Alysha, age 15, is an “A” student and top athlete who feels her parents push her to be perfect. After getting a B on a test, she feels overwhelmed by shame and guilt. She locks herself in the bathroom and begins cutting her arm with a razor blade.
Self-injurious behavior (SIB) in adolescents can be associated with internalizing, externalizing, and substance abuse disorders (Table 1). For most practitioners, such as Alysha, a major goal of SIB is to relieve intolerable stress and negative affect.1
Although this secretive, highly addictive, learned behavior can be difficult to control, some clinical approaches can help these distressed teens and their parents. This article examines the dynamics of SIB, the association between suicidal ideation and SIB, and recommended treatments such as substitute behaviors and dialectic behavioral therapy.
Table 1
Common Axis I disorders among teens with SIB
| Axis I disorder | Prevalence* |
|---|---|
| Any internalizing disorder | 52% |
| Major depressive disorder | 42 |
| Posttraumatic stress disorder | 24 |
| Generalized anxiety disorder | 16 |
| Any externalizing disorder | 63 |
| Conduct disorder | 49 |
| Oppositional defiant disorder | 45 |
| Any substance use disorder | 60 |
| Alcohol abuse | 18 |
| Alcohol dependence | 17 |
| Nicotine dependence | 39 |
| Marijuana abuse | 13 |
| Marijuana dependence | 30 |
| Other substance abuse | 3 |
| Other substance dependence | 6 |
| *Among a sample of 89 adolescents who engaged in SIB | |
| Source: Nock MD, Joiner TE Jr, Gordon KL, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relationship to suicide attempts. Psychiatry Res 2006;144(1):68. | |
| Reprinted with permission from Elsevier. | |
Growing problem in adolescents
SIB is the deliberate infliction of harm to oneself, either internally or externally, without suicidal intent.1 This behavior is also known as impulsive self-injury, non-suicidal self-injury, self-mutilation, cutting, and self-harm. Once reported primarily in adults with borderline personality disorder, SIB is becoming common among adolescents:
- Among 663 teens in community-sample survey, 46% engaged in some form of SIB in the past year, and 28% engaged in serious, repetitive behaviors.2
- 13% to 23% of teenagers have engaged in SIB, according to literature review.3
- Children as young as 9 have presented with SIB.
- burning
- swallowing objects or substances
- hitting oneself with the fist or against an object
- cutting circulation to a digit
- picking at skin
- pulling out hair.
Socially sanctioned behaviors, such as body piercing and tattoos, usually are not considered SIB. They can be used as SIB, however, by teens who impulsively self-pierce or tattoo without appropriate hygiene or anesthetic agents. Their purpose is not to make a fashion statement but to produce pain or discomfort. Cultural behaviors that cause scarring as a rite of passage, such as the Native American Sun Dance, are not considered SIB.1
Despite increasing prevalence among adolescents, SIB remains a solitary behavior. Based on my clinical experience, teens may share ideas about SIB, but they generally don’t practice it in groups.
SIB psychodynamics
Adults and adolescents with SIB frequently have:
- difficulty regulating emotions
- unstable interpersonal relations
- limited coping strategies.1
Shame is also common and can be a major barrier to diagnosing SIB. Adolescents who are ashamed of the behavior will go to great lengths to hide it from others, including clinicians. Despite the shame, many adolescents feel unable to stop engaging in SIB because it fulfills a powerful need.
Adults and adolescents who practice SIB most often report their behavior is motivated by affect regulation and tension release.4 Some adolescents engage in a different, manipulative form of SIB not to relieve tension but as a threat to prevent loss (Box).4
Behavioral reinforcement. An acute stressor—such as parental limits on behavior, feelings of rejection or abandonment by peers, or failing to achieve an unrealistic goal—triggers an escalating, intolerable affect. By experimentation or accident, an adolescent discovers that SIB provides rapid relief of the intolerable state—a calmness that may last for minutes, hours, or days. This relief reinforces the behavior, and the adolescent repeats SIB when faced with the next stressor.
Most individuals with SIB report a similar sequence of events. There is a trigger event, usually involving a real or perceived feeling of loss, rejection, or abandonment. The adolescent tries to resist the impulse to self-harm, feels escalating emotional distress, engages in SIB, and feels immediate relief.5