Accidental scratch—or a sign of self-cutting?

Self-harm behaviors occur across many disorders and are not unique to any single diagnosis.¹⁶ Moreover, evidence suggests that many (if not most) adolescents who self-harm do not fit the profile of psychiatric and social distress that has been well described in the literature.^14,15 That is, many adolescents who self-harm may be categorized as psychologically “normal,” meaning they don’t meet the criteria for a diagnosis of depression, anxiety, or impulsivity.^14,15

Being female is a strong predisposing factor for self-cutting.¹¹ This may be because females have higher rates of depression and tend to internalize, whereas males tend to externalize and may underreport self-harm. Research suggests that modeling of self-cutting behavior by, for example, posting videos online may encourage other females to self-cut, and that contagion (ie, group cutting) is a factor.¹⁷ Self-injury is especially common in adolescent girls who have a history of physical abuse.¹⁸ In a study of patients with a history of cutting and suicidality, exposure to physical or sexual abuse, physical or emotional neglect, and chaotic family life during childhood and adolescence was associated with more frequent and more severe cutting.^5,19

Cutting may help patients cope with emotional distress

Although adolescents may cut for many reasons, in general, the behavior is a coping strategy for affect regulation; cutting appears to displace emotional pain or relieve emotional blunting.^2,16 Cutting provides an immediate—albeit unhealthy and temporary—method of coping. However, this is often followed by shame and low self-esteem, and the underlying emotional distress returns. Others may use self-cutting as a means of obtaining cathartic release, responding to peer pressure, or inflicting self-punishment.⁹ Adolescents with limited interpersonal skills may use cutting to affect relationships by, for example, communicating their distress to others and, in turn, eliciting sympathy, status, or camaraderie. If the adolescent who self-cuts interprets the resulting responses as positive, the cutting behavior is reinforced.²⁰

The importance of the pain associated with self-injury is unclear. In an Internet survey of 128 adolescents who injured themselves, 43% reported the injuries often or always caused pain, whereas 25% said such injuries never caused pain.²¹ Some research suggests that self-inflicted trauma (including pain) may provide emotional relief by increasing serotonin levels, or may deliver desired euphoria by releasing endorphins.²²

Self-cutting, suicide, and mortality risk. Suicide does not appear to be the intent or motivation of most adolescents who self-cut.^11,12 Adolescents tend to cut themselves to “make life feel better,” not to end their life. However, the intent of self-cutting may change over time, and may lead adolescents to adopt more lethal forms of injury. In a study of adolescents receiving treatment for major depressive disorder, NSSI was found to be a strong predictor of suicidal behavior.²³

Although self-harm and self-cutting occur more frequently in females, suicide is observed significantly more often in males and individuals with multiple self-harm episodes.^3,24 Further, males who use analgesics to relieve the pain of cutting are at especially high risk for suicide.²⁵

In general, individuals who self-harm have an increased risk of premature death.^3,4 In a cohort study, more than 30,000 individuals with self-harm who presented to emergency departments in England had a mean loss of 31.4 years of life compared to the general population.⁴ Also, adolescent self-cutting is associated with adverse childhood experiences (eg, maltreatment), and these experiences are associated with early death in adults.²⁶

A structured approach to assessment and care

If during the course of a physical examination you notice injuries such as cuts, scratches, burns, or rub marks, be especially suspicious of self-injury if they are located in areas of the body that the patient could easily reach. Also consider the possibility that the injuries may be a direct result of child abuse trauma. If you suspect physical or sexual abuse or neglect, federal law mandates you report such concerns to the appropriate state child protective services agency.

Some research suggests that self-inflicted trauma may provide emotional relief by increasing serotonin levels, or may deliver desired euphoria by releasing endorphins.

As you might expect, it’s important to use a nonjudgmental, empathic, and supportive approach when speaking to the patient about his or her motivation for cutting.⁵ A review of 74 studies found that attitudes of hospital staff, especially physicians, largely were negative toward patients who engaged in self-harm.²⁷ One approach to talking to patients about self-cutting involves asking questions based on motivational interviewing techniques. (See “Talking to patients about self-harm: 5 questions to ask” below.⁵)

Be sure to document the location(s) and extent of the injury, and estimate the timeframe of the cutting based on the age of any scars. You’ll also need to treat the wounds and administer tetanus immunization, as appropriate.