Nursing

RN/Thomson AHC Home Study Program CE CENTER

CE credit is no longer available for this article. (Expired November 2007)

Originally posted November 2005

By Sharon Van Sell, RN, EdD, PAHM, Lois O'Quin, RN, MS, APRN, BC, NCSN, CAN, PNP, Eula Oliphant, Patricia Shull, RN, Kerry Austin, Elizabeth Johnston, and Chad Nguyen.

The Authors: Sharon Van Sell, a member of the RN editorial board, and Lois O'Quin, are faculty members at Texas Woman's University College of Nursing in Dallas. Eula Oliphant is a librarian there, while Patricia Shull, RN, Kery Austin, Elizabeth Johnston, and Chad Nguyen are BSN candidates at the college. The authors have no financial relationships to disclose.

If you suspected a teenage patient of cutting or otherwise harming herself, would you know what to do?

I cut when people don't listen. And then, of course, people are going to notice it, and, of course, people are going to ask you why. I mean, nobody really looks at somebody with scratched-up marks on their arm and ignores it. It's obviously a sign of trouble.¹

These are the words of a 17-year-old girl, identified only as Harmony, who took part in an investigation of self-destructive behavior in adolescents. She is among what appears to be a growing number of teenagers who deal with emotional pain by deliberately injuring themselves physically.^2,3

Throughout her childhood, Harmony was exposed to her father's alcoholism and physical violence. Cutting herself helped her cope in a world that had become almost unbearable.

And Harmony is not alone. She's among an estimated 1% of the population that uses self-inflicted physical injury as a means of dealing with an overwhelming situation or feeling. This disturbing behavior usually begins in adolescence.^4,5

Heeding the cries and soothing the wounds of young people like Harmony who self-injure may constitute one of nursing's greatest challenges. If you're a primary care or school nurse, you may be the first to notice unusual scars on a teenager's arms or legs. Or, as a hospital nurse, you might be called upon to administer care in the ED, where many of these patients end up—often more than once. If their injuries are particularly severe, you might encounter them on a med/surg floor or even in the ICU.

While most of these teens do not intend to seriously hurt themselves, they are at high risk of accidentally inflicting a fatal injury or doing permanent damage to their bodies.⁵ How you deal with a patient such as Harmony can make a difference in whether she recovers or becomes yet another statistic.

An attempt to control pain that's unendurable

To identify and effectively care for those you suspect of being self-abusers, you need to understand who engages in this kind of behavior—and why.

Typical onset for self-injurious behavior is around the time of puberty, and it usually lasts five to 10 years. Without appropriate treatment, however, it can continue much longer.⁵

Contrary to popular belief, this is not a disorder exclusively seen with adolescent girls; boys self-injure, too.³ However, statistics on the number of boys vs. girls who self-injure are hard to come by. That's because self-injury is often overlooked or undiagnosed by clinicians and may be hidden or unreported by patients.³ Often, not even family and close friends know of the existence or the extent of self-injuring behavior. That may be due to the contradictory nature of the behavior—it's a cry for help, but it's also a source of shame that the teen is compelled to repeat in secret.

The discovery of self-injury is often misinterpreted as a suicide attempt. In fact, individuals who physically harm themselves usually aren't suicidal. Many of them aren't looking for a way to die, but are trying to find a way to deal with living. Unfortunately, they're 18 times more likely than the general population to die at their own hand by causing more harm than they intended.^5,6

Cutting with a sharp object, such as a razor blade, scissors, paper clip end, or knife—usually superficially but in some instances deeply—is the most common expression of the disorder, variously known as self-injury, self-mutilation, auto-aggression, or even "delicate" self-cutting, a reference to multiple superficial incisions.⁷ Using a lighted cigarette to burn flesh is another variation, as is hitting, hair-pulling, bone-breaking, and disturbing wounds before they heal.⁸

In a physical exam, one or many scars from cutting may be detected. You'll usually see faint, pink, well-demarcated lines on the arms, wrists, ankles, or lower legs. But the scars or wounds may also be in "hidden" areas such as the abdomen, inner thighs, feet, axillae, and under the breasts. They may form a pattern, design, symbol, or word, or you may see a single, large, repeatedly scarred line in the skin.³

Although previously documented in adolescents with schizophrenia, severe depression, a history of physical or sexual abuse or chemical dependency, experts have observed the biggest increase in self-injuring behavior among those who have no history of these disorders.³ What they have in common is a need for relief from the severe stress or emotional pain that often accompanies adolescence.⁹

Research indicates that young people injure themselves because they can't handle intense feelings, and so turn to self-destructive behavior as a way to express their emotions.

From the patient's perspective, self-inflicting pain accomplishes two things: It offers a sense of control; the adolescent can decide when and how to harm herself physically, which she can't do with emotional pain. More importantly, physical injury provides a distraction or relief from psychic pain.^10,11

In the published study that Harmony, the 17-year-old cutter, participated in, she offered this insight into the contradictory and complicated reasons for her behavior: "I don't always cut to make a point, I cut because I need to ... when I cut, when I see the blood, and I feel it rushing, it's such a relief. I can feel it; it's like everything that's bad is just going out."¹

This pattern of relief can make self-injury a compulsion—and just as addictive as smoking, overeating, and drinking alcohol.¹ Some researchers maintain that endorphins are released when a patient cuts or burns herself, contributing to the addictive nature of this behavior. The result: a numbing or pleasurable experience similar to a runner's high.^12,13

Human connection makes a difference

Regardless of the setting in which you practice, look for warning signs that a young patient is harming herself. You'll find evidence of unexplained frequent injury, including cuts, burns, and multiple scars. Some patients may wear long pants and long sleeves in warm weather and resist requests to remove clothing—even for a physical exam. The patient may also admit that she's having difficulty handling feelings or that she has relationship problems. And finally, you may find evidence that the patient is functioning poorly at school, work, or home.⁵

Once you identify an at-risk adolescent, you'll need to broach the subject with her carefully. Tell her, for instance, that your conversations will be confidential, except if there is a risk of serious physical harm to herself or others.

Talk to her about what you've observed. One approach might be to say: "I notice you have several scars on your arm." Then inquire about what happened. If signs indicate self-injury, such as a pattern of scarring, you might say to your patient, "Some people who do this can't deal with their feelings. Is that something you experience?"

To move the discussion along without getting too personal too quickly, you can turn to an assessment tool such as the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS), accessible at www.ama-assn.org/ama/pub/category/1981.html. Many adolescent clinics use the GAPS assessment during any visit in which a teen shows signs of self-injuring behavior.³ The assessment includes questions about the patient's lifestyle and is designed to uncover concerns in a safe, confidential manner. Versions are available for family members, as well.

Another handy tool is one used by pediatricians. HEEADSSS, an acronym for Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety (www.patientcarenp.com/pcnp/article/articleDetail.jsp?id=110644), is designed to elicit a history of the psychosocial issues concerning teenagers. The instrument moves from less intimidating questions about home, family members, and pastimes to more personal and private issues like drug use, sexual orientation and behavior, and relationships. It then progresses to questions like: "Have you ever had to hurt yourself to calm down or feel better?" and "Have you ever tried to kill yourself?"

Should the patient confirm your suspicions, your next step is to get her the help she needs. Before discharge, make a referral to therapy, and set an appointment date and time. You can also:

? Ask her to keep a journal to record the feelings that trigger self-injury. Identifying and acknowledging self-injury stressors, particularly in writing, can help quell the urge to take action.

? Provide the number of a crisis hotline (See the resource box on page 58.), and suggest she call when she begins thinking about injuring herself. Although these hotlines were set up to help people considering suicide, the counselors who take the calls have also been trained to render advice to self-abusers. You might also suggest she check out some self-injury Web sites, assuming, of course that you have reviewed them first. Be aware that some of these sites contain graphic stories, testimonials, and artwork that can act as triggers for more episodes of self-injury. Among teens, self-injury can have a contagious effect.¹⁴

Harmony, the girl involved in the study on self-destructiveness, gave the following advice on what can be done to help teens who hurt themselves: First and foremost, she said, you need to really listen—and not give advice until you know what's going on. Then, offer lots of support, and help the patient figure out exactly why she cuts. Finally, "make sure they always have somebody to talk to when they're about to cut."¹

Looking at life in a different way

Patients who self-mutilate often want help in the acute phase, but become less motivated to change as time goes on.¹⁵ That's why rapid follow-up with a mental health provider is essential.

Healing typically requires ongoing participation in psychotherapy. These teens need to be taught new coping mechanisms and better impulse control.¹⁵ Cognitive behavioral therapy can help them understand and manage their destructive thoughts and behaviors.⁵

Counseling is sometimes combined with drug therapy; opiate receptor blockers like naloxone (Narcan) have been somewhat effective. Opiate receptor blockers work to block the uptake of endorphins released during self-injury, thereby decreasing the emotional reward.¹²

Recent data indicate that a multifaceted approach that engages the patient, family, and trusted primary care and mental health providers goes a long way toward reducing and even eliminating self-cutting behavior. But none of this is possible without alert clinicians like yourself, who can spot self-injury during emergencies and routine health visits and line up the resources patients need to put an end to the self-abuse.

REFERENCES

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Common myths

Self-injury is a failed suicide attempt.

Self-injury is not a suicide attempt. Those involved are, however, 18 times more likely than the average person to kill themselves because the harm they intended to cause themselves inadvertently goes "too far."

Self-injurers are always female.

Boys engage in this type of behavior, as well. In fact, boys are more likely to begin self-injuring during preadolescence, while girls are more likely to do so at around age 15. Researchers say that the timing can be linked to when boys and girls are at heightened risk of depression—a risk factor for self-injury.

Scars from self-injury are always obvious.

Not necessarily. Some teens dress in long sleeves and long pants—even during hot weather—to keep their scars covered. They also may resist removing their clothing for a medical examination and avoid participating in activities—like phys ed classes—that require them to expose their skin. They keep their scars secret so that they can continue engaging in this behavior, without adults intervening.

Sources: 1. McAllister, M. (2003). Multiple meanings of self-harm: A critical review. Int J Ment Health Nurs, 12(3), 177. 2. Ayton, A., Cottrell, D., & Rasool, H. (2003). Deliberate self-harm in children and adolescents: Association with social deprivation. Eur Child Adolesc Psychiatry, 12(6), 303. 3. Fritz, G. (Ed.). (2004). Self-injury: Is this troubling behavior a growing problem in adolescents? The Brown University Child and Adolescent Behavior Letter, 20(3), p. 1. 4. Derouin, A., & Bravender, T. (2004). Living on the edge: The current phenomenon of self-mutilation in adolescents. MCN Am J Matern Child Nurs, 29(1), 12.

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Hotlines...

National Adolescent Suicide Hotline (800) 621-4000

The Trevor HelpLine (for gay and lesbian youths) (800) 850-8078

Youth Crisis Hotline (800) HIT-HOME (448-4663)

...and resources

American Self-Harm Information Clearinghouse distributes information about who self-injures, why they do it, and how they can learn to stop. It's accessible online at www.selfinjury.org.

SAFE Alternatives (Self Abuse Finally Ends) is a treatment approach, professional network, and educational resource base. Go to www.selfinjury.com or phone (800) DON'T-CUT (366-8288).

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