Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases–especially when self-inflicted wounds are deep and in potentially lethal locations–the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad–and not necessarily a deviant one–that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts–or even when she experiences the physical pain of a recent wound–she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.

'Cutting' Wounds May Be More Than Skin Deep : The behavior may be an attempt by a severely disconnected, depressed teen to gain focus and control.