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14-year-old girl • history of bullying • lack of social support • multiple linear scars on breasts • Dx?
THE CASE
A 14-year-old girl with no significant medical history presented to the office accompanied by her mother for a routine well-adolescent visit. She attended school online due to a history of severe bullying and, when interviewed alone, admitted to a lack of a social life as a result. On questioning, she denied tobacco, alcohol, or illicit drug use. Her gender identity was female. Her sexual orientation was toward both males and females, but she was not sexually active. She denied exposure to physical or emotional violence at home and said she did not feel depressed or think about suicide.
Physical examination revealed multiple erythematous linear scars surrounding the areola of both breasts. When questioned about these lesions, she admitted to cutting herself on the breasts during the past several months but again denied suicidal intent. She believed that her behavior was a normal coping mechanism.
The physical exam was otherwise normal. Lab results, including thyroid-stimulating hormone and complete blood count, were within normal limits.
THE DIAGNOSIS
The physical exam findings and the patient’s self report pointed to a diagnosis of nonsuicidal self-injurious (NSSI) behavior involving cutting.
DISCUSSION
The NSSI behavior displayed by this patient is a common biopsychosocial disorder observed in adolescents. Self-injury is defined as the deliberate injuring of body tissues without suicidal intent.1 Self-injurious behavior typically begins when patients are 13 to 16 years of age, and cutting is the most common form. Most acts occur on the arms, legs, wrists, and stomach.2 Studies have shown that the prevalence of this behavior is on the rise among adolescents, from about 7% in 2014 to between 14% and 24% in 2015.3
Risk for suicide. Although a feature of NSSI is the lack of suicidal intent, this type of high-risk behavior is associated with past, present, and future suicide attempts. It is important for physicians to identify NSSI in an adolescent, as it is linked to a 7-fold increased risk for a suicide attempt.3
Screening for NSSI. Less than one-fifth of adolescents who injure themselves come to the attention of health care providers.4 We propose that primary care physicians add NSSI to the list of risky behaviors—including drug abuse, sexual activity, and depression—for which they screen during well-child visits.
Continue to: Identifying risk factors
Identifying risk factors. The case patient experienced bullying and reported a nonheterosexual orientation, both of which have been demonstrated as strong risk factors for NSSI.5 Female gender has also been identified as a risk factor for NSSI.3
In adolescent psychiatric samples, prevalence rates of NSSI were found to be as high as 60% for 1 incident of NSSI and around 50% for repetitive NSSI.6 NSSI coincides with other psychiatric comorbidities, including eating disorders, mood disorders (depression), anxiety disorders, posttraumatic stress disorder, and borderline personality disorder.3 In a study of 93 subjects, each of whom was a self-reported abuse survivor with a history of self-injury, 96% were in therapy for diagnoses that included posttraumatic stress disorder (73%), dissociative disorder (40%), borderline personality disorder (37%), and multiple personality disorder (29%).7
The experience of adverse childhood events also increases risk for NSSI. This includes parental neglect, abuse, or deprivation.6 Insecure paternal attachment and parental neglect are significant predictors for women, while childhood separation is a primary predictor for men.8 Indirect childhood maltreatment, such as witnessing domestic violence or increased parental critique, is also associated with NSSI.8 NSSI is also more prevalent among young people who identify with a subculture such as gothic or emo.6
Why they do it and how to help
In multiple studies aimed at identifying reasons for self-injury, converging evidence suggests that nearly all patients act with the intent of alleviating negative affect.9 Patients self-harm to regulate distress, anxiety, and frustration that they perceive to be intolerable.9 They may self-harm to generate feeling when emotionally empty or to avert suicidal intent.9 For others, self-harm is a way to communicate their distress.
How to proceed. After a physician identifies NSSI, the patient should be assessed for suicidality and medical severity of the injury.3 Factors associated with higher likelihood of suicidality in patients with NSSI include multiple self-injurious methods and locations, early age of onset, longer history of NSSI, recent worsening of the injuries, simultaneous substance use, and the perception that the patient is addicted to self-injury.10
Continue to: It is also important...
It is also important to ask the patient whether she or he has told anyone about the behavior. Participation in NSSI communities may reinforce it.3
Treatment found to be effective for NSSI involves dialectical behavioral therapy, cognitive behavioral therapy, and mentalization-based therapy.11
Our patient was admitted to the hospital several weeks after her well visit because she expressed suicidal ideation. After being discharged, she was referred to outpatient Psychiatry with a treatment plan that included cognitive behavioral therapy.
THE TAKEAWAY
While our patient may have concealed her self-injurious experience because of stigma and concern about others’ reactions, there were several risk factors for NSSI in her history that prompted further investigation with a skin exam.
If a patient presents with 1 or more risk factors, an initial assessment for possible NSSI should be performed with detailed history-taking and a skin exam. Once NSSI is identified, the initial response and tone of questioning toward the patient need to convey a sense of genuine curiosity about the patient’s experience. From there, the physician can avail the patient to the proper treatment modalities.
NSSI patients can be resistant to sharing and participating in support groups. However, a referred counselor can follow up with a stepwise approach to slowly gain the trust of the individual, find the root cause, and get the patient to a point where she or he is ready to start the necessary treatment.
1. Klonsky ED, Glenn CR. Resisting urges to self-injure. Behav Cogn Psychother. 2008;36:211-220. doi: 10.1017/S1352465808004128
2. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117:1939-1948. doi: 10.1542/peds.2005-2543
3. Lewis SP, Heath NL. Non-suicidal self-injury among youth. J Pediatr. 2015;166:526-630. doi: 10.1016/j.jpeds.2014.11.062
4. Ystgaard M, Arensman E, Hawton K, et al. Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not. J Adolesc. 2009;32: 875-891.
5. Lereya ST, Copeland WE, Costello EJ, et al. Adult mental health consequences of peer bullying and maltreatment in childhood: two cohorts in two countries. Lancet Psychiatry. 2015;2:524-531. doi: 10.1016/S2215-0366(15)00165-0
6. Brown RC, Plener PL. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep. 2017;19:20. doi: 10.1007/s11920-017-0767-9
7. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry. 1998;68:609-620. doi:10.1037/h0080369
8. Gratz KL, Conrad SD, Roemer L. Risk factors for deliberate self-harm among college students. Am J Orthopsychiatry. 2002;1:128-140. doi: 10.1037//0002-9432.72.1.128
9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27:226-239.
10. Nock MK, Joiner Jr. TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144:65-72. doi: 10.1016/j.psychres.2006.05.010
11. Lewis SP, Baker TG. The possible risks of self-injury websites: a content analysis. Arch Suicide Res. 2011;15:390-396. doi: 10.1080/13811118.2011.616154
THE CASE
A 14-year-old girl with no significant medical history presented to the office accompanied by her mother for a routine well-adolescent visit. She attended school online due to a history of severe bullying and, when interviewed alone, admitted to a lack of a social life as a result. On questioning, she denied tobacco, alcohol, or illicit drug use. Her gender identity was female. Her sexual orientation was toward both males and females, but she was not sexually active. She denied exposure to physical or emotional violence at home and said she did not feel depressed or think about suicide.
Physical examination revealed multiple erythematous linear scars surrounding the areola of both breasts. When questioned about these lesions, she admitted to cutting herself on the breasts during the past several months but again denied suicidal intent. She believed that her behavior was a normal coping mechanism.
The physical exam was otherwise normal. Lab results, including thyroid-stimulating hormone and complete blood count, were within normal limits.
THE DIAGNOSIS
The physical exam findings and the patient’s self report pointed to a diagnosis of nonsuicidal self-injurious (NSSI) behavior involving cutting.
DISCUSSION
The NSSI behavior displayed by this patient is a common biopsychosocial disorder observed in adolescents. Self-injury is defined as the deliberate injuring of body tissues without suicidal intent.1 Self-injurious behavior typically begins when patients are 13 to 16 years of age, and cutting is the most common form. Most acts occur on the arms, legs, wrists, and stomach.2 Studies have shown that the prevalence of this behavior is on the rise among adolescents, from about 7% in 2014 to between 14% and 24% in 2015.3
Risk for suicide. Although a feature of NSSI is the lack of suicidal intent, this type of high-risk behavior is associated with past, present, and future suicide attempts. It is important for physicians to identify NSSI in an adolescent, as it is linked to a 7-fold increased risk for a suicide attempt.3
Screening for NSSI. Less than one-fifth of adolescents who injure themselves come to the attention of health care providers.4 We propose that primary care physicians add NSSI to the list of risky behaviors—including drug abuse, sexual activity, and depression—for which they screen during well-child visits.
Continue to: Identifying risk factors
Identifying risk factors. The case patient experienced bullying and reported a nonheterosexual orientation, both of which have been demonstrated as strong risk factors for NSSI.5 Female gender has also been identified as a risk factor for NSSI.3
In adolescent psychiatric samples, prevalence rates of NSSI were found to be as high as 60% for 1 incident of NSSI and around 50% for repetitive NSSI.6 NSSI coincides with other psychiatric comorbidities, including eating disorders, mood disorders (depression), anxiety disorders, posttraumatic stress disorder, and borderline personality disorder.3 In a study of 93 subjects, each of whom was a self-reported abuse survivor with a history of self-injury, 96% were in therapy for diagnoses that included posttraumatic stress disorder (73%), dissociative disorder (40%), borderline personality disorder (37%), and multiple personality disorder (29%).7
The experience of adverse childhood events also increases risk for NSSI. This includes parental neglect, abuse, or deprivation.6 Insecure paternal attachment and parental neglect are significant predictors for women, while childhood separation is a primary predictor for men.8 Indirect childhood maltreatment, such as witnessing domestic violence or increased parental critique, is also associated with NSSI.8 NSSI is also more prevalent among young people who identify with a subculture such as gothic or emo.6
Why they do it and how to help
In multiple studies aimed at identifying reasons for self-injury, converging evidence suggests that nearly all patients act with the intent of alleviating negative affect.9 Patients self-harm to regulate distress, anxiety, and frustration that they perceive to be intolerable.9 They may self-harm to generate feeling when emotionally empty or to avert suicidal intent.9 For others, self-harm is a way to communicate their distress.
How to proceed. After a physician identifies NSSI, the patient should be assessed for suicidality and medical severity of the injury.3 Factors associated with higher likelihood of suicidality in patients with NSSI include multiple self-injurious methods and locations, early age of onset, longer history of NSSI, recent worsening of the injuries, simultaneous substance use, and the perception that the patient is addicted to self-injury.10
Continue to: It is also important...
It is also important to ask the patient whether she or he has told anyone about the behavior. Participation in NSSI communities may reinforce it.3
Treatment found to be effective for NSSI involves dialectical behavioral therapy, cognitive behavioral therapy, and mentalization-based therapy.11
Our patient was admitted to the hospital several weeks after her well visit because she expressed suicidal ideation. After being discharged, she was referred to outpatient Psychiatry with a treatment plan that included cognitive behavioral therapy.
THE TAKEAWAY
While our patient may have concealed her self-injurious experience because of stigma and concern about others’ reactions, there were several risk factors for NSSI in her history that prompted further investigation with a skin exam.
If a patient presents with 1 or more risk factors, an initial assessment for possible NSSI should be performed with detailed history-taking and a skin exam. Once NSSI is identified, the initial response and tone of questioning toward the patient need to convey a sense of genuine curiosity about the patient’s experience. From there, the physician can avail the patient to the proper treatment modalities.
NSSI patients can be resistant to sharing and participating in support groups. However, a referred counselor can follow up with a stepwise approach to slowly gain the trust of the individual, find the root cause, and get the patient to a point where she or he is ready to start the necessary treatment.
THE CASE
A 14-year-old girl with no significant medical history presented to the office accompanied by her mother for a routine well-adolescent visit. She attended school online due to a history of severe bullying and, when interviewed alone, admitted to a lack of a social life as a result. On questioning, she denied tobacco, alcohol, or illicit drug use. Her gender identity was female. Her sexual orientation was toward both males and females, but she was not sexually active. She denied exposure to physical or emotional violence at home and said she did not feel depressed or think about suicide.
Physical examination revealed multiple erythematous linear scars surrounding the areola of both breasts. When questioned about these lesions, she admitted to cutting herself on the breasts during the past several months but again denied suicidal intent. She believed that her behavior was a normal coping mechanism.
The physical exam was otherwise normal. Lab results, including thyroid-stimulating hormone and complete blood count, were within normal limits.
THE DIAGNOSIS
The physical exam findings and the patient’s self report pointed to a diagnosis of nonsuicidal self-injurious (NSSI) behavior involving cutting.
DISCUSSION
The NSSI behavior displayed by this patient is a common biopsychosocial disorder observed in adolescents. Self-injury is defined as the deliberate injuring of body tissues without suicidal intent.1 Self-injurious behavior typically begins when patients are 13 to 16 years of age, and cutting is the most common form. Most acts occur on the arms, legs, wrists, and stomach.2 Studies have shown that the prevalence of this behavior is on the rise among adolescents, from about 7% in 2014 to between 14% and 24% in 2015.3
Risk for suicide. Although a feature of NSSI is the lack of suicidal intent, this type of high-risk behavior is associated with past, present, and future suicide attempts. It is important for physicians to identify NSSI in an adolescent, as it is linked to a 7-fold increased risk for a suicide attempt.3
Screening for NSSI. Less than one-fifth of adolescents who injure themselves come to the attention of health care providers.4 We propose that primary care physicians add NSSI to the list of risky behaviors—including drug abuse, sexual activity, and depression—for which they screen during well-child visits.
Continue to: Identifying risk factors
Identifying risk factors. The case patient experienced bullying and reported a nonheterosexual orientation, both of which have been demonstrated as strong risk factors for NSSI.5 Female gender has also been identified as a risk factor for NSSI.3
In adolescent psychiatric samples, prevalence rates of NSSI were found to be as high as 60% for 1 incident of NSSI and around 50% for repetitive NSSI.6 NSSI coincides with other psychiatric comorbidities, including eating disorders, mood disorders (depression), anxiety disorders, posttraumatic stress disorder, and borderline personality disorder.3 In a study of 93 subjects, each of whom was a self-reported abuse survivor with a history of self-injury, 96% were in therapy for diagnoses that included posttraumatic stress disorder (73%), dissociative disorder (40%), borderline personality disorder (37%), and multiple personality disorder (29%).7
The experience of adverse childhood events also increases risk for NSSI. This includes parental neglect, abuse, or deprivation.6 Insecure paternal attachment and parental neglect are significant predictors for women, while childhood separation is a primary predictor for men.8 Indirect childhood maltreatment, such as witnessing domestic violence or increased parental critique, is also associated with NSSI.8 NSSI is also more prevalent among young people who identify with a subculture such as gothic or emo.6
Why they do it and how to help
In multiple studies aimed at identifying reasons for self-injury, converging evidence suggests that nearly all patients act with the intent of alleviating negative affect.9 Patients self-harm to regulate distress, anxiety, and frustration that they perceive to be intolerable.9 They may self-harm to generate feeling when emotionally empty or to avert suicidal intent.9 For others, self-harm is a way to communicate their distress.
How to proceed. After a physician identifies NSSI, the patient should be assessed for suicidality and medical severity of the injury.3 Factors associated with higher likelihood of suicidality in patients with NSSI include multiple self-injurious methods and locations, early age of onset, longer history of NSSI, recent worsening of the injuries, simultaneous substance use, and the perception that the patient is addicted to self-injury.10
Continue to: It is also important...
It is also important to ask the patient whether she or he has told anyone about the behavior. Participation in NSSI communities may reinforce it.3
Treatment found to be effective for NSSI involves dialectical behavioral therapy, cognitive behavioral therapy, and mentalization-based therapy.11
Our patient was admitted to the hospital several weeks after her well visit because she expressed suicidal ideation. After being discharged, she was referred to outpatient Psychiatry with a treatment plan that included cognitive behavioral therapy.
THE TAKEAWAY
While our patient may have concealed her self-injurious experience because of stigma and concern about others’ reactions, there were several risk factors for NSSI in her history that prompted further investigation with a skin exam.
If a patient presents with 1 or more risk factors, an initial assessment for possible NSSI should be performed with detailed history-taking and a skin exam. Once NSSI is identified, the initial response and tone of questioning toward the patient need to convey a sense of genuine curiosity about the patient’s experience. From there, the physician can avail the patient to the proper treatment modalities.
NSSI patients can be resistant to sharing and participating in support groups. However, a referred counselor can follow up with a stepwise approach to slowly gain the trust of the individual, find the root cause, and get the patient to a point where she or he is ready to start the necessary treatment.
1. Klonsky ED, Glenn CR. Resisting urges to self-injure. Behav Cogn Psychother. 2008;36:211-220. doi: 10.1017/S1352465808004128
2. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117:1939-1948. doi: 10.1542/peds.2005-2543
3. Lewis SP, Heath NL. Non-suicidal self-injury among youth. J Pediatr. 2015;166:526-630. doi: 10.1016/j.jpeds.2014.11.062
4. Ystgaard M, Arensman E, Hawton K, et al. Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not. J Adolesc. 2009;32: 875-891.
5. Lereya ST, Copeland WE, Costello EJ, et al. Adult mental health consequences of peer bullying and maltreatment in childhood: two cohorts in two countries. Lancet Psychiatry. 2015;2:524-531. doi: 10.1016/S2215-0366(15)00165-0
6. Brown RC, Plener PL. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep. 2017;19:20. doi: 10.1007/s11920-017-0767-9
7. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry. 1998;68:609-620. doi:10.1037/h0080369
8. Gratz KL, Conrad SD, Roemer L. Risk factors for deliberate self-harm among college students. Am J Orthopsychiatry. 2002;1:128-140. doi: 10.1037//0002-9432.72.1.128
9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27:226-239.
10. Nock MK, Joiner Jr. TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144:65-72. doi: 10.1016/j.psychres.2006.05.010
11. Lewis SP, Baker TG. The possible risks of self-injury websites: a content analysis. Arch Suicide Res. 2011;15:390-396. doi: 10.1080/13811118.2011.616154
1. Klonsky ED, Glenn CR. Resisting urges to self-injure. Behav Cogn Psychother. 2008;36:211-220. doi: 10.1017/S1352465808004128
2. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117:1939-1948. doi: 10.1542/peds.2005-2543
3. Lewis SP, Heath NL. Non-suicidal self-injury among youth. J Pediatr. 2015;166:526-630. doi: 10.1016/j.jpeds.2014.11.062
4. Ystgaard M, Arensman E, Hawton K, et al. Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not. J Adolesc. 2009;32: 875-891.
5. Lereya ST, Copeland WE, Costello EJ, et al. Adult mental health consequences of peer bullying and maltreatment in childhood: two cohorts in two countries. Lancet Psychiatry. 2015;2:524-531. doi: 10.1016/S2215-0366(15)00165-0
6. Brown RC, Plener PL. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep. 2017;19:20. doi: 10.1007/s11920-017-0767-9
7. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry. 1998;68:609-620. doi:10.1037/h0080369
8. Gratz KL, Conrad SD, Roemer L. Risk factors for deliberate self-harm among college students. Am J Orthopsychiatry. 2002;1:128-140. doi: 10.1037//0002-9432.72.1.128
9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27:226-239.
10. Nock MK, Joiner Jr. TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144:65-72. doi: 10.1016/j.psychres.2006.05.010
11. Lewis SP, Baker TG. The possible risks of self-injury websites: a content analysis. Arch Suicide Res. 2011;15:390-396. doi: 10.1080/13811118.2011.616154
