While many people are much more aware of anxiety now than in the past, some details and symptoms still aren’t as commonly discussed.

One lesser-known symptom of anxiety is the urge to self-harm. Not all or even most people who experience anxiety will have these urges, and there are people who self-harm who do not struggle with anxiety. Yet, when anxiety and self-harm co-occur, it may be crucial to a person’s well-being and safety to identify the issue in order to connect with help.

Can Anxiety Cause Self-Harm?

It’s very possible for anxiety to spark urges to self-harm. Self-harm is frequently associated with a sense of release from overwhelming emotions or situations in those who engage in the behavior. Since anxiety is characterized by a sense of feeling overwhelmed or worried about not being able to handle life situations, self-harm acts can bring relief from anxious feelings. While anxiety does not always lead to self-harm, studies have shown people who engage in self-harm are more likely to experience anxiety and vice-versa.

Types of Anxiety That May Lead to Self-Harm

Certain types of anxiety may be more likely to lead to self-harm than others:

• Social anxiety: This type of anxiety is characterized by an intense fear or worry of being judged by others. Studies have shown that this type of anxiety has a high likelihood of leading to self-harm behaviors.
• Generalized anxiety: General anxiety is a constant sense of worry or stress in the long-term that doesn’t seem to have one specific cause. This type of anxiety has also been shown to have a higher chance of leading to self-harm behaviors.

While obsessive-compulsive disorder (OCD) was once listed as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5 lists it as an obsessive-compulsive disorder. Although OCD is now technically in a different category than anxiety, is may frequently co-occur with anxiety and has been known to cause self-harm.

One type of OCD, known as harm OCD, can cause intense fear of hurting oneself or others. While this anxiety about harming oneself may be severe and vivid, those with harm OCD are thought to be no more likely to act on their thoughts of self-harm than someone without harm OCD.

Why Is Anxiety Connected to Self-Harm?

Anxiety is frequently accompanied by overwhelming feelings of worry, racing thoughts, and sometimes panic attacks. This can make people with anxiety feel they’ve completely lost control of their minds and bodies. They may turn to self-harm in order to focus their mind outside of their racing thoughts or worries, or they may use it as a way to regain feeling if they’ve begun to feel numb from long-term anxiety.

Alternatively, self-harm is sometimes used out of anger. People with anxiety may feel frustrated or mad at themselves for not being able to keep their anxious thoughts under control or that they can’t “fix” themselves. In this case, self-harm may not be done for the purpose of relief, but as self-inflicted punishment. Self-harm used in anger can be especially damaging, as it isn’t a coping mechanism, but a sign of deeper emotional struggle.

Self-harming thoughts often lead to self-harming behaviors in an effort to either feel relief, feel pain, or punish oneself.

Angela Avery, MA, LLPC, NCC, a therapist in Clarkston, Michigan, notices that self-harm may tend to occur with social anxiety. She explains,

“In my clinical practice with teenagers, I often see self-harming behaviors co-occur with social anxiety. Those who experience social anxiety are afraid that they will be judged by others and often that belief is validated because they lack social skills and social confidence to create friendships or engage with others.

When you feel like no one is your friend, and you are too afraid to speak to anyone, you tend to feel poorly about yourself. Low self-worth then leads to self-critical, irrational thoughts presuming we are “bad” and “stupid” and “no one likes us.” Self-harming thoughts often lead to self-harming behaviors in an effort to either feel relief, feel pain, or punish oneself.

I tend to view harming behaviors as coping strategies of choice for people who view themselves with a severely critical eye. Add in a sprinkling of social anxiety or limited social skills and we have a combination for continued harm.”

It’s important to note that anxiety can lead to multiple forms of self-harm that aren’t always what people typically think of. The stereotyping around self-harm as a form of “attention seeking” or something people do when they’re into a certain type of music has deeply damaged our society’s ability to recognize self-harming behaviors in some cases.

Anxiety and Personality Disorders As a Cause of Self-Harm

In addition to anxiety, some some studies show that certain personality disorders may have a higher likelihood of leading to self-harm. Some of these disorders are closely linked to anxiety and may co-occur, and some can lead to self-harming behaviors independent of anxious thoughts or feelings.

Some disorders that have been linked to self-harm include:

• Borderline personality
• Schizophrenia
• Dependent personality
• Avoidant personality

At the end of the day, regardless of the cause, people who are engage in destructive self-harming behavior should not try to overcome these patterns alone. They’re a maladaptive coping mechanism, and while they can be painful and scary, there is hope. With the help of a licensed mental health professional and plenty of love and encouragement from friends and family, people can learn to manage their anxiety and overcome their self-harm behaviors.

References:

1. Bhandari, S. (2018, February 21). Mental health and self-injury. Retrieved from https://www.webmd.com/anxiety-panic/guide/self-injuring-hurting#1
2. Bolton, J., Chartrand, H., Sareen, K., & Toews, M. (2011, September 21). Suicide attempts versus nonsuicidal self‐injury among individuals with anxiety disorders in a nationally representative sample. Depression and Anxiety, 29(3), 172-179. doi: 10.1002/da.20882
3. Klonsky, E. D., Oltmanns, T., Turkheimer, E. (2003, August 1). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. The American Journal of Psychiatry, 160(8), 1501-1508. Retrieved from https://doi.org/10.1176/appi.ajp.160.8.1501
4. Living with harm OCD: What’s going on? (n.d.). Retrieved from https://www.intrusivethoughts.org/ocd-symptoms/harm-ocd
5. O’Connor, R., Rasmussen, S., & Hawton, K. (2009). Predicting depression, anxiety and self-harm in adolescents: The role of perfectionism and acute life stress. Behaviour Research and Therapy, 84(1), 52-59. doi: 10.1016/j.brat.2009.09.008
6. Pierce, L. (2018, April 21). OCD, Self Injury, and Suicidal Thoughts. Retrieved from https://www.verywellmind.com/ocd-self-injury-and-suicidal-thoughts-2510599
7. Self-harm. (2018, May 25). Retrieved from https://www.nhs.uk/conditions/self-harm

Head-banging, face-slapping, scratching, and other self-injurious behaviors (SIB) are common among children who become frustrated. According to United Cerebral Palsy, up to 20% of all young children bang their heads in frustration. The behavior is common and considered developmentally typical until a child is about four years old. Among autistic people, self-injury is even more common, and it may persist later into childhood and even adulthood. A 2016 analysis found 27.7% of autistic eight-year-olds engaged in head-banging or similar actions.

Self-injurious behavior can be alarming to parents and caregivers. It can also lead to frustrating and painful judgment from bystanders. In most cases, self-harm does not cause severe damage such as concussions or life-threatening wounds, though some autistic people do seriously injure themselves.

SIB is a symptom of an underlying problem. Parents, spouses, friends, and others invested in the well-being of autistic people must look to the underlying motivation. Understanding the emotions and frustrations that trigger self-harm is the fastest route to ending it.

Common Causes of Self-Injurious Behavior in Autism

People on the autism spectrum process information, emotions, and sensory input differently from neurotypical individuals. While the experience of every autistic person is slightly different, some characteristics of autism that increase the risk of self-injury include:

Sensory overload

Autism can make a person highly sensitive to sensory input. They may feel overwhelmed by loud noises, find certain textures intolerable, or be unable to concentrate in certain environments. A small change in an autistic person’s sensory environment can feel like torture. Some autistic people engage in self-injury out of frustration when sensory stimuli become overwhelming. Others self-injure as a physical counterweight to painful sensory input.

Lack of control

Both autistic and neurotypical children may self-harm in frustration when they have little control over their environments. For instance, a child forced to play with the toys their parents choose instead of the toys they desire might bang their head. Outdated notions about how to support children with autism sometimes advocate restraint or punishment. This may trigger self-harm in some kids.

Reinforcement

Parents and bystanders may inadvertently reinforce SIB by giving the child more attention while trying to stop the behavior. They might also reward a child immediately after they stop self-injuring. This tactic can backfire and reinforce the action itself rather than the act of stopping.

Pain

Autism is linked to a number of other conditions and symptoms. For example, autistic children are more likely to have gastrointestinal problems. For some children, self-injury is a way of coping with or distracting from pain. A 2017 study argues that some physical symptoms of autism, such as stomach discomfort, are likely due to stress instead of an underlying medical condition. This suggests stressful experiences and chronic stress may play a role in SIB.

Chemical changes

Research suggests SIB and other forms of self-harm may cause the body to release feel-good chemicals called endogenous opioids. This means self-injury can be a source of pleasure. For a person experiencing stress or pain, the pleasurable chemical rush associated with self-injury can be appealing. (This theory applies to both autistic and neurotypical people.)

Environmental changes

Autism often causes a person to crave routine, order, and control. So when their environment changes, their schedule is chaotic, or they can’t go about their usual routine, they may self-harm to cope.

How to Help an Autistic Person Who Self-Injures

A generation ago, much advice about managing autism-related challenges focused on rewards and punishments. Now, with the advent of autism self-advocacy communities, autistic individuals are able to weigh in on various strategies. The overwhelming majority of autistic people and autism advocates strongly oppose punishments. Many also have expressed concerns about rewards, especially when the person giving the reward does nothing to address the underlying cause of the behavior.

Parents and others who care for an autistic person should view SIB as communication. Some strategies that may help include:

• A change in parenting strategy. Autistic individuals often thrive on order and routine. Parenting strategies that support this need can minimize SIB. A 2006 study found that a mindfulness-based parenting intervention improved parenting skills, helped parents feel more competent, and reduced aggression and self-harm.
• Offering more control over the environment. A number of studies have shown that giving autistic people more choices and more agency can reduce self-injury. For example, rather than telling a child what they will eat for dinner, offer them two or three options.
• Addressing underlying sensory issues. Sensory overload can be intense and painful. Parents and other caregivers should work to identify and understand their child’s sensory triggers. Advocates recommend removing or reducing these triggers as soon as possible. Many autistic people cannot function or concentrate until their triggers are gone. Something as simple as buying seamless socks could make a meaningful difference.
• Avoiding inadvertently reinforcing the behavior. Don’t yell, punish, or immediately divert your attention to an autistic child engaged in self-harm. Some autistic children feel chronically unheard and have learned that self-harm is the only way to get a caregiver’s attention. Reverse this cycle by listening attentively when an autistic child attempts to communicate but minimizing attention during moments of self-harm.

Self-Help for Autistic People Who Engage in Self-Injurious Behavior

Some autistic people feel an overwhelming impulse to self-harm, even when doing so causes them difficulties at home, work, school, and in friendships or romantic relationships.

The right therapist can help an autistic person advocate for themself, building an environment that feels safe and healthy.Correcting SIB begins with understanding what causes it. Try asking yourself which triggers are most likely to bring about SIB? Then explore how you feel while self-injuring. Does it cause feelings of relief? Pleasure? Distraction? Identifying what you get out of SIB can help you begin cultivating healthy alternatives. For example, meditation might help with feeling calm in response to stress, while exercise might help with feeling jittery or frustrated.

Autistic people often find support and help from autistic self-help and advocacy groups. These groups view autism as an identity rather than a disability or illness. They say autism is a unique lens through which to view the world. Participation in such a group can help an autistic person cultivate new strengths and find healthy alternatives for managing challenging feelings.

Medication for Autistic Self-Injury

No specific medication is approved by the U.S. Food and Drug Administration (FDA) to prevent SIB. A number of drugs, however, may help treat the underlying causes of SIB:

• Antipsychotics: The FDA has approved antipsychotics such as risperidone to treat autism-related irritability. Lowering anger may reduce one’s need to use SIB as an outlet. However, antipsychotics often make anxiety worse. Because many autistic people already struggle with anxiety, it’s often better to try other drugs first.
• Antidepressants: Some antidepressants can help with anxiety, depression, irritability, and aggression.
• Opioid agonists: Medications such as naltrexone counter the effects of opioids in the brain. Research suggests naltrexone can reduce the pleasure an autistic person experiences when self-injuring, potentially stopping the behavior.

Therapy for Self-Injury in People on the Spectrum

Therapy can help autistic people who self-injure, as well as their spouses, parents, and other loved ones. A therapist may work with an individual to identify triggers for SIB and cultivate healthier alternatives. The right therapist can help an autistic person advocate for themself, building an environment that feels safe and healthy.

Family counseling helps families better understand autism while dispelling myths about the spectrum. This can help parents better support their children, foster communication between autistic and neurotypical siblings, and offer a safe space for every family member to strategize and share concerns.

Couples counseling can help autistic people and their partners understand one another’s emotions. This fosters better communication, reduces frustration, and offers greater intimacy.

If you or a loved one would like support, you can find a therapist here.

References:

1. About autism. (n.d.). Retrieved from http://autisticadvocacy.org/about-asan/about-autism
2. ASAN Letter to FDA on banning electric shock devices. (2018, April 23). Retrieved from http://autisticadvocacy.org/2018/04/asan-letter-to-fda-on-banning-electric-shock-devices
3. Humenik, A. L., Curran, J., Luiselli, J. K., & Child, S. N. (2008). Intervention for self-injury in a child with autism: Effects of choice and continuous access to preferred stimuli. Behavioral Development Bulletin, 14(1), 17-22. doi:10.1037/h0100503
4. Living with children: Head-banging [PDF]. (n.d.). United Cerebral Palsy. Retrieved from http://ucphuntsville.org/wp-content/uploads/2015/06/Head-Banging.pdf
5. LeClerc, S., & Easley, D. (2015). Pharmacological therapies for autism spectrum disorder: A review. Pharmacy and Therapeutics, 40(6), 389-397. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450669
6. Minshawi, N., Hurwitz, S., Fodstad, J., Biebl, S., Morriss, D., & McDougle, C. (2014). The association between self-injurious behaviors and autism spectrum disorders. Psychology Research and Behavior Management, 7(1), 125-136. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990505
7. Singh, N. N., Lancioni, G. E., Winton, A. S., Fisher, B. C., Wahler, R. G., Mcaleavey, K., . . . Sabaawi, M. (2006). Mindful parenting decreases aggression, noncompliance, and self-injury in children with autism. Journal of Emotional and Behavioral Disorders, 14(3), 169-177. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/10634266060140030401
8. Soke, G. N., Rosenberg, S. A., Hamman, R. F., Fingerlin, T., Robinson, C., Carpenter, L., . . . DiGuiseppi, C. (2016). Brief report: Prevalence of self-injurious behaviors among children with autism spectrum disorder—A population-based study. Journal of Autism and Developmental Disorders, 46(11), 3607-3614. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392775
9. Stress, not diet, likely source of GI problems in children with autism. (2017, July 14). Retrieved from https://www.healio.com/gastroenterology/stomach-duodenum/news/online/%7B6c9e6171-0a63-4f1e-9dcb-c7f0dd8e0b59%7D/stress-not-diet-likely-source-of-gi-problems-in-children-with-autism
10. Walters, A. S., Barrett, R. P., Feinstein, C., Mercurio, A., & Hole, W. T. (1990). A case report of naltrexone treatment of self-injury and social withdrawal in autism. Journal of Autism and Developmental Disorders, 20(2), 169-176. Retrieved from https://link.springer.com/article/10.1007/BF02284716

Though some people believe self-harming behaviors such as cutting or burning may indicate a person’s desire to die or serve as a precursor to a suicide attempt, not everyone who self-harms has suicidal thoughts or ideation. Many misconceptions surround nonsuicidal self-harm, from demographics affected to possible outcomes of this behavior. Though there may currently be more data available on adolescent girls who self-harm than on any other population, this should not be taken as an indication that adolescent girls are the only individuals who self-harm. People of any age, gender, or ethnicity might be inclined to self-injure.

Another common misconception about self-injury is that those who self-harm do so only in order to seek attention. For some people, self-injury may indeed be a method of asking for help, but for others, actions like cutting or burning might be a way to relieve stress or cope with anxiety-inducing situations. Others report self-harming behaviors help them stop dissociating, or feeling numb or disconnected from life.

Self-harming behavior might also be related to another mental health concern such as posttraumatic stress, borderline personality, bipolar, or depression. When a person receives treatment for the mental health concern, the desire to self-harm may decrease as well-being improves. [fat_widget_right]

If you or someone who know is self-harming, whatever the cause and whether suicidal thought or intent is present or not, it is very important to seek help for yourself or the person you care about immediately. Please visit our crisis resources page for more information about finding the right help.

If you would like to learn more about non-suicidal self-injury and find related information and resources, GoodTherapy.org has collected several resources that address non-suicidal self harm. Keep reading for our top websites and organizations discussing self-harm in 2017.

• Cornell Research Program on Self-Injury and Recovery (CRPSIR): Launched in 2003, CRPSIR was developed to translate research into user-friendly resources. It contains a variety of resources for anyone who needs help with or wants to learn more about self-injury. Visitors to the site can find information on prevention and treatment of self-harm, as well as links to media resources, information on recovery and support, common myths about self-harm, and fact sheets. It also offers links to training programs for youth-serving providers and parents of youth who self-injure.
• Self-injury Outreach and Support: This nonprofit organization that was established to promote education about self-injury. It provides resources for people who want to get help for self-harm and those already in recovery and also offers school professionals information about helping students. SOS also provides detailed information for loved ones who want to support someone they know, coping strategies for people who have the urge to self-harm, and personal stories of people who have been affected by self-harm.
• To Write Love On Her Arms: This nonprofit began with the founder’s desire to help a friend enter recovery for depression, addiction, self-harm, and suicidal ideation. Visitors to the site, which offers hope for many seeking help with self-harm, can read the founder’s story, access helpful resources for self-harm issues as well as other mental health conditions, and read messages of inspiration and support. The goal of the movement is to encourage people that a better life is possible and their story is not over.
• S.A.F.E. Alternatives: Since 1986, S.A.F.E. Alternatives has worked to promote self-harm treatment that emphasizes self-efficacy in the individual. The website provides research and news articles on self-harm, as well as intervention tips for concerned family and friends. Visitors to the site can also apply to support groups and outpatient programs through the digital portal.
• RecoverYourLife.com: Recover Your Life is one of the largest internet support communities for self-harm. It offers forums, live chat rooms, and a monthly e-zine. Recover Your Life maintains a non-judgmental atmosphere, emphasizing advice and sympathy over stigmatization.
• Self Injury Support: Though this charity, based in Bristol, primarily directs their support to women and girls who injure themselves or are otherwise affected by self-harm, it also works to increase awareness of self-harm and other mental health concerns. The online library offers publications and research reports about self-harm. Visitors to the site can also download worksheets and exercise booklets. Self Injury Support also offers a confidential hotline and email support to people in the UK. 
• SelfharmUK: This website seeks to lower the incidence of self-harm in teens. Young people can read blog entries from other young adults and join a free chat room several times a week and explore their concerns with a counselor. Professionals can access training and workbooks, and concerned parents can seek education about self-harm through fact sheets, an advice blog, and a community forum.

References:

1. Hilt, L. M., Nock, M. K., Lloyd-Richardson, E. E., & Prinstein, M. J. (2008). Longitudinal study of nonsuicidal self-injury among young adolescents: Rates, correlates, and preliminary test of an interpersonal model. The Journal of Early Adolescence, 28(3), 455-469. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0272431608316604
2. Wilkinson, P., & Goodyer, I. (2011). Non-suicidal self-injury. European Child & Adolescent Psychiatry, 20(2), 103-108. Retrieved from https://link.springer.com/article/10.1007/s00787-010-0156-y

Dear GoodTherapy.org,

I am under 18 and live with my dad and stepmom. I’ve been cutting for almost a year from depression and anxiety and basically not feeling like I want to be here. I HATE the idea of seeing a therapist and “talking about my feelings,” but apparently the school counselor told my dad I needed to see someone outside the school for help. The school counselor doesn’t know about the cutting, but I’ve talked to him a bit because apparently I have “anger issues.”

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So now my dad and stepmother are looking up therapists for me to go see. I really don’t want to talk to anyone about my “issues,” but it’s getting hard to cover the marks on my arms and legs and I don’t know how to stop cutting. And also I know they’re just going to keep me in therapy longer if I refuse to talk. But I REALLY don’t want my parents to know about me cutting myself or the suicidal thoughts I sometimes have. Can I get through counseling without my parents finding out about it? How much is the counselor going to tell my parents about what I say in therapy? —Under Rage

Dear Under Rage,

These are good questions to ask any therapist you see. Find out from them what their policies are regarding confidentiality with people in therapy under 18. Much of what they say will depend on legal and ethical guidelines based on where they live and what kind of license they have. When I work with people under the age of 18, I discuss in great detail with both the young person and the parents what those guidelines are. That allows everyone to have the same understanding and expectation about how the process works. It also allows the young person to decide how much to share with me and to be aware of what my responsibilities to report are.

Most professionals are obligated to report when a person in therapy, regardless of age, is in imminent danger. That danger could be significant risk of suicide or conditions of abuse/neglect. Thoughts of suicide alone, however, do not necessarily trigger a mandated report—it depends on the circumstances. There are many people who have such thoughts but no intention or plan on following through. What is essential, however, is that anyone who is struggling with thoughts of suicide finds sources of support with whom they can talk. A trusted therapist is a great option. There are also national hotlines where you can reach out for support 24/7.

I hear the frustration in your message about all that the adults in your world “apparently” believe to be true for you. Instead, look at what YOU can get out of this experience. You can have a voice and share your truth with someone.

I’ve worked with a number of people who also HATED the idea of talking about their feelings. Usually that stems from a place of fearing they would be judged, a massive discomfort with feeling vulnerable and exposed, and a reluctance to trust someone they don’t know well. All of those feelings are natural. I can share with you that all of those people, in their own time, came to trust me and the process. When you find a therapist you can work with, who allows you to share at your own pace, who offers you a safe place to speak your truth without fear of being judged, counseling can be an amazing experience.

If I can offer you a suggestion, don’t reject therapy completely because it feels like something being “done” to you. I hear the frustration in your message about all that the adults in your world “apparently” believe to be true for you. Instead, look at what YOU can get out of this experience. You can have a voice and share your truth with someone. You can get support for the anger, anxiety, and depression you say you’ve been feeling for a year now. You can have support in finding alternative strategies beyond cutting to cope with the intensity of the feelings you have. You can be seen. You can be heard.

Nobody can make you share what you aren’t willing to share. You are right, though, that refusing to talk or engage will likely limit your choices and your control over your situation. So, how can you engage in ways that work for you? Ask your potential therapist the tough questions about confidentiality and how they manage those issues. Find out if your parents are willing to let you take part in the process of choosing a therapist. Many professionals have directory profiles and websites that can tell you a bit about what they might be like to work with. I’ve had people meet me first before deciding to work with me. Many therapists are very willing to meet to assess fit, as we know a good fit leads to more positive outcomes. You might just find someone you can open up to who can offer relief from what you’ve been feeling.

Best of luck,

Erika

“Self-injury is an expression of acute psychological distress. It is an act done to oneself, by oneself, with the intention of helping oneself rather than killing oneself. Paradoxically, damage is done to the body in an attempt to preserve the integrity of the mind.” —Sutton and Martinson, 2003

Self-injury is a serious phenomenon that affects millions of adolescents. Current prevalence estimates of non-suicidal self-injury (NSSI) among middle school and high school students range from 15% to 20%, and some studies estimate rates even higher than that.

It can be difficult for family members, friends, and even professionals to understand what causes young people to hurt themselves, or to know how to respond. Discovering that a child or adolescent is engaging in self-harming behaviors can be frightening. It is not uncommon to feel panic, worry, or even disgust when you suspect or discover this type of behavior. Having accurate information is an important first step for parents, teachers, and other helping professionals who may be the first line of defense when adolescents engage in non-suicidal self-injury.

What’s the Difference Between Self-Injury and a Suicide Attempt?

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Non-suicidal self-injury (NSSI) describes the intentional injury to or destruction of one’s own body tissue, most commonly through cutting, burning, or self-hitting. Sometimes parents wonder if cutting and other self-harming behaviors are simply a cry for attention. If that’s true and someone needs attention that badly, then I can’t imagine a more appropriate response than to give it. Instead of looking at it as a bid for attention, though, try thinking of it as an attempt at communication.

Cutting and other forms of self-harm should always be taken seriously. Most individuals who engage in non-suicidal self-injury do so in secret and go to great lengths to hide the behavior from others. Most often, NSSI is performed as a way to regulate or modulate strong, painful emotions. Sometimes, NSSI is also described as a way for individuals who feel numb to “feel alive.”

NSSI should not be construed as a failed suicide attempt. NSSI is an attempt to live with or manage painful feelings—unlike suicide, which attempts to permanently end pain by ending one’s life.

NSSI should not be construed as a failed suicide attempt. NSSI is an attempt to live with or manage painful feelings—unlike suicide, which attempts to permanently end pain by ending one’s life. It is important to note, however, that although they serve different functions, NSSI is associated with an increased risk of future suicide attempts, and therefore should never be taken lightly.

Signs to Watch For

It is important for parents, teachers, and other helping professionals to learn to recognize the signs and symptoms of self-injury. A few things to watch for include: wearing long sleeves even when it is hot outside; a pressing desire for a lot of time alone; and, of course, unexplained, or suspicious cuts, burns, or bruises.

Sometimes, individuals who engage in self-harming behaviors may appear to be clumsy or have frequent accidents, and use these incidents to explain self-inflicted injuries. Adolescents who experience depression or anxiety, have difficulty solving problems, or who tend to feel things deeply may have an increased risk of turning to NSSI as a method of coping.

What to Do If Your Child Is Cutting

How you respond matters! If you suspect or discover that your child is cutting or engaging in other self-harming behaviors, it is important to seek help from a qualified mental health professional. A professional will begin with an assessment and may recommend family or individual therapy, or a combination of both.

Early intervention is best, so don’t wait to get help. Treatment can be effective at both reducing the behaviors and addressing painful emotions.

Reference:

Sutton, J., & Martinson, D. (2003). Because I hurt: Understanding self-injury & healing the hurt. Oxford: How To Books.

You are feeling frightened and ashamed to talk to your counselor about your problems with self-injury and other “bad habits.” You might worry that your counselor will feel critical or think less of you, even though you know that it is an unlikely reaction to occur to a trained therapist. You know that you must discuss your worries and problems in order for the therapy to work. This is the hardest part of therapy—and the best part, too—because here is where you learn and develop yourself more than almost anywhere else. I have some thoughts and suggestions that might help you out.

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You write that you’ve been meeting with your counselor since September. The first part of therapy usually has to do with developing a relationship of deep trust, and that takes time, as it should. Even though you understand that your counselor is experienced and qualified, you are still getting acquainted and learning to have faith in yourselves and in each other, too. So your first step is to have patience and let the treatment develop.

It’s also important to understand what a good therapist does. A good therapist has compassion for the parts of you that are destructive, the parts you’re most ashamed of, and can help you see that those parts are protective and well-intentioned—even when it doesn’t feel like it, even when the strategies behind them produce unwanted behaviors and harm.

Sometimes, before we are able to talk about what we fear, we have to learn ways to handle feeling afraid. Your counselor might be able to help you become less blown about by the winds of your powerful emotions and more able to navigate your feelings and use that feeling energy for your well-being. Right now it sounds as if you are being controlled by gale-force winds of feelings—at their mercy, really, with little ability to grab the rudder and set out for a particular direction of your choice.

The first part of therapy usually has to do with developing a relationship of deep trust, and that takes time, as it should.

You write that you “can’t find the words to start the conversation.” I think that when you are ready for the discussion the words will come—it sounds to me like you have them already. In the meantime, maybe you don’t need words anyway.

“How can I not need words?” you might ask.

Maybe at this point in your treatment, words are less important than simply being comfortable with the person who will help you learn how to live with your strong feelings. Could you ask the counselor if he or she might know some methods for calming the self, centering the self, soothing the self? Breathwork, for example, is one way to calm down, but there are other ways that you might know of already, and with a little encouragement, you can use them.

These are important issues about caring for yourself. An important part of therapy is learning how to care for yourself. Maybe you could ask for help in self-care, then later get to know who you really are, deep down. Therapy is an exploration, done with a guide who will walk the deep walk with you and protect you in your journey. Feeling safe and good self-care come first.

Eventually you will feel safe enough to speak up and communicate your fears and needs more directly. Even now I think you are beginning. Soon you might tell your counselor that you are afraid, that you have a secret and you’re afraid to say what it is. That’s the truth, and the truth is a good place to start.

Sincerely,
Lynn

You look over at your lovely daughter and think to yourself how time flies. Gazing at her with love, you notice red marks and lines on her youthful arms. Immediate panic sets in; you reach over with shock and say, “What is this?!” Your parental urgency sounds like terror, and your daughter pulls away quickly and rebuffs your concern. She retreats to her room, and you are left wondering where you went wrong and concerned that she’s in danger.

As much as it’s an unwanted membership, you’ve just joined with other parents who have children who cut. You may not even know that’s what you’ve exposed, but most likely it is. If your child has been acting more irritable, overwhelmed, and on edge, be aware of the signs of potential self-harm. Generally, the signs distinct to a person who cuts include:

• Wearing long sleeves in warm weather. People who cut themselves usually hide the evidence.
• Wearing a multitude of bracelets to cover their wrists. Again to hide the evidence, not necessarily to be in fashion.
• A teen who explains away marks and cuts in unlikely ways, such as “cat scratches” when you don’t own a cat.

The biggest question becomes, then, what do we do as parents? Here are some suggestions to help you parent through this challenging time:

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1. Don’t freak out. This is the hardest part for parents, but a necessary one with teens. If you freak out, they freak out. They are just as afraid of their behavior as you are, and if they see you unable to control yourself and handle it, how is there hope for them to cope? Instead, breathe, think it through, and speak calmly.
2. Check your anxiety. How do you handle your anxiety? Do they see you cope in healthy ways or do you create maladaptive behaviors as well? Are you stressed all the time, yell at everyone, and otherwise handle life poorly? Remember, they are watching you.
3. Ask them if they want to talk about it, and create opportunities for them to talk. Forcing teens to talk is a recipe for disaster. Instead, be available and let them know repeatedly that you are there to listen if they want to talk. They will appreciate that they can choose to talk or not, and that you are accessible. Create time and opportunities to engage with them.
4. Don’t embarrass them by telling all your friends. As much as being secretive is damaging, so is telling everyone you know because YOU can’t handle it. This is the time to put your teen’s feelings first and care for them without alerting the media.
5. Know your limits. If this is too much to handle, seek help for your teen. Self-harm is relatively newly acknowledged and understood as a coping mechanism. A mental health provider can provide guidance and teach appropriate techniques to help your teen handle life.
6. Don’t tell them to stop cutting. Telling your teen to “knock it off” or “don’t do it again” is simply asking for rebellion. Although that’s how we feel and what we want to say, it’s best to understand the behavior fully before seeking demands.
7. Create a plan. This is a great time to create a plan for healthy coping mechanisms. Brainstorm with your teen alternative solutions during stressful times. Maybe they can go for a walk, call a friend, bake a cake, draw, listen to music, watch a movie, or journal. This can be a fun activity to do together—use your creativity!
8. Spend one-on-one time with your teen. Kids spell love: T-I-M-E. Make time.

Discovering that your teen cuts may lead to panic and unease. How you handle yourself during this scary time can create a path to peace or leave a destructive wake. Checking yourself and your own anxiety can be a powerful tool to teaching your teen how to do it, too.

Editor’s note: If you or someone you know is in crisis, please click here for information about seeking help.

Cutting is a popular way for teens to self-injure without the intent of suicide. Using scissors, razor blades, pins, pens, or other sharp objects, some teenagers puncture or cut their skin in various places on the body. If you’re a parent, you are probably wondering, “Why would they do that?” The answers may surprise and scare you.

Simply put, cutting is a maladaptive coping mechanism during times of stress and anxiety that is rarely accompanied by suicidal thoughts. According to the American Association for Marriage and Family Therapy, self-harming behavior such as cutting has no single cause. It does not discriminate across cultural and socioeconomic levels, but the behavior is predominately carried out by females.

Reasons behind teen cutting are varied. Often it can be categorized by those who already feel numb as a way to experience intense emotion and pain. Numbness may be due to being emotionally overwhelmed for too long, which almost short-circuits the system into a feeling of dullness—neither happy nor sad. Teens who feel numb often identify that the only way to feel alive is to cut.

Another way to categorize cutting is as a release of emotions, similar to a drain when the sink is overflowing. Teens who feel burdened by stress, anxiety, depression, and other emotions may use cutting to vent the unwanted leftovers of those difficult feelings.

Other reasons for cutting include an intense and overriding feeling of aloneness, feeling helpless, and feeling the need to punish or blame for something that happened.

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The theory behind why teens use cutting as a coping mechanism reasons that endorphins play a major role. When teens cut, endorphins rapidly invade the bloodstream, resulting in a feeling of pleasure and relief. For some teens, the cutting and the endorphin release make them feel “high.”

Take for example, a 16-year-old girl who is a high academic achiever, member of the elite volleyball team, and a positive role model for her younger sisters. She is an all-around overachiever, earning money babysitting and as a lifeguard, striving to excel in school to make sure she gets into a prominent university. Her volleyball team travels on the weekends, and she is looked at as a leader to the other members. In addition, she volunteers at her church and with her community. She dresses well and in fashion, and is always attempting to make sure her hair is perfect. Although she doesn’t love her body, she knows it could be worse, since she’s an athlete and in somewhat decent shape physically.

Emotionally, however, she’s not in shape, nor positive, nor excelling. She is overburdened by academia, struggling to achieve all A’s in her advanced classes. She has to study from the minute she gets home from school until volleyball practice, and then more upon returning. She is not sure her grades will get her into a “good enough” college. She is worried that her best friend is mad at her, and she’s certain that her father hates her. To make matters worse, her right knee has been bothering her, but she doesn’t tell anyone for fear that her team will be mad at her. She has had to cancel when invited out because she had too much homework and she promised her best friend she’d be available if she needed to talk.

At first glance, this teen seems to have a full and rich life, with opportunity abounding. However, she’s so overwhelmed that at night she uses her desk scissors to slice her wrists repeatedly. To make sure no one suspects anything, she hides the bloody tissues at the bottom of the trash can. She wears stacks of bracelets to cover the damage so no one asks. She doesn’t know what else can release the pressure she feels from school, family, friends, and her team. She heard about cutting during lunch a few years ago, and now uses scissors to pour her emotions out.

This is real life for some teens. As much as parents are disgusted by the idea, and instinctively react with shock about what their child has done to their body, it is an unwanted aftereffect of overworked, overscheduled, overwhelmed children. Never before have we put the same amount of pressure on our children and teens to succeed academically, socially, and beyond.

While it may not make sense that they cut their bodies, it makes sense that they find a way to release the pressure. Without learning new coping skills and understanding their triggers, teens often end up alone in their pressure-cooker lives. Through counseling, teens can learn how to handle distress, how to prioritize in their lives, and how to communicate about their feelings.

The Diagnostic and Statistical Manual of Mental Disorders serves as the “bible” of mental health practitioners, who rely on it to match diagnostic criteria with behaviors. The American Psychiatric Association periodically examines trends in mental health conditions and recent scientific evidence to revamp the criteria. The latest edition, the DSM-5, is slated for release in May 2013, and the APA recently approved several changes.

Among the new diagnoses is excoriation, which is associated with chronic skin-picking. The issue is most common among women between the ages of 30 and 45. It’s classified as an impulse control disorder and is related to obsessive compulsion.

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What Is Excoriation?
Although excoriation disorder is the name of the new “official” diagnosis, the issue has been studied for years—sometimes called neurotic excoriation, compulsive skin-picking, dermatillomania, and psychogenic skin-picking. The issue was not included in previous editions of the DSM because it is believed to sometimes be a symptom of another issue.

Skin-picking is common among people with autism spectrum as well as obsessive compulsion. When it does not co-occur with another issue, however, it qualifies for its own diagnosis. Symptoms of the issue include compulsive skin-picking that leads to injuries or wounds as well as stress. Skin-picking is relatively common. Some people pick their skin to the point of bleeding or pain by popping pimples, picking at hangnails, or peeling scabs.

Controversy Surrounding Diagnosis
Whenever the APA adopts new diagnoses or symptoms, there is always some controversy, and excoriation is no exception. Although the diagnosis has received considerably less attention than some other changes, some mental health experts have expressed concern. Because excoriation often is a symptom of an underlying issue, a separate diagnosis might stigmatize people by giving them multiple diagnoses when only one is necessary.

Some clinicians have argued that excoriation does not meet the criteria for a mental health diagnosis and is more akin to a habit. By creating diagnostic criteria for a habit, the DSM might eventually have to include other habits. However, excoriation does sometimes occur on its own, and people with the condition can experience considerable distress, so the APA opted to include it.

How Excoriation Is Treated
When compulsive skin-picking occurs, it’s important to rule out a potential medical cause such as allergies or infection. Occasionally, skin conditions can superficially resemble symptoms of excoriation. Further, excoriation can cause dermatological problems, so patients frequently need dermatological treatment along with mental health treatment.

Antidepressants are the first line of treatment for excoriation. Opioid antagonist medications, which interfere with the body’s ability to respond to endorphins and opioids, also are sometimes effective. Because compulsive skin-picking often co-occurs with anxiety, anti-anxiety medications can be helpful.

Psychotherapy that helps people develop better approaches for dealing with anxiety, enables them to develop better impulse control, and helps patients cope with changes to appearance as a result of excoriation is also a typical part of treatment.

References:

1. American Psychological Association. APA concise dictionary of psychology. Washington, DC: American Psychological Association, 2009. Print.
2. Brauser, D. (2012, December 3). Experts react to DSM-5 Approval. Medscape Reference. Retrieved from http://www.medscape.com/viewarticle/775526
3. Colman, A. M. (2006). Oxford dictionary of psychology. New York, NY: Oxford University Press.
4. Neurotic excoriations. (2012, June 27). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/1122042-overview
5. Neurotic excoriation. (n.d.). SkinPick. Retrieved from http://www.skinpick.com/neurotic-excoriation

Nonsuicidal self-injuries (NSSI) are believed to be inflicted as a method of coping with distressing emotions. People who cut, burn, or otherwise harm themselves may do so in an attempt to escape overwhelming feelings of sadness, pain, guilt, depression, or shame. Although the research on NSSI is growing, little attention has been focused on the relationship between guilt and NSSI. Yoel Inbar of the Department of Social Psychology at Tilburg University in the Netherlands recently conducted an experiment to determine if people were more motivated to hurt themselves by feelings of guilt versus feeling of sadness or ambiguity.

For the study, Inbar recruited 46 college students and assigned them to either a neutral, sad, or guilty condition. The participants were instructed to recall an event that elicited the assigned emotion and write about the severity of their emotion at the time of the event and presently. They were then given one set of electric shocks, after which they were allowed to either increase or decrease the intensity of the remaining five sets of shocks. After the shock treatment, the participants were assessed for levels of sadness and guilt. Inbar found that the participants who recalled guilt-inspiring events chose to increase the shock severity, while those who remembered sad or neutral events did not. Additionally, the guilty participants reported feeling less guilt after they received the shocks than they had before.

The evidence presented in this study suggests that guilt acts as a motivator for self-injurious behavior. The participants in this experiment did not acknowledge being consciously aware of this relationship, but may have been prompted intuitively. “Such intuitively driven moral judgments are quite common,” Inbar said. Although some people who feel guilty may choose to diminish their guilt in other ways, such as doing a good deed to make up for their bad one, others may feel as if the level of their atonement must match the level of their transgression. Existing research has shown that certain emotions, such as self-anger and shame, often precede a self-injurious event. Inbar believes that future research should look at how these states influence the decision to self-injure compared to feelings of guilt. It would also be prudent to examine if people who have a history of self-injury to assuage guilt would choose a good deed if that option was available to them.

Reference:
Inbar, Y., Pizarro, D. A., Gilovich, T., Ariely, D. (2012). Moral masochism: On the connection between guilt and self-punishment. Emotion. Advance online publication. doi: 10.1037/a0029749