When she was 16, Laura Snow moved back to the United States from Hong Kong, where her parents had been working as missionaries for more than six years.
It was a hard adjustment, and the problems she encountered compounded difficulties she already had experienced.
"Being a minister's kid, you have to behave better than everybody else," said Snow, now 22.
So one day shortly after she returned, Snow picked up a pair of scissors and cut her skin. For years, razor blades were her weapon of choice in a bloody ritual performed by thousands of Americans, often as a form of release.
People have engaged in self-harming behavior for decades, or even for millenniums, some experts say. Professionals agree that younger and younger people are cutting their skin, burning themselves, bloodletting, even cutting off portions of fingers and ears in extreme cases.
Although experts point out that there is an element of copycat behavior among individuals who cut, nearly all cutters have a trait in common: They are clinically depressed.
"Depression itself has increased," said Dr. Graham Emslie, a psychiatrist and a professor at the University of Texas. "It [self-injury] decreases with the treatment of depression."
Experts say depression is at the core of the behavior but modern societal realities contribute. Those include busy lifestyles where parents take less of a role in rearing their children; a culture where beauty, sex and perfection are exalted; and new technologies allowing teen cutters to communicate with each other.
"The self-injury phenomenon has been around for centuries," said Kammie Juzwin, a psychologist at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Ill. "Early Christian writing discusses the use of self-injury as ritual."
Juzwin started working with young people who intentionally injure themselves almost 20 years ago. At that time, the average age of her patients was 18 to 20. Now, the average age is 14 to 16, with some as young as 8.
"Globally, any behavior that happened at 16 is now happening at 12 or 13," said Jennifer Hartstein, a psychologist at Montefiore Medical Center in the Bronx. "Kids are growing up faster and faster."
Juzwin added, "We over-sexualize our children. We are asking them to mature in a society ... that grows increasingly less mature. We have Paris Hilton, who has lived a life of privilege and got everything for her looks alone. Their [teens'] peer group is no longer the norm. Britney Spears is the norm."
Hartstein echoed the view that societal changes are driving younger children toward self-harming behavior.
"In the United States, we are such a quick-fix society," she said, adding that some people are attracted to cutting's instant gratification. "I've had teenagers say to me that it 'makes me feel alive.' "
According to the National Institutes of Health, 15% to 20% of American teenagers have experienced a serious episode of depression, about the same percentage as the adult population.
But, Hartstein said, "Depression presents itself differently in all people. Not all depressed teens cut."
Internet chat rooms allow cutters to share what used to be an isolated practice, and group cutting has become more common, experts say.
"There are lots of sites and Web logs you can access just by typing in 'self-injury,' or 'cutting.' Many parents would be shocked if they read the contents of the sites their kids are visiting," Juzwin said.
"We have kids that tell us they have cutting circles," Hartstein said.
But not all aspects of group cutting sites are negative, she said; patients have told her that people in such groups look out for one another, sometimes trying to discourage cutting.
According to Juzwin and others, the story of Snow, the missionaries' daughter, is typical.
"I cut because it was the one time that I had control of where I hurt, how bad it felt and whether or not it left a scar," said Snow, who went into treatment, stopped self-injury seven months ago and now works as an assistant store manager for Starbucks in Longview, Texas. "The forces of life that affected every other aspect of my life I had no control over. My heart ached, and for those few seconds I could focus on another pain.
"I can tell you from experience that not all kids who cut are after attention," she said. "It wasn't until I was 20 years old that my parents even discovered that I had a problem."
Doctors use various methods to modify the behavior of cutters and break their impulse to cut. They suggest, for example, that cutters hold a cube of ice until it becomes painful, or wear rubber bands on their wrists and snap them when the urge to cut strikes.
Treatment also involves the use of standard antidepressants and dialectical behavior therapy, or DBT, which encourages change while eschewing judgment about the behavior.
Jennifer, who is 29 and asked that only her first name be used, started cutting when she was a teenager. She stopped nine years ago using DBT, counseling and antidepressants. The counseling lasted three years.
"I would take red markers and mark my body," she said of one technique she employed.
The behavior does not fit neatly into any social or economic category, doctors treating such patients say.
Actress Angelina Jolie has spoken of her experiences with self-injury as a teenager.
"I was 14," she said during a recent interview on Bravo's "Inside the Actors Studio." "I had started having sex, and that sex didn't feel like enough, and no emotions were really enough."
She said that she first cut herself after having sex with her first boyfriend.
"In kind of a moment of kind of wanting to find something else, I grabbed a knife and cut him and he cut me back and we had this exchange of something, and then somehow covered in blood and feeling that my heart was racing and there was something dangerous and ... [I] suddenly felt more honest than whatever this sex was supposed to be, this connection between two people [was] supposed to be," Jolie said.
"So I went through a period of when I'd feel trapped. I'd cut myself because it felt like I was releasing something and it was honest."
Jolie acknowledged that she was left with "a lot of scars."
Studies by Dr. Armando Favazza, a psychiatry professor at the University of Missouri-Columbia, and others show a limited link between cutting and sexual behavior.
In a study of 250 chronic self-mutilators published in 1996, Favazza reported that 2% reported being "often or always" sexually aroused when harming themselves. But 20% said they used self-injurious behavior to rid themselves of troublesome sexual feelings.
Lauren C. Solotar, chief psychologist at the May Institute, a behavioral hospital in Norwood, Mass., says she sees increasing desperation and isolation among the young people she treats.
"These kids are lost," she said. "They have nobody to turn to."
For Snow, "it eventually got to the point that I couldn't live without those few moments away from the pain of my life," she said. "I already felt dead inside; by cutting, I was attempting to feel alive. It was almost as if when I saw the blood running down my arm, it was then that I knew that I was alive and that I was OK."