Accidental scratch—or a sign of self-cutting?
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.
Assess for additional risks, especially suicide. Such risks may include other behavioral issues (eg, alcohol or substance use, promiscuity, antisocial behavior), academic problems, or eating disorders. In addition, evaluate for prior and/or current mental health concerns, family dysfunction and conflict, and acute or chronic patient or family psychosocial stressors.
Assessment of suicidality should include direct queries about past, recent, and current suicidal ideation, intent, and plan. Further details on how to evaluate suicidality, including red flags to watch for, are available from the American Academy of Pediatrics at https://pediatrics.aappublications.org/content/105/4/871.full.pdf.
When evaluating a patient whose injuries might be self-inflicted, family physicians can use a subset of motivational interviewing (MI) techniques to promote a positive and supportive atmosphere for the patient, with the goal of making it easier for the patient to discuss self-injury.
Kerr et al5 suggests that family physicians can use a set of questions based on MI techniques to facilitate discussion of self-injury and prompt a patient to consider seeking help for his or her self-injury. Such questions might include:
1. What effect is self-cutting having on your life?
2. While it seems like self-cutting serves a function for you, what disadvantages are there if you continue to cut yourself?
3. What factors may motivate you to stop self-injuring right now?
4. How would your life be different right now if you were not self-cutting?
5. What do you think you would need in the way of help in order to stop self-cutting?
A patient who self-cuts and expresses the intent to commit suicide should be directly transferred to the emergency department for a psychiatric evaluation. A patient who admits he has been thinking about suicide or a suicide plan but does not state an intent to commit suicide should receive an immediate mental health referral to a psychotherapist or psychiatrist. Patients who have engaged in longstanding self-cutting should be referred to a therapist with experience in treating childhood trauma, especially if the patient has a history of behavioral or mental health disorders.12,28
The role of the family
Family members often will not have known about the cutting behavior. Family and caregivers should be educated about self-cutting (eg, its use as a coping strategy, the complexity of contributing factors), ways to provide a safe environment (eg, increased adult supervision, safeguarding of sharp objects), and the importance of mental health treatment. Positive family support is critical in addressing the patient’s self-cutting and underlying factors.
Determine if family intervention is needed. If family stressors, conflict, or dysfunction is identified as a contributing factor, recommend family counseling.
Several treatment options but few specifically for cutting
Many adolescents who self-cut want to stop cutting. In a survey of self-injured adolescents, 37% wanted to stop the behavior.14 However, even with treatment, cutting behavior often continues because cutting as a coping strategy may feel highly effective in the moment and can become addictive.29 Also, videos with explicit imagery of self-cutting are readily available on various Web sites and could normalize and reinforce the behavior.30
There are few evidence-based treatments for self-harm in general, let alone specifically for adolescent self-cutting.12,31 For adolescents with self-harm behaviors, individual cognitive behavioral therapy, dialectical behavioral therapy, group developmental therapy, multisystemic therapy, family intervention, psychotropic medication, and inpatient psychiatric treatment may help reduce risks and improve psychosocial functioning.12,31 Psychotropic medication has been shown to relieve psychiatric symptoms in patients who self-harm, but its effectiveness in reducing self-cutting behavior is unclear.12
CASE › After you speak to Alice with her parents out of the room, she admits that she had scratched her arms several times in the past few weeks because she felt stressed about her grades in certain classes. She says she’d done this scratching before as a coping mechanism, but never thought about suicide. With Alice’s permission, you discuss these incidents with her parents. You refer her to a psychotherapist to begin counseling, and ask that she return in 3 months so that you can monitor her progress.
CORRESPONDENCE
Jerry G. Jones, MD, University of Arkansas for Medical Sciences, College of Medicine, Department of Pediatrics, 1 Children’s Way, Slot 512-24A, Little Rock, AR 72202; jonesjerryg@uams.edu
