Accidental scratch—or a sign of self-cutting?

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Applied Evidence

Accidental scratch—or a sign of self-cutting?

J Fam Pract. 2015 May;64(5):277-281

By

Jerry G. Jones, MD

Andrew L. Cohen, PhD

Karen B. Worley, PhD

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.

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References

1. Whitlock J, Muehlenkamp J, Purington A, et al. Nonsuicidal self-injury in a college population: general trends and sex differences. J Am Coll Health. 2011;59:691-698.

2. Shain BN; American Academy of Pediatrics Committee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics. 2007;120:669-676.

3. Miller M, Hempstead K, Nguyen T, et al. Method choice in nonfatal self-harm as a predictor of subsequent episodes of self-harm and suicide: implications for clinical practice. Am J Public Health. 2013;103:e61-e68.

4. Bergen H, Hawton K, Walters K. Premature death after self-harm: a multicentre cohort study. Lancet. 2012;380:1568-1574.

5. Kerr PL, Muehlenkamp JJ, Turner JM. Nonsuicidal self-injury: a review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010;23:240-259.

6. Fordam K, Bailham D. Self-harm in young people. In: Beinart H, Kennedy P, Llewelyn S, eds. Clinical Psychology in Practice. West Sussex, England: BPS Blackwell; 2009:73-84.

7. Barrocas AL, Hankin BL, Young JF, et al. Rates of nonsuicidal self-injury in youth: age, sex, and behavioral methods in a community sample. Pediatrics. 2012;130:39-45.

8. Kuentzel JG, Arble E, Boutros N, et al. Nonsuicidal self-injury in an ethnically diverse college sample. Am J Orthopsychiatry. 2012;82:291-297.

9. Taylor JD. Cutting, piercing, and self-mutilation. In: Bryant CD, ed. Handbook of Deviant Behavior. New York, NY: Routledge; 2011:305-312.

10. Laukkanen E, Rissanen ML, Tolmunen T, et al. Adolescent self-cutting elsewhere than on the arms reveals more serious psychiatric symptoms. Eur Child Adolesc Psychiatry. 2013;22:501-510.

11. Hall B, Place M. Cutting to cope – a modern adolescent phenomenon. Child Care Health Dev. 2010;36:623-629.

12. Wood A. Self-harm in adolescents. Advances in Psychiatric Treatment. 2009;15:434-441.

13. Sornberger MJ, Heath NL, Toste JR, et al. Non suicidal self-injury and gender: patterns of prevalence, methods, and locations among adolescents. Suicide Life Threatening Behav. 2012;42:266-278.

14. Stanford S, Jones MP. Psychological subtyping finds pathological, impulsive, and “normal” groups among adolescents who self-harm. J Child Psychol Psychiatry. 2009;50:807-815.

15. Hintikka J, Tolmunen T, Rissanen ML, et al. Mental disorders in self-cutting adolescents. J Adolesc Health. 2009;44:464-467.

16. Nock MK. Why do people hurt themselves? New insights into the nature and functions of self-injury. Curr Dir Psychol Sci. 2009;18:78-83.

17. Hawton K, Harriss L, Rodham K. How adolescents who cut themselves differ from those who take overdoses. Eur Child Adolesc Psychiatry. 2010;19:513-523.

18. Swannell S, Martin G, Page A, et al. Child maltreatment, subsequent non-suicidal self-injury and the mediating role of dissociation, alexithymia and self-blame. Child Abuse Negl. 2012;36:572-584.

19. van der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behavior. Am J Psychiatry. 1991;148:1665-1671.

20. Brickell CM, Jellinek MS. Self-injury: why teens do it, how to help. March 2014. Contemporary Pediatrics Web site. Available at: http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/borderline-personalitydisorder/self-injury-why-teens-do-it-how. Accessed March 4, 2015.

21. Murray CD, Warren A, Foxe J. An Internet survey of adolescent self-injuries. Australian e-Journal for the Advancement of Mental Health. 2005;4:7-9.

22. Fikke LT, Melinder A, Landro NI. The effects of acute tryptophan depletion on impulsivity and mood in adolescents engaging in non-suicidal self-injury. Hum Psychopharmacol. 2013;28:61-71.

23. Wilkinson P, Kelvin R, Roberts C, et al. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011;168:495-501.

24. Hawton K, Bergen H, Kapur N, et al. Repetition of self-harm and suicide following self-harm in children and adolescents: findings from the Multicentre Study of Self-harm in England. J Child Psychol Psychiatry. 2012;53:1212-1219.

25. Matsumoto T, Imamura F, Chiba Y, et al. Analgesia during self-cutting: clinical implications and the association with suicidal ideation. Psychiatry Clin Neurosci. 2008;62:355-358.

26. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14:245-258.

27. Saunders KE, Hawton K, Fortune S, et al. Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review. J Affect Disord. 2012;139:205-216.

28. Harrington R, Pickles A, Aglan A, et al. Early adult outcomes of adolescents who deliberately poisoned themselves. J Am Acad Child Adolesc Psychiatry. 2006;45:337-345.

29. Puskar KR, Bernardo L, Hatam M, et al. Self-cutting behaviors in adolescents. J Emerg Nurs. 2006;32:444-446.

30. Lewis SP, Heath NL, St. Denis JM, et al. The scope of nonsuicidal self-injury on YouTube. Pediatrics. 2011;127:e552-e557.

31. Gonzales AH, Bergstrom L. Adolescent non-suicidal self-injury (NSSI) interventions. J Child Adolesc Psychiatr Nurs. 2013;26:124-130.

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.