"Cutting" - Understanding Self-Mutilation…
By Judy Foreman
05/06/03

Years ago, Boston University psychiatrist Dr. Bessel van der Kolk tried a simple experiment to understand one of the most disturbing, and bizarre, of all psychiatric disorders: self-mutilation, or more simply, cutting.

He asked his cutters, mostly young women, to come see him when they felt the urge to scratch, slash or burn themselves. When they came, he asked them to put their hands in ice water. They were able to keep their arms buried in ice much longer than normal people, he found, because they didn’t feel the pain.

Then, when he gave them an injection of a drug that blocks endorphins, the body’s natural painkillers, they felt pain again  “and with that, a sense of feeling alive,” van der Kolk says.

To the uninitiated, cutting may seem like a suicide attempt or a cry for attention, and in rare cases that’s true.  In reality, both cutters and psychiatrists say,  the urge to self-mutilate is a coping behavior triggered by an inner sense of  numbness or deadness. Far from a wish to die, cutting is a terrible urge to feel something , even physical pain, rather than nothing at all. And far from flaunting their cuts to get attention, cutters usually hide them. 

The numbness that these teenagers – and some older cutters – feel is usually triggered by overwhelming trauma, family conflict, sexual or physical abuse, emotional neglect and, perhaps, genetics. This deadness  “is so terrifying, that to feel one’s physicality brings relief -- that one is still present and has definable boundaries,” says Dr. Michael Strober, a professor of psychiatry and director of the eating disorders program at the UCLA Neuropsychiatric Institute.

No one knows how prevalent cutting is, nor why it seems to be on the rise, though in some schools, contagion - kids copying each other’s strange behavior –  may  be involved. Nor do researchers know why roughly 75 percent of cutters are female, though one theory is that girls turn their feelings against themselves while boys attack others.

But researchers do know far more than they did a few years ago about what triggers cutting and, more important, and how to help kids stop.

Cutting often overlaps with anorexia or bulimia. In fact, roughly half of girls who cut themselves with pins, knives and razors start out with eating disorders, says New York psychotherapist Steven Levenkron, author of “Cutting: Understanding and Overcoming Self-mutilation.”

Curiously, black and Latina girls may be less prone to cutting than white girls, says psychologist Wendy Lader who, with Karen Conterio, started the SAFE program (Safe Alternative – Self Abuse Finally Ends) at Linden Oaks, a psychiatric facility at Edward Hospital in Naperville, Ill. 18 years ago. Perhaps darker-skinned girls, she says, may have more realistic ideas about what a healthy body looks like and may feel freer to express anger.

Levenkron agrees. Most of his cutters are white, perfectionistic and, contrary to outward appearances, filled with self-loathing. “I never met a cutter who liked herself.”  

One way to help cutters is to teach them how to talk about their emotional pain so that they don’t express it nonverbally. “I teach cutters a full vocabulary for feelings and mental pain,” says Levenkron. By the time they learn to talk “in the language I taught them,” he adds, “they are not cutting anymore.”

All of this, of course, takes time, money and commitment. Levenkron sees patients twice a week for several years, and insurance rarely pays full freight.  But like their desperate offspring, desperate parents often hang in, writing the checks and learning, slowly, how to deal with a more emotionally expressive, but less self-abusive, daughter.

He recalls one terrified teenager who came to him straight from a locked psychiatric ward and stayed in therapy for four years. “When I started seeing you,” Levenkron recalls her saying, “I thought I couldn’t breathe between appointments. I would kill to see you.” Three years later, she told him, “You’ve helped me a lot. Is it okay if I stop coming?”

That kind of intense support is also part of the SAFE approach, says psychologist Lader.

In the first phases of treatment, giving up the crutch of cutting – the one behavior that brings relief - can be terrifying, adds Lader. “This is a nihilitive fear, the fear that they won’t exist, that they will explode… If we ask them to give up this coping strategy,  we have to be there for them.”

But, despite some web sites that seem to glorify cutting, Lader says the emphasis should be teaching that cutting “is not a healthy coping strategy.” In fact, SAFE makes cutters sign a “no harm” contract. That’s partly common sense, but partly good biology as well.

That’s because cutting may produce transient good feelings by triggering trigger a flood of endorphins, the endogenous opiates. In fact, many doctors now do just what van der Kolk did in his early experiments – give opiate- blocking drugs such as Naloxone or Naltrexone. By blocking the good feelings that cutting stimulates, cutters often stop injuring themselves because cutting no longer has the desired effect, says Dr. Alan Langlieb, a psychiatrist at The Johns Hopkins School of Medicine.

Other drugs help, too, because most girls who cut are “some combination of depressed and anxious,” says Dr. David Herzog, a psychiatrist at Massachusetts General Hospital who heads the Harvard Eating Disorders  Center.

Some cutters, like Lydia Gibson, 38, a Baltimore woman who has been cutting herself off and on for 25 years, must take a number of drugs simultaneously. Gibson, who says she  “ had to hurt myself because I had to get the anger out somehow,” now takes Buspar for anxiety, Paxil for depression, Naltrexone to blunt the positive effects of cutting, as well as Depakote, a mood stabilizer, and Seroquel, a tranquilizer.

In fact, not only do drugs and psychotherapy often work, cutting, perhaps surprisingly, is actually less dangerous than anorexia. Longterm outcome studies suggest that the mortality rate for anorexia is about 10 percent , says Herzog. Longterm mortality data from women without anorexia who cut themselves is scant, but doctors say that, except for accidentally deep cuts, the risk of death from any given cutting episode is minimal.

Herzog of MGH puts it this way. “It may sound nuts, but most of these girls are not nuts.”  They’re stressed, depressed and scared. But what they really feel Herzog says is that they look good on the outside, but inside, they feel empty.

 
Judy Foreman is  Lecturer on Medicine at Harvard Medical School and an affiliated  scholar  at the Women’s Studies Research Center  at Brandeis University.. Her column appears every other week. Past columns are available on www.myhealthsense.com.

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