Cutting

I was in my first year of psychiatry residency, and I was very concerned about a young woman that had been admitted to the inpatient ward. She had long before been given the diagnosis of Borderline Personality Disorder, but what led to her admission was an increase in episodes of cutting on herself. Her wrists and legs bore multiple scars  from years of engaging in this behavior. They looked like tiger stripes due to large, lumpy keloid scars that had developed in some of the cuts. My major concern was her potential for suicide. However, as was often the case in individuals with Borderline Personality Disorder, she was purposefully ambiguous about her suicidal intent. When I asked her if she wanted to kill herself, she would reply with a disturbing nonchalance, “sometimes” or “not right now” and thus gave me little basis to form a firm opinion about her degree of risk. I recall a very stressful phone conversation I had with the psychiatrist that her insurance company engaged to speak with me after her inpatient stay was nearing two weeks in length. I told this hired-gun psychiatrist that I was fearful about discharging her.  I further explained that her cutting behavior had increased in frequency, and I was afraid that in the next round she might cut too deep, slice into an artery or vein, and thus  inadvertently or “inadvertently on purpose” die from loss of blood. The psychiatrist on the line was silent for a moment, then asked in a weary voice, “You’re a new resident, aren’t you?” The clear implication was that I was being bamboozled by a manipulative patient that did not need to be on an inpatient ward and was only wasting my time and the insurance company’s money.  I then realized this was not going to be easy.

It is troubling and perplexing for a mental health care provider when a patient causes deliberate harm to his or her body. Such self-injury usually begins in adolescence. It is surprisingly common and reported to occur in up to 17% of adolescents. It is often resistant to treatment, and can become habitual and persist into adulthood. The usual methods include cutting, hitting, scratching, or burning oneself. In some cases, these individuals have suicidal intent. However, non-suicidal self-injurious behavior, or NSSI, occurs about ten times more often than suicide attempts, which suggests that most who engage in this self-injurious behavior do not intend to end their lives and will often insist that they don’t. Unfortunately, while self-inflicted injury is usually of trivial physical consequence, it sometimes is a harbinger of actual suicidal thoughts and behavior. Indeed, sometimes self-injury can be rehearsal for suicide. Thus, although most self-injury is not suicidal in intent, the risk of suicide is higher among individuals who injure themselves than in those who do not. Thus, understanding and knowing how to deal with individuals that habitually self-injure is as important as it is difficult.

Complex combinations of factors are involved in why an individual might engage in NSSI. These are predominantly social and psychological. Some people admit that they do so as a means to communicate their distress to others. It can be the classical “cry for help.” However, the social components are complex. A troubling fact is that the incidence of NSSI has increased dramatically in the last few decades along with the growing use of social media.  Individuals that frequent social media sites are significantly more likely to engage in this behavior than those who do not. This is particularly true for vulnerable populations, such as adolescents. For them, the behavior appears to almost be contagious. Among the more purely psychological reasons that drive sufferers to habitually self-injure are reductions of negative feelings, such as anxiety, agitation, or assuagement of guilt that in their mind deserves punishment. Again, there are complexities. Some cause physical pain to overshadow or distract themselves from their emotional pain. However, others cause themselves pain simply to feel something to prove their own existence in the midst of unbearable emptiness.

NSSI is associated with certain psychological disorders. It is extremely common among individuals that suffer Antisocial or Borderline Personality Disorder. Indeed, up to 80% of individuals diagnosed with Borderline Personality Disorder engage in self-injurious behaviors. It is often taken as a diagnostic sign of that condition. Transgendered adolescents suffering gender dysphoria or simply reacting to the bullying and rejection of others are at high risk for self-injury. Adolescents with other minority sexual orientations are also at risk. Eating disorders are associated with higher risk of NSSI. Sometimes extreme forms of self-injurious behavior are seen in the psychological disorder, Munchausen Syndrome. Individuals with this condition will fake illnesses for sympathy. However, it is not uncommon for such individuals to harm themselves in unusual, sometimes dangerous and ingenious means. Rather than self-injuring to convey their distress, they use it to manipulate others into caring for them, feeling sorry for them, indulging their unreasonable demands, or even admiring their tolerance for suffering.

Some of how self-injury reduces negative feelings is through quelling painful psychodynamic processes. However, self-inflicted injury can arise during psychiatric illnesses, such as Major Depression, that are associated with  abnormal chemical activity in the brain. When such behaviors emerge as part of the presentation of Major Depression, relieving the depression with antidepressants can often reduce the self-injury. However, antidepressants offer little benefit in treating self-injury arising under other circumstances.  Social anxiety, particularly in the context of peer victimization and bullying, can increase the risk of NSSI. Again, contrary to expectations, medications that relieve anxiety, such as benzodiazepines, generally  have little ability to curtail the behavior. NSSI is seen somewhat more often in sufferers of Attention Deficit Hyperactivity Disorder, or ADHD. This is particularly the case in those with strong symptoms of inattention and impulsivity rather than hyperactivity. Curiously, although stimulants such as amphetamine or methylphenidate can be extremely effective in treating ADHD, there are reports that stimulants can increase NSSI in such patients.

The medications that appear most helpful in treating the various presentations of NSSI  are those that interact with the opiate system in the brain. It has long been known that the brain produces chemicals, called “endorphins,” that act on opiate receptors in brain tissue. Indeed, the word, “endorphin” is derived from the term, “endogenous morphine.” An increase in endorphin levels in the body acts in ways similar to the administration of an opiate. Along with providing some decrease in intensity of pain, it can offer a rewarding, calming effect. Levels of endorphins increase after episodes of self-injury, and the more severe the injury, the higher the levels of endorphins. Endorphins are not only produced in the brain and spinal cord, but also in tissues outside of the nervous system, primarily from cells in the immune system. Chemicals called cytokines such as IL-1, TNF and IL6 can also be released by damaged tissue and stimulate release of endorphins in the brain. It is suspected that the rewarding effects of NSSI mediated by the actions of endorphins in the brain can  become addictive in ways similar to the development of opiate addiction.

Two medications used to treat opiate addiction, buprenorphine and naltrexone, have both been found useful in treating NSSI. However, buprenorphine is a partial opiate agonist. That is, it only partially mimics the effects endorphins in the brain. Naltrexone, on the other hand, is a drug that can completely block the effects of endorphins. Consequently, whereas buprenorphine guarantees a steady level of opiate activity in the brain, naltrexone, particularly at high doses, prevents the rewards to be obtained from trying to artificially increase opiate activity. Thus, the effects they produce may be quite different. Whether certain subgroups might respond to one better than the other is unclear. It does appear that pain and endorphins may play different roles across the range of people who engage in NSSI. Some individuals report little or no sensations of pain while actually injuring themselves; others report that only intense pain concomitantly lowers their emotional/psychic pain; whereas others report that the injury hurts, but helps them feel better when they are through. The latter being like the proverbial description of wanting to beat your head against a wall because it feels so good when you stop.  There is also evidence that some, though not all, individuals drawn to NSSI behaviors may suffer low baseline levels of endorphins. Thus, they may experience a larger sense of relief and reward than those with normal levels of endorphins might experience. That, in turn, would make it more likely to perpetuate the behavior. Of course, while the release of endorphins in the brain is likely to help perpetuate self-injurious behavior, it stands to reason that other factors drive the initiation of cutting behavior.  It is likely that many first injure themselves after being exposed to the practice through social media or other social venues, and then continue after experiencing pleasure due to neurochemical processes.

After what I had learned through years of practice, my approach to dealing with habitual self-injurious behavior came to be taking the behavior very seriously but not letting the patient know I was taking it so seriously. If I was convinced that they were not at significant risk for suicide, I would tell them something to the effect of, “I don’t recommend hurting yourself, but if you’re not trying to kill yourself, then do what you want.” At the same time, I continued to pay strict attention to changes in mood, and any potential increases in risk for suicide. I also treated co-morbid conditions, such as major depression or anxiety disorders that could sometimes induce or exacerbate the behavior. When psychological factors were evident, such as personality disorders or difficulty dealing with psychological pain, I would arrange for psychotherapy in addition to standard psychiatric treatment.  If psychotherapy was ineffective, and the NSSI remained frequent, severe, and disruptive to the patient’s social life, I would start a trial of naltrexone. These steps kept the patient under an umbrella of safety, without rewarding self-injury by giving it the unnecessary attention that can only worsen the behavior.