Self-injury: Raising the profile of a dangerous behavior

Yet, the condition -- known as nonsuicidal self-injury -- is not officially recognized by the American Psychiatric Association (APA) as a mental disorder, which means insurance may not cover treatment.

"The mental health system is failing patients who have a clear problem for which they need help," says Edward Selby, an assistant professor of psychology in Rutgers' School of Arts and Sciences in New Brunswick.

Selby, who recently published a paper in Clinical Psychological Review on the topic, is among a growing number of psychologists who believe that non-suicidal self-injury should be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard compilation of psychiatric disorders used by mental health practitioners and insurers.

Since self-injury is not on that list, to qualify for medical coverage those who cut, burn or otherwise injure themselves must fit other existing diagnoses, such as borderline personality disorder, depression or an anxiety disorder, which, Selby says, occurs barely half the time.

The current fifth edition of the manual -- issued in 2013 and called DSM-5 -- calls self-injury a condition that needs "further study," well short of the recognition needed to trigger insurance coverage, better define the affected population and permit development of more effective treatment methods.

Selby's research, including his most recent paper, "Nonsuicidal self-injury disorder: The path to diagnostic validity and final obstacles," is aimed at filling in any blanks that are holding the APA back, leading -- he hopes -- to the full recognition he feels the disorder deserves.

The urge to self-injure can baffle people who do not engage in it. Most obvious is the severe pain it can cause. But in cases where psychological pain becomes overwhelming -- negative thoughts that cascade and won't stop -- Selby says a person may feel that a diversion, even if it hurts, is the only solution available. "By applying one type of pain," he says, "they get rid of a different type of pain,"

Most people who self-injure are not trying to kill themselves. But, Selby says, they do become more likely to consider or attempt suicide later -- yet another reason, he argues, to raise self-injury's profile.

Research recently published in the journal Pediatrics, based on visits by teens to hospital emergency rooms, suggests that nonsuicidal self-injury appears to be on the rise. If that finding is accurate, there is reason to suspect that use of social media is among the causes. Before there were smartphones and chat forums, young people who cut and burned themselves most likely kept their behavior a secret. But now there are online communities where adolescents promote self-injury among themselves.

In fact there are schools, says Selby, where self-injury has become "contagious," such as a high school in Middletown, Connecticut, where the school district reported last year that 31 students had recently been hospitalized for mental health behaviors that included cutting.

Seeking effective solutions

In his Emotion and Psychopathology Lab at Rutgers, Selby is exploring practical solutions for research participants who self-injure. Some of those methods involve the same smartphones that those at risk have used to go online. One still-experimental app invites patients to track their thoughts and feelings at multiple times during the day -- data that may be especially enlightening on days they self-injure.

Selby estimates that at least half of young people who cut and burn want to stop hurting themselves and would welcome effective help. His first advice is that they seek out a trusted and sympathetic adult, potentially a teacher or school nurse, who can steer them toward the care they need. Another is finding more constructive ways to divert their attention from their emotional pain. Selby says smartphone games like Angry Birds or Tetris -- or a lower-tech diversion like Sudoku or a crossword puzzle, might be just enough to take a person's mind away from self-injuring.

"These may help someone focus away from the problem they're experiencing," Selby says, "and give them a natural chance to calm down."