by Mary Kuhn, RNBC, BSN

Self-mutilation (cutting) is the deliberate destruction of body tissue.  Usually the person does not have suicidal intent.  This behavior is increasingly common among adolescents and adults.  Epidemiological literature estimates a prevalence rate of about 750 self-mutilations per 100,000 in the general population.  It is thought to be seriously underreported.

The onset of self-injurious behavior has been linked to overwhelming interpersonal stress. Predisposing factors are pathological childhood experiences, including isolation, abandonment, neglect and physical, sexual, and /or psychological abuse by parents. Witnessing violence has been shown to be correlated with self-destructive behavior.  It can be a part of PTSD (post traumatic stress disorder). 

Suffering abuse before age 14 may result in not learning to modulate anger leading to the idea of self-destruction.  The normal regulation of emotional states is disrupted by traumatic experiences that evoke terror, rage, and grief.  These emotions can create a sad or depressed state in response to perceived threats of abandonment.  The abused person may discover that intolerable feelings can be most effectively terminated by a major jolt to the body.  Deliberate infliction of injury is one means of achieving this end.  The feelings of emptiness and numbness, and experiences of depersonalization (a state in which the normal sense of normal personal identity and reality is lost) can produce a state of dissociation (such as occurs with multiple personality disorder). The act of cutting involves no pain; instead it provides a satisfying release of tension and anxiety.  Reintegration of reality and identity results and the self-mutilator may appear quite normal and can function adequately. Those who do feel physical pain find it preferable to emotional pain. 

Those who self injure can be secretive.  The individual is not trying to "manipulate" other people. They are often evasive to avoid unwanted attention and embarrassment.  They may dress in ways to camouflage their cutting with long sleeves, for example.  If a family member accidentally discovers a wound, the mutilator will usually fabricate stories to explain how he or she was hurt.

Cutting or self-mutilating behavior is a complex interaction of biological, psychological, and environmental factors.  It can co-exist with substance abuse and eating disorders.  The most serious complications are accidental death.  Suicide attempts, on the other hand, typically occur by means other than self-mutilation, such as drug overdose.

Effective treatment combines education, self-management techniques, medication, and psychotherapy.  Pharmacotherapy (medication) and psychotherapy produce the best treatment outcomes.  These treatments can be very helpful in decreasing symptoms.  Selective serotonin reuptake inhibitors (SSRI's) such as Paxil and Zoloft are helpful as well.  There is no drug of choice to prevent self-harm.  Since symptoms of anxiety, depression, obsessive thinking, and sleep impairment can add to the desire to cut, those symptoms must be treated in order to lessen the likelihood of further cutting.

One of the most important pieces to decreasing or stopping the cutting behavior is the establishment of the trusting relationship.  The advocate or therapist must stay empathetic, understand the despair of the client, and convey that understanding to the client.  A nurturing posture and optimism about the future must be continually relayed.  The cutter must learn to identify and express feelings verbally and learn to use constructive behavioral alternatives to mutilation.  One of the alternatives suggested in the literature (provided the client has no underlying vascular problems) is to hold an ice cube in the hand as it melts.  The cold creates a pain analogue and activates the release of endorphins.  Through treatment with a knowledgeable clinician, the client will understand he is using a maladaptive attempt at self-help.  The goal is to replace the negative behavior with constructive alternatives and to reduce physical tension, anxiety, and the desire to cut.

References:
Levenkron, Steven: Cutting, W.W. Norton and Co., 1998.

Dallam, Stephanie: "The Identification and Management of Self-Mutilating Patients in Primary Care".  The Nurse Practitioner, May 1997, 151-164

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