David Baxter PhD
Late Founder
Why She Cuts
by Jessica Bennett, Newsweek
Dec 29, 2008
One woman's fight against the compulsion to injure herself, and why medical experts disagree about how to diagnose those who cut, or in extreme cases, embed objects under their skin.
The first time was with a broken glass. Becki Bagnato was 13, and struggling with the emotions typical of a girl her age: confusion, angst, insecurity. On top of that, her brother was battling drug abuse, and her father, who'd skipped town years earlier, had stopped sending child support. So when she accidentally broke a glass while she was cleaning her room one day, she wondered, "What would it feel like if I cut my hand?"
[detail omitted] But as the sharp pain eased, replaced by a singular throbbing, somehow, the teen felt a strange calmness and a sense of relief.
It started that way, the cutting. When Becki was feeling alone, or stressed, the cuts became a companion, each slice like a friend who understood her pain. She stole her first razor blade from her grandfather's tailor workshop in her family's home in Middletown, N.J. Later, she'd buy them in bulk?$1.99 at a local Target for a pack of 20. She'd cut in the morning before school, then cover up her arms with long sleeves. She'd take a razor with her on the bus, stored flat in her wallet or back pocket of her jeans, so that during class, when she couldn't handle the pressure, she could sneak into the girls bathroom and slide the edge across her forearm. She'd cut before she went to bed. Sometimes, in the middle of the night. "I wouldn't have a good day if I didn't wake up and hurt myself," Becki, now 22, remembers. "It made me forget all the crap going on in my life."
This is how it began for Becki. For the millions of others who hurt themselves intentionally, the story may start differently, but the result is often the same: What is at first just an impulse, a moment of relief, becomes a secret habit?a need for pain that medical science doesn't fully understand and can treat with only mixed success. Eventually, for Becki, the cuts became too much to hide, and her excuses?"I burned myself," "It was a cat scratch."?rang hollow. Her mother sent her to a therapist, then a psychiatric ward, where she was diagnosed with borderline personality disorder, and put on mood stabilizers and antidepressants. But the cutting didn't stop?it worsened. Years passed, middle school became high school, friends and interests changed, one therapist merged into another. Yet the cutting remained ritual, sometimes happening a dozen times a day?on arms, thighs and stomach. "Seeing the blood would give me a sense of being alive," Becki explains.
Self-injury has been documented for hundreds of years. Cases of women and girls, mostly teens, hurting themselves with blades or other implements, even inserting small objects under their skin, go as far back as the medical literature will reach. Though figures vary, researchers estimate between two and eight million Americans, most of them women, have engaged in self-injury at some point in their lives. Yet, while experts agree that this propensity exists, from there, opinions diverge. Is non-suicidal self-injury a diagnosable disorder, or simply a symptom of more profound mental disorders? Can it become an addiction? Does this behavior create changes in the brain chemistry of sufferers? And how do you treat it?
All these questions surfaced earlier this month when a team of radiologists presented new, graphic evidence of what they describe as an increase in the number of self-injurers who are embedding sharp objects underneath their skin. On Dec. 3, at an annual meeting of North American radiologists, Dr. William Shiels, the chief of radiology at Nationwide Children's Hospital in Columbus, Ohio, showed documentation and X-rays of eleven patients that had "self-embedded"?ending up in Shiels office for a surgical procedure more commonly used to remove shrapnel from war vets. [details omitted] "They come in with pain, infections, and sometimes guilt," says Shiels. "The infections can be very severe?putting nerves, veins, even tendons at risk."
The 11 self-embedding cases had gone unnoticed in the 505 incidents of (usually accidental) embedding Shiels' team had treated since 2005. But last year, one of his research assistants, who was going back through past files, identified a trend. Shiels says he'd never focused much on the practice before, but when he looked back at these cases and talked to other radiologists around the country, he heard similar reports. This data, he is careful to note, is still anecdotal. To his knowledge (and NEWSWEEK's) there have been no other studies looking specifically at self-embedding, and it is unclear how many people nationwide have been treated for such injuries. Still, in reviewing the literature and talking with mental health professionals, Shiels has come to believe that the practice is increasing, and that it could be viewed as the "next phase" of self-injury. He has put together an interdisciplinary team and database to track its prevalence around the country. "We've been treating patients with accidental foreign bodies under their skin for 13 years, but before 2005, we never saw [self-inflicted] cases like this in adolescence," says Shiels. "We believe this is out there more than people think?it's just that we didn't know what to call it or understand its significance."
Despite its anecdotal nature, Shiels' report caused a sensation. X-ray images revealing the silhouettes of embedded objects lodged between bones were plastered across news sites and blogs. But the hubbub only fueled the debate over what is going on in the minds of those who hurt themselves deliberately, but not fatally. Shiels says embedders are different from other self-injurers in that they've taken the behavior to the extreme. He's dubbed their pathology "Self-Embedding Disorder" and is lobbying for its inclusion into the American Psychiatric Association's Diagnostic and Statistical Manual (the DSM), considered the bible of psychological disorders, which is currently under revision.
But the assertion that self-embedding is a new trend, or a disorder at all, has caused a stir among many mental health experts, who say embedding is a known method of nonsuicidal self-injury and a symptom of a larger problem and not itself a psychological disorder. Though it's often believed to be a common behavior among those with bipolar disorder?and is described in the DSM as such?self-injury of any kind does not appear in the manual itself as a diagnosable disorder. As Bessel van der Kolk, the medical director of the nonprofit Trauma Center, in Boston, and an adviser for the updated DSM, puts it: "Self injury is part of a larger picture; it should never be seen as an isolated thing."
Wendy Lader, a clinical psychologist and cofounder of S.A.F.E. Alternatives, a Dallas-based treatment center for self-injurers, says that people who harm themselves almost always suffer from larger mental conditions, often the result of emotional trauma, or in extreme cases, physical or sexual abuse. Though she estimates five percent of her patients this past year have been embedders, she doesn't distinguish between the two kinds of behavior: self-injury of any kind, she says, is a physical coping mechanism used to deal with or distract from extreme emotional distress. "I think a lot of people tend to look at the behavior versus what the behavior represents," she says. "But these are all just methods of trying to maintain some emotional equilibrium."
The way self-injurers describe the relief the practice gives them varies. For some, it's about control: the ability to create and end physical pain amid emotional turmoil. Others see the blood as a physical release of overwhelming stress. Some say it causes an almost euphoric feeling, the way an addict might describe a much-needed fix. Lader says that people who engage in self-injury are nine times more likely to attempt suicide than non self-injurers?but it's a common misperception that self-injury itself is an attempt to die. In fact, say experts, it's in many cases the exact opposite: an attempt to feel more alive. Van Der Kolk, a leading expert in self-injury, explains it like this: self-injury is almost always associated with emotional stress or trauma. To deal with stress, the brain secretes opiates that can shut down our pain perception. A lack of pain perception can cause feelings of numbness. Self-injurers often say they hurt themselves to avoid feeling numb.
Whatever the feeling, medical literature is rich with tales of mentally ill people who inflict pain upon themselves. In 19th century Europe, some women became known as "needle girls" because they would injure themselves with sewing needles. In 1875, a New York woman serving time in an asylum for insane criminals had at least 150 foreign objects removed from her body, including pieces of glass, wooden splinters, needles, pins, shoe nails and a piece of tin. Another woman, at a nearby lunatic asylum, had 300 needles withdrawn from her body. "This is nothing new," says Joan Jacobs Brumberg, a social historian and professor of human development at Cornell University. "But the early writing on this was of the tone that this was just another lunatic, hysterical female behavior."
It wasn't until 1995 that self-injury made its way into the mainstream consciousness?and with a sympathetic protagonist?when Princess Diana told a BBC interviewer that she had often cut her arms and legs, explaining, "You have so much pain inside yourself that you try and hurt yourself on the outside because you want help." The behavior has since been referenced in film (1999's Girl, Interrupted), music (the 2005 Garbage album, Bleed Like Me) as well as dozens of written analyses, including 1999's A Bright Red Scream, by Pulitzer-prize winning journalist Marilee Strong. Today, there are dozens of websites devoted to self-injury education.
Nevertheless, scientific research on self-injury is still its infancy. Recent studies show that it is most common among teen girls. (In one survey by researchers at Brown University of 633 high school students, 46 percent had injured themselves in the past year on multiple occasions). But it may be growing among college students, and even men. (A recent study of 1,000 self-injurers by UK mental health charity SANE found that 10 percent of respondents were male and that some didn't start until they were in mid-life.) Clinicians like Shiels believe more research is urgent?and that inclusion in the DSM as a diagnosable and treatable disorder could help free up funding. (It might also make obtaining insurance coverage less of a battle?as many insurers will only reimburse from conditions listed in the DSM.)
While there's not enough evidence yet to call self-injury a true addiction, its characteristics are addiction-like: the high a self-injurer may get from the blood flowing from their wounds; the obsessive, often agitated need to engage in it is not unlike that of a junkie desperate for a hit. Some studies do suggest that self-injury releases endorphins to the brain. "Everyone deals with problems differently: some people take drugs, some cut," says 27-year-old Sarah Brecht, the co-author of a book of essays on self-injury called Beyond the Razor's Edge (iUniverse, 2005).
Becki describes it as an obsessive battle, and one she often lost. At her worst, she says she spent every hour living and breathing self-injury. She dreamed about it. She'd think about it at school. She bought every book published on it. She searched for self-injury Websites, and compiled what she found into a 13-page Website of her own. "I was cutting 10-plus times a day, and still, if I didn't do it, I would feel like I was missing something," she says.
Though the blade was Becki's instrument of choice, she wasn't limited to it: at times, she'd use glass, burn herself with lighters, or scratch her healing wounds to make them worse. Often, she'd coat her wounds with hair spray to enhance the pain. Studies have shown that, like Becki, some 75 percent of those who hurt themselves, do so in more than one way. And many self-injurers will go as far as to swallow razor blades, bleach or battery acid.
Those who treat people who harm themselves say that getting to the root of the problem?the emotion that's causing the urge to injure?is at the heart of any recovery process. But it often takes a lot to get to that point. When she was 17, Becki cut herself so many times that she landed in a New Jersey child psych ward?a 19-bed, acute inpatient unit where she spent 11 days. She says her arms were unrecognizable; cut hundreds of times from wrist to shoulder. The first few days were rough, in part, Becki says, because the medical staff didn't understand why she'd want to hurt herself?a common complaint among self-injurers who seek treatment. They stared at her wounds and made faces. They assumed she was on drugs. But as the time went on, the experience got better, and Becki liked the regimented nature of it all: Wake up. Eat. Therapy. Group Therapy. Dinner. Bedtime. And repeat. The success was short-lived, though: four days after she was discharged, Becki overdosed on cold medicine?in part, she says so she'd be sent back in. "I wanted that structure," she says. "Outside, my life was just a jumble of chaos."
With years of treatment (both talk therapy and medication), familial support and the help of a good friend, Becki says she's come through the worst of it. She started college in 2005, at Montclair State University, in New Jersey, and says it has been more than a year now since she has cut. She says she channels much of her negative energy into positive things, like a Facebook group she's created to help other self-injurers. But it will be a constant battle: it's easy to be "triggered" to cut, she says, by things she sees or hears. When the media hypes a certain issue?like self-embedding?it can both hurt and help: hurt in that it sometimes oversimplifies the issue, but help in raising awareness.
Education, she says, is key to helping those like her who are suffering. On a recent weekday, she conducts a workshop at her school: "Understanding Self-Injury," aimed at fighting the stigma related to self-injury she says is still rampant. When she graduates next year, she wants to work in adolescent psychology?with an emphasis on self-injury. "It's funny, because people can understand people who go to extremes to lose weight, or drink, or even do drugs," Becki says. "But bringing a razor to your arm and pressing down is still very taboo." If anyone can educate, it's those who've overcome their own battles. Becki's certainly got the scars to prove it.
To learn more about self-injury and treatment options, check out these Web-sites: S.A.F.E. Alternatives, Self-Harm Information Clearinghouse, Psyke.org, and Self Injury Support.
by Jessica Bennett, Newsweek
Dec 29, 2008
One woman's fight against the compulsion to injure herself, and why medical experts disagree about how to diagnose those who cut, or in extreme cases, embed objects under their skin.
The first time was with a broken glass. Becki Bagnato was 13, and struggling with the emotions typical of a girl her age: confusion, angst, insecurity. On top of that, her brother was battling drug abuse, and her father, who'd skipped town years earlier, had stopped sending child support. So when she accidentally broke a glass while she was cleaning her room one day, she wondered, "What would it feel like if I cut my hand?"
[detail omitted] But as the sharp pain eased, replaced by a singular throbbing, somehow, the teen felt a strange calmness and a sense of relief.
It started that way, the cutting. When Becki was feeling alone, or stressed, the cuts became a companion, each slice like a friend who understood her pain. She stole her first razor blade from her grandfather's tailor workshop in her family's home in Middletown, N.J. Later, she'd buy them in bulk?$1.99 at a local Target for a pack of 20. She'd cut in the morning before school, then cover up her arms with long sleeves. She'd take a razor with her on the bus, stored flat in her wallet or back pocket of her jeans, so that during class, when she couldn't handle the pressure, she could sneak into the girls bathroom and slide the edge across her forearm. She'd cut before she went to bed. Sometimes, in the middle of the night. "I wouldn't have a good day if I didn't wake up and hurt myself," Becki, now 22, remembers. "It made me forget all the crap going on in my life."
This is how it began for Becki. For the millions of others who hurt themselves intentionally, the story may start differently, but the result is often the same: What is at first just an impulse, a moment of relief, becomes a secret habit?a need for pain that medical science doesn't fully understand and can treat with only mixed success. Eventually, for Becki, the cuts became too much to hide, and her excuses?"I burned myself," "It was a cat scratch."?rang hollow. Her mother sent her to a therapist, then a psychiatric ward, where she was diagnosed with borderline personality disorder, and put on mood stabilizers and antidepressants. But the cutting didn't stop?it worsened. Years passed, middle school became high school, friends and interests changed, one therapist merged into another. Yet the cutting remained ritual, sometimes happening a dozen times a day?on arms, thighs and stomach. "Seeing the blood would give me a sense of being alive," Becki explains.
Self-injury has been documented for hundreds of years. Cases of women and girls, mostly teens, hurting themselves with blades or other implements, even inserting small objects under their skin, go as far back as the medical literature will reach. Though figures vary, researchers estimate between two and eight million Americans, most of them women, have engaged in self-injury at some point in their lives. Yet, while experts agree that this propensity exists, from there, opinions diverge. Is non-suicidal self-injury a diagnosable disorder, or simply a symptom of more profound mental disorders? Can it become an addiction? Does this behavior create changes in the brain chemistry of sufferers? And how do you treat it?
All these questions surfaced earlier this month when a team of radiologists presented new, graphic evidence of what they describe as an increase in the number of self-injurers who are embedding sharp objects underneath their skin. On Dec. 3, at an annual meeting of North American radiologists, Dr. William Shiels, the chief of radiology at Nationwide Children's Hospital in Columbus, Ohio, showed documentation and X-rays of eleven patients that had "self-embedded"?ending up in Shiels office for a surgical procedure more commonly used to remove shrapnel from war vets. [details omitted] "They come in with pain, infections, and sometimes guilt," says Shiels. "The infections can be very severe?putting nerves, veins, even tendons at risk."
The 11 self-embedding cases had gone unnoticed in the 505 incidents of (usually accidental) embedding Shiels' team had treated since 2005. But last year, one of his research assistants, who was going back through past files, identified a trend. Shiels says he'd never focused much on the practice before, but when he looked back at these cases and talked to other radiologists around the country, he heard similar reports. This data, he is careful to note, is still anecdotal. To his knowledge (and NEWSWEEK's) there have been no other studies looking specifically at self-embedding, and it is unclear how many people nationwide have been treated for such injuries. Still, in reviewing the literature and talking with mental health professionals, Shiels has come to believe that the practice is increasing, and that it could be viewed as the "next phase" of self-injury. He has put together an interdisciplinary team and database to track its prevalence around the country. "We've been treating patients with accidental foreign bodies under their skin for 13 years, but before 2005, we never saw [self-inflicted] cases like this in adolescence," says Shiels. "We believe this is out there more than people think?it's just that we didn't know what to call it or understand its significance."
Despite its anecdotal nature, Shiels' report caused a sensation. X-ray images revealing the silhouettes of embedded objects lodged between bones were plastered across news sites and blogs. But the hubbub only fueled the debate over what is going on in the minds of those who hurt themselves deliberately, but not fatally. Shiels says embedders are different from other self-injurers in that they've taken the behavior to the extreme. He's dubbed their pathology "Self-Embedding Disorder" and is lobbying for its inclusion into the American Psychiatric Association's Diagnostic and Statistical Manual (the DSM), considered the bible of psychological disorders, which is currently under revision.
But the assertion that self-embedding is a new trend, or a disorder at all, has caused a stir among many mental health experts, who say embedding is a known method of nonsuicidal self-injury and a symptom of a larger problem and not itself a psychological disorder. Though it's often believed to be a common behavior among those with bipolar disorder?and is described in the DSM as such?self-injury of any kind does not appear in the manual itself as a diagnosable disorder. As Bessel van der Kolk, the medical director of the nonprofit Trauma Center, in Boston, and an adviser for the updated DSM, puts it: "Self injury is part of a larger picture; it should never be seen as an isolated thing."
Wendy Lader, a clinical psychologist and cofounder of S.A.F.E. Alternatives, a Dallas-based treatment center for self-injurers, says that people who harm themselves almost always suffer from larger mental conditions, often the result of emotional trauma, or in extreme cases, physical or sexual abuse. Though she estimates five percent of her patients this past year have been embedders, she doesn't distinguish between the two kinds of behavior: self-injury of any kind, she says, is a physical coping mechanism used to deal with or distract from extreme emotional distress. "I think a lot of people tend to look at the behavior versus what the behavior represents," she says. "But these are all just methods of trying to maintain some emotional equilibrium."
The way self-injurers describe the relief the practice gives them varies. For some, it's about control: the ability to create and end physical pain amid emotional turmoil. Others see the blood as a physical release of overwhelming stress. Some say it causes an almost euphoric feeling, the way an addict might describe a much-needed fix. Lader says that people who engage in self-injury are nine times more likely to attempt suicide than non self-injurers?but it's a common misperception that self-injury itself is an attempt to die. In fact, say experts, it's in many cases the exact opposite: an attempt to feel more alive. Van Der Kolk, a leading expert in self-injury, explains it like this: self-injury is almost always associated with emotional stress or trauma. To deal with stress, the brain secretes opiates that can shut down our pain perception. A lack of pain perception can cause feelings of numbness. Self-injurers often say they hurt themselves to avoid feeling numb.
Whatever the feeling, medical literature is rich with tales of mentally ill people who inflict pain upon themselves. In 19th century Europe, some women became known as "needle girls" because they would injure themselves with sewing needles. In 1875, a New York woman serving time in an asylum for insane criminals had at least 150 foreign objects removed from her body, including pieces of glass, wooden splinters, needles, pins, shoe nails and a piece of tin. Another woman, at a nearby lunatic asylum, had 300 needles withdrawn from her body. "This is nothing new," says Joan Jacobs Brumberg, a social historian and professor of human development at Cornell University. "But the early writing on this was of the tone that this was just another lunatic, hysterical female behavior."
It wasn't until 1995 that self-injury made its way into the mainstream consciousness?and with a sympathetic protagonist?when Princess Diana told a BBC interviewer that she had often cut her arms and legs, explaining, "You have so much pain inside yourself that you try and hurt yourself on the outside because you want help." The behavior has since been referenced in film (1999's Girl, Interrupted), music (the 2005 Garbage album, Bleed Like Me) as well as dozens of written analyses, including 1999's A Bright Red Scream, by Pulitzer-prize winning journalist Marilee Strong. Today, there are dozens of websites devoted to self-injury education.
Nevertheless, scientific research on self-injury is still its infancy. Recent studies show that it is most common among teen girls. (In one survey by researchers at Brown University of 633 high school students, 46 percent had injured themselves in the past year on multiple occasions). But it may be growing among college students, and even men. (A recent study of 1,000 self-injurers by UK mental health charity SANE found that 10 percent of respondents were male and that some didn't start until they were in mid-life.) Clinicians like Shiels believe more research is urgent?and that inclusion in the DSM as a diagnosable and treatable disorder could help free up funding. (It might also make obtaining insurance coverage less of a battle?as many insurers will only reimburse from conditions listed in the DSM.)
While there's not enough evidence yet to call self-injury a true addiction, its characteristics are addiction-like: the high a self-injurer may get from the blood flowing from their wounds; the obsessive, often agitated need to engage in it is not unlike that of a junkie desperate for a hit. Some studies do suggest that self-injury releases endorphins to the brain. "Everyone deals with problems differently: some people take drugs, some cut," says 27-year-old Sarah Brecht, the co-author of a book of essays on self-injury called Beyond the Razor's Edge (iUniverse, 2005).
Becki describes it as an obsessive battle, and one she often lost. At her worst, she says she spent every hour living and breathing self-injury. She dreamed about it. She'd think about it at school. She bought every book published on it. She searched for self-injury Websites, and compiled what she found into a 13-page Website of her own. "I was cutting 10-plus times a day, and still, if I didn't do it, I would feel like I was missing something," she says.
Though the blade was Becki's instrument of choice, she wasn't limited to it: at times, she'd use glass, burn herself with lighters, or scratch her healing wounds to make them worse. Often, she'd coat her wounds with hair spray to enhance the pain. Studies have shown that, like Becki, some 75 percent of those who hurt themselves, do so in more than one way. And many self-injurers will go as far as to swallow razor blades, bleach or battery acid.
Those who treat people who harm themselves say that getting to the root of the problem?the emotion that's causing the urge to injure?is at the heart of any recovery process. But it often takes a lot to get to that point. When she was 17, Becki cut herself so many times that she landed in a New Jersey child psych ward?a 19-bed, acute inpatient unit where she spent 11 days. She says her arms were unrecognizable; cut hundreds of times from wrist to shoulder. The first few days were rough, in part, Becki says, because the medical staff didn't understand why she'd want to hurt herself?a common complaint among self-injurers who seek treatment. They stared at her wounds and made faces. They assumed she was on drugs. But as the time went on, the experience got better, and Becki liked the regimented nature of it all: Wake up. Eat. Therapy. Group Therapy. Dinner. Bedtime. And repeat. The success was short-lived, though: four days after she was discharged, Becki overdosed on cold medicine?in part, she says so she'd be sent back in. "I wanted that structure," she says. "Outside, my life was just a jumble of chaos."
With years of treatment (both talk therapy and medication), familial support and the help of a good friend, Becki says she's come through the worst of it. She started college in 2005, at Montclair State University, in New Jersey, and says it has been more than a year now since she has cut. She says she channels much of her negative energy into positive things, like a Facebook group she's created to help other self-injurers. But it will be a constant battle: it's easy to be "triggered" to cut, she says, by things she sees or hears. When the media hypes a certain issue?like self-embedding?it can both hurt and help: hurt in that it sometimes oversimplifies the issue, but help in raising awareness.
Education, she says, is key to helping those like her who are suffering. On a recent weekday, she conducts a workshop at her school: "Understanding Self-Injury," aimed at fighting the stigma related to self-injury she says is still rampant. When she graduates next year, she wants to work in adolescent psychology?with an emphasis on self-injury. "It's funny, because people can understand people who go to extremes to lose weight, or drink, or even do drugs," Becki says. "But bringing a razor to your arm and pressing down is still very taboo." If anyone can educate, it's those who've overcome their own battles. Becki's certainly got the scars to prove it.
To learn more about self-injury and treatment options, check out these Web-sites: S.A.F.E. Alternatives, Self-Harm Information Clearinghouse, Psyke.org, and Self Injury Support.
