Depression, anxiety can lead teens to self-cutting

Monday, February 28, 2011
By Pohla Smith, Pittsburgh Post-Gazette

It's a pretty common scenario at Children's Hospital of Pittsburgh of UPMC, says adolescent medicine specialist Jonathan Pletcher.

"We'll see a girl who's having menstrual problems, missing periods," he said. "And the reason she's having menstrual problems is because she's lost weight, and the reason she's lost weight is because she's depressed, and part of her dealing with that is cutting as well."

For those unfamiliar with the term, "cutting" means the patient is intentionally slicing open wounds on his or her body. It's the most common form of non-suicidal self-injury by young patients suffering from emotional problems like depression or anxiety.

And just how often does Dr. Pletcher see a self-injurer?

"I do all adolescent health," he said, "so I'm seeing it on a weekly basis."

David Brent, the psychiatrist who directs Services for Teens at Risk at Western Psychiatric Institute and Clinic-UPMC, also sees such patients regularly.

"I run an out-patient program, and we see a lot of kids who engage in that. It's not necessarily their main problem," Dr. Brent said.

"If you do a community survey you find 15 percent of adolescents have done this at least once," he added. "In the psychiatric population it's much higher, associated with depression and anxiety, things associated with being in a psychiatric hospital."

It's commonly thought that most self-injurers are non-suicidal, that they're just using the physical pain of cutting or burning or bruising themselves to get rid of a negative emotion, but Dr. Brent said that's not necessarily the case. "Some of them are suicidal as well," he said. "In fact, kids who engage in non-suicidal self-injury also have a higher risk for suicide, and I think it's because both types of behaviors are related to the same kinds of risk behaviors. So non-suicidal self-injury behavior and suicidal behavior are two different types of behavior, but we often see them in the same people.

"The non-suicidal self-injury is either to get rid of a negative emotion or feeling numb or to get attention or to get out of a difficult social situation -- like being bullied -- but there's no intent or desire to die. It's often superficial cutting." But there is nothing superficial about suicidal behavior, Dr. Brent said.

"A suicidal person does something destructive with at least an implied attempt to die. They take pills or try to hang themselves. You do have people who slash their wrists, but they report their attempt was to die, not to gain relief from a negative emotion."

Still, the more frequently a patient has self-injured, the more chance of a suicide attempt, he said. "Looking at the in-patient population, it can be upwards of 70 percent [who have attempted suicide], but non-suicidal injury behavior -- particularly if you've done it a number of times -- you're four or five times as likely to have made a suicide attempt." Dr. Pletcher said he's seen a self-injurer as young as 11 but hasn't seen many in their 20s. "I would say [the common age is] mid-adolescence, 13 to 16."

"The peak is adolescence and young adulthood," Dr. Brent agreed.

Depression and/or anxiety are common causes for both those who commit non-suicidal self-injury and those who have attempted suicide.

"A kid who does [self-injury] doesn't have as much wrong, but repetitively, there's an increased incidence of depression and anxiety [and] having a low threshold for tolerating distress," the psychiatrist said. "There's not as good an ability to regulate their emotions. They're not as good at generating alternate solutions to their problems. "There're a lot of things the two groups of kids have in common."

Dr. Brent also said non-suicidal self-injury can be either a cry for help, an attempt to mask internal pain, or both. "Most kids in community surveys will endorse more than one reason," he said. "In the psychiatric population, it tends to be more commonly related to emotional regulation ... because they're there for emotional disorders like depression."

But Dr. Pletcher said he didn't think the patients he sees at Children's -- who usually are there for other medical reasons -- were cutting as a cry for help.

"If it's a cry for help, it's an internal one. It's not to get their parents' attention, though it often has that effect," he said. "More than anything, it's a method of coping. The way I've heard it described to me is you're really lost and the cutting brings you back to reality," he said.

"There's also a feeling of being disconnected, loneliness to the extreme degree."

He said he also has seen patients who use the pain of self-harm to snap out of an anxiety attack.

But Dr. Pletcher said he has had patients who are looking to end their destructive behavior.

"My feelings are that if kids can't control it, they are distressed by it ... and once they're distressed by their cutting behavior they are motivated to find new coping mechanisms. Once they do that, the cutting gets better."

Dr. Brent said patients who are self-injuring "to get a rise out of their parents" aren't distressed, "but in general if they can find another way to achieve the same ends they would.

"I couldn't tell you what proportion want to get help [but] it's rare that you get someone who doesn't want at least to try to make it stop."

As a pediatrician at Children's, Dr. Pletcher does some short-term counseling. "Then we work with teams who do the long-term counseling," either community-based counselors or personnel at Western Psychiatric.

"To be honest," Dr. Brent said, "there's never been a study of kids that has shown the ability to reduce the behavior. "What I will say is if you look at the treatment of depression, as the depression symptoms drop so does the urge to self-injure, so part of the treatment is treating the psychiatric disorder they are trying to get relief from. "Most people feel some psychotherapy techniques are helpful."

Screening for Mental Health, Inc. (MentalHealthScreening.org) has both Signs of Self-Injury and SOS Signs of Suicide prevention programs. They are designed to work in a school environment, with materials for students, parents and school staff. The programs' goals are to teach adolescent students to recognize the signs of self-injury or suicidality in themselves or friends and encourage help-seeking through the ACT technique. ACT stands for Acknowledge, Care, Tell.

Pohla Smith: psmith@post-gazette.com or 412-263-1228.  

First published on February 28, 2011 at 12:00 am  

Read more: http://www.post-gazette.com/pg/11059/1128186-114.stm#ixzz1FH3YQdIy