The revelation was shocking enough. That a growing number of teenagers and young adults deliberately embed needles, paper clips or staples in their skin may have seemed unthinkable before an Ohio radiologist presented disturbing proof at a medical meeting Wednesday.
Even more disturbing than his X-rays and accompanying report, however, could be the size and pervasiveness of the trend from which it derives -- self-injury.
Cutting, burning and biting one's body is a habit increasingly taken up by young people who find themselves simply unable to cope with stress. Embedding appears to represent a more extreme form of the disorder.
"We always saw a little bit of this, but it was in people already identified as having a psychiatric disorder," says Janis Whitlock, a prominent researcher on self-injury at Cornell University. "What doesn't seem to make much sense is why we're seeing it so much in seemingly healthy kids."
Experts who study the behavior say that 15% to 22% of all adolescents and young adults have intentionally injured themselves at least once in their lifetimes. One study of 94 girls, ages 10 to 14, found that 56% had hurt themselves at least once. It was published in February in the Journal of Consulting and Clinical Psychology, part of a special issue devoted to self-injury.
The behavior may be building among adults as well. One study found that 1% of adults self-injure.
Illinois therapist Karen Conterio, who operates a self-injury treatment program, says 11% of her clients are age 40 and older. And surveys by Whitlock have identified self-injurers in their late 20s and 30s.
Many questions remain about why some people feel compelled to hurt themselves -- and what can be done to help them. The current edition of the Diagnostic and Statistical Manual of Psychiatric Disorders, the professional encyclopedia on mental illness, barely mentions self-injury.
The Journal of Consulting and Clinical Psychology's self-injury issue calls the problem "remarkably prevalent and woefully understudied." Prevention and treatment programs backed by scientific studies are virtually nonexistent.
But work has begun on a new edition of the Diagnostic and Statistical Manual, which will be published in 2012, and at least two committees are addressing self-injury for inclusion in the text.
"In the last few years there has been an explosion of research, but it's still in its infancy," Whitlock says. "There is so much more we need to know."
The leading theory behind the behavior is that cutting, burning or hitting oneself externalizes brutal and persistent emotional pain. A poem published in a newsletter called the Cutting Edge sums up the disorder, says Ruta Mazelis, a consultant with the Sidran Institute in Baltimore, an organization that focuses on traumatic stress.
"I hurt so much
-- Robin et al.
"The self-injury becomes a coping mechanism for many of the repercussions in their lives," says Mazelis, who strongly believes that most self-injurers suffered a previous emotional trauma. "It tends to be an all-purpose tool for trauma survivors who use it to manage incredibly intense emotions: horror, anger and grief."
Most therapists agree that self-injury helps relieve negative emotions, at least temporarily. "People have so much bad feelings in them -- shame, guilt, rage -- that they need to let it out," Whitlock says. "They punish themselves by injuring or distract themselves by injuring. It helps them blow off steam."
For some sufferers, the physical pain of self-injury is outweighed by the emotional relief, researchers say. For others, pain is a reminder that they are alive when they feel dead inside. "It's a way of feeling something in the presence of nothing," Whitlock says.
Adds Conterio, chief executive of SAFE Alternatives, a treatment center in Naperville, Ill: "Blood represents life. There is a warmth to it."
The disorder clearly ranges in severity. Most self-injuries are not serious, and some people try it once and never again -- or they outgrow the behavior. Others become suicidal.
"Self-injury allows you to get used to self-inflicted injury, so if you develop suicidal thoughts you are more capable of acting on it," says E. David Klonsky, an assistant professor of psychology at Stony Brook University in New York.
That's what makes self-embedding a particularly dangerous form of self-injury. Radiologist William E. Shiels II of Nationwide Children's Hospital in Columbus, Ohio, presented his report on this emerging type of self-injury at a meeting of the Radiological Society of North America on Wednesday, identifying it as the behavior of those who are highly suicidal.
Shiels specializes in using ultrasound technology to see and remove embedded fragments from the body, an expertise he developed while working with injured military personnel. He became interested in self-embedding after several children were referred to him with wounds that were swollen, irritated and had no apparent cause.
Over time, he identified 19 episodes of self-embedding injury in 10 girls, ages 15 to 18. The girls had inserted such things as metal staples, unfolded paper clips, glass shards, wood slivers, pencil lead, crayons and stones into their arms or legs. Ninety percent of those girls said they'd had thoughts of suicide or had attempted suicide previously. Forty percent said they were victims of sexual abuse.
Effect of stress?
But many self-injurers are not suicidal and may not even have an underlying psychiatric disorder, Whitlock says. They're simply under too much stress.
"We're starting to see that self-injurers can be different from each other," Klonsky says. "Most self-injurers don't have incredibly severe psychiatric symptoms; they have some." In a study published in the Journal of Consulting and Clinical Psychology's self-injury issue, Klonsky found that about 80% of the self-injurers engage in less severe behavior; they don't do it often and have few or no other symptoms of mental illness. A small group self-injures to seek attention or as a cry for help. Another group self-injures excessively and is at high risk for suicide.
The high rates found among young people seem to go hand in hand with other studies suggesting today's youth may suffer from more mental health problems than previous generations.
"We see more young people who don't cope very well," Whitlock says. "Colleges around the country are saying they have kids who expect a lot more but lack the skills to deal with adversity."
Who's at risk, treatment options What mental health experts know about self-injury -- and how to treat it -- is limited. But they're learning.