reduce self-injury, but these treatments are still under study.
Treatment is based on a thorough psychiatric evaluation, with a focus on safety issues, suicidal risk, and clarification of comorbid psychiatric conditions. Treating self-injury involves determining the needs that the behavior fulfills and helping the teen devise other, healthier ways to meet those needs (e.g., if self-injury helps a teen to calm down, the therapist will help to find techniques that may provide the same result).
Involving parents in the support and treatment of teens who engage in self-injury is also very important. Poor communication with parents has been associated with suicide in some teens. Improving the parents’ understanding of self-injury can be useful in decreasing conflicts. It can be helpful for the parents to learn de-escalation strategies and expand listening and communication skills. Mothers and fathers can also help with safety plans and practicing problem solving skills.
Medication for self-injury should primarily focus on any underlying psychiatric disorders. Currently, there are no specific medications approved for the treatment of self-injury. Since depression and anxiety often accompany self-injury, identifying and treating these disorders should be a top priority. Concerns about an increase in suicidal thoughts with teens using antidepressant medication should be reviewed with the client and his/her parent(s). While the protective effects of antidepressants appear to outweigh the risk of increased suicidal thoughts, medications should be monitored regularly.
My Out-of-Control Teen: Help for Parents