Applied Evidence

Accidental scratch—or a sign of self-cutting?

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Having a high index of suspicion is key to identifying adolescents who cut themselves. The approach described here can help you properly evaluate these patients and get them the help they need.


 

References

PRACTICE RECOMMENDATIONS

› Examine the forearms and legs of all patients ages 11 to 19 years as part of the routine health assessment, looking specifically for injuries that may be self-inflicted. C
› Make an immediate referral for outpatient psychotherapy for any patient with self-cutting behavior who admits to recent or current suicidal ideation or a plan. C
› Facilitate a direct transfer to the local emergency department for psychiatric evaluation for any patient with self-cutting behavior who admits to current suicidal intent. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE  Alice R, a 14-year-old student, comes to your office for a preparticipation exam in advance of volleyball season. During the exam, you note several scratches on her left forearm. When you ask about them, Alice tells you she scratched herself when she accidentally brushed up against some bushes while walking home from school. Her explanation strikes you as odd, given that it’s been rather cold out, and it seems likely that she would have been wearing a jacket.

If Alice were your patient, how would you proceed?

Few health disorders are as clouded in mystery as self-cutting behavior in adolescents. Self-cutting is often overlooked or undetected by the medical community.1 When examining an adolescent, a family physician (FP) may pay minimal attention to the patient’s forearms and legs, but such attention can provide clues to critical health information. Relatively minor injuries in a physically active adolescent might be easy to dismiss as “normal,” but knowing the types of injuries to look for—and what to ask your young patients—can help you identify injuries that are self-inflicted and intervene accordingly.

Being aware of self-cutting, understanding its potential sequelae, and having the skills necessary to develop an individualized treatment plan are essential tools for appropriately managing this behavior.2 Failure to recognize and address self-cutting in an adolescent has immediate consequences, such as the exacerbation of other psychiatric disorders or an increased risk of suicide. Potential longer-term consequences include an increased risk of premature death for adults who engaged in self-cutting as adolescents.3,4

For many young people, self-injury occurs only a few times, but the behavior may increase in frequency and severity when combined with other psychosocial factors.5 FPs can play a crucial role by identifying cutting behavior, providing medical treatment, educating patients and families about self-cutting, making an appropriate mental health referral, coordinating multidisciplinary collaboration, and, ultimately, supporting the patient and his or her family.

Cutting is a common form of self-harm

Some adolescents use sharp or rough objects to inflict injuries on their arms, legs, or other parts of their body. Individuals may cut, scratch, burn, abrade, or prick the skin repeatedly, often leaving scars. They may then attempt to hide the resulting injuries with clothing.6 Most self-cutting injuries are superficial, but can result in scarring. Severe injuries, such as lacerated tendons, penetrated major blood vessels, or disfiguring scars, are uncommon.

Many who self-harm may be categorized as psychologically “normal,” meaning they don’t meet the criteria for a diagnosis of depression, anxiety, or impulsivity.

Because self-cutting behavior often remains private or intentionally hidden, its true incidence is unclear.6 However, self-cutting is not rare. In published literature, statistics for self-cutting often are grouped with those for other forms of non-suicidal self-injury (NSSI), including burning, hair-pulling, self-hitting, and self-poisoning. These self-harm behaviors have been reported in more than 10% of ninth graders7 and college students,8 and in up to 4% of adults.9 The lifetime prevalence of self-cutting is estimated to be 11.5%,10 and research suggests that the frequency of adolescent self-cutting may be increasing.5,11,12

Adolescent girls are 2 to 4 times more likely than adolescent boys to engage in NSSI.7,12 Girls primarily cut, scratch, or otherwise injure their skin, whereas boys more commonly hit or burn themselves, and inflict more injuries to the face, chest, and genitals.7,13 Most adolescents who self-cut do so only on their arms (67%).10

Not every patient who self-cuts has a psychiatric illness

Adolescents who cut themselves do not fit neatly within a typical profile.7,14,15 Self-harm in adolescents appears to be associated with a range of psychological factors, including internalizing disorders (eg, depression, anxiety, eating disorders), mood regulation difficulties (eg, impulsivity and related impulse control disorders, borderline personality traits/disorder), negative affect (eg, sadness, anxiousness, anger, stress, low self-esteem), and poor coping strategies (eg, avoidance, internalizing, substance use).14

The strong empirical relationship between psychological factors and self-harm has led many researchers and clinicians to view self-harm as a symptom of a psychiatric disorder.16 A study of psychiatric disorders among 44 adolescents (41 girls) with self-cutting behavior found a strong association with certain internalizing disorders: 63% had major depressive disorder, 37% suffered from anxiety, and 15% had an eating disorder.15 However, viewing self-cutting primarily as a manifestation of a psychiatric disorder doesn’t fully explain the behavior.

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