New Facet of Self Harm

Thursday, December 18, 2008


By Tiffany Sharples, from Time Magazine--link is here, with other links to photographs and x-rays

At a recent medical conference in Chicago, a team of radiologists from Nationwide Children's Hospital presented intriguing X-ray evidence of a psychological phenomenon — what they believed was a new form of self-injury among teens and adolescents. Eleven out of 505 patients whom the team had treated in more than a decade had inserted objects — from chunks of crayons to unfolded paper clips — under their skin in a behavior the Nationwide team labeled "self-embedding."

All of Nationwide's patients were young females, but when the researchers, including Dr. William Shiels II, the hospital's chief of radiology, turned to medical literature for other examples of self-embedding, they found very few — and those were among adults, primarily males. Shiels and his colleagues asked around at the hospital, but not even mental-health specialists had heard of it, nor had many of their colleagues outside the hospital. "As a profession in general, psychologists were not aware that this was happening," Shiels says.

At the time of the conference, however, a Chicago Tribune reporter uncovered two more instances of self-embedding in an Illinois town — two teen girls had deliberately inserted pencils into their skin and broken off the tips — lending credence to the possibility that self-embedding was a growing trend, albeit off the radar. "We know it's elsewhere," says Shiels, who is creating a protected database for medical professionals worldwide to track the behavior. "It just hasn't been discussed and it hasn't been studied."

Shiels' team stumbled on the peculiar practice largely by chance. In 2007, a premed student named Adam Young, then 21, was compiling data during his summer internship at Nationwide. Part of his responsibilities included maintaining a database of patients who had been treated by the hospital's radiology department using Image Guided Foreign Body Removal, a technique that was developed by Shiels during his Army days to help remove foreign objects like shrapnel from soft tissue. Shiels' method was less invasive than surgery, which often requires an incision of 2 to 3 inches and can lead to damage in surrounding tissues or organs; the new method requires a quarter-inch incision and uses a combination of ultrasound and fluoroscopy — live X-ray — to carefully guide forceps to the object, steering clear of the body's vital structures during extraction. The scar is also much smaller, "about the size of a freckle," Shiels says.

While Young was cataloging the hospital's data on procedures involving Shiels' technique, which Shiels first introduced to the hospital in 1995, Young realized that some of the patients hadn't injured themselves accidentally. Unlike the majority of people who came in for treatment — for stepping on a piece of glass or being impaled by a particularly large splinter — these patients' wounds were self-inflicted. "I started to see three or four instances where the foreign-body cases were not accidental," he says. "I started to think it was a little strange and mentioned it to Dr. Shiels."

Young went back to school in the fall, and two or three more patients came to Nationwide with similar wounds. For Shiels and Young, it became clear that they were on to something. The following summer, Shiels, Young (who graduated from Miami University in Ohio) and three others worked their way through the data, unearthing cases of self-embedding going back to 2005. They also discovered that the majority of patients who harmed themselves in this way did so more than once — the average recurrence was three times — and that the materials embedded under the skin varied dramatically in size, from several unfolded staples embedded into a hand to a 6.3-in. unfolded paper clip inserted into a bicep.

Once they were aware of the trend, Shiels and his colleagues analyzed the patients' medical records, finding consistent histories of self-injury and mental-health problems. There are numerous psychological and emotional factors that drive people to self-harm, but according to Harvard psychology professor Matthew Nock, who specializes in the study of self-injurious behavior and edited a book on the subject, Understanding Non-Suicidal Self-Injury (due March 2009), many do it for two broad reasons: to regulate their emotions and to communicate with others. "Self-injurers experience greater physiological arousal in response to stress, show poor ability to tolerate distress, and have greater deficits in social problem-solving skills," Nock explains, meaning that people self-injure to distract themselves from other emotional pain, to counter feelings of numbness or to let people know that they're suffering.

The Nationwide team's findings sparked a frenzy on the Internet, with stories cropping up one after the other and chatter lighting up on blogs. But as the news spread, globally even, some mental-health professionals grew wary. Without discounting the severity of the problem — particularly among adolescent girls — some experts felt the headlines declaring self-embedding a new "disorder" went too far. Characterizing it as a disorder rather than a symptom of one may miss the mark, says Dr. John Campo, chief of child and adolescent psychiatry at Nationwide Children's and one of the specialists consulted by Shiels. "Young people with a variety of different psychiatric diagnoses may engage in this behavior," says Campo, and proclaiming it as its own condition may deter comprehensive mental-health care to identify the true nature of the problem.

Nock believes self-embedding is a dangerous evolution, but says it is not unique. "I view this as a more severe variation of self-injury," he says. An analysis of the data Nock has compiled in his years of research reveals that some 10% to 20% of adolescents who injure themselves have inserted objects beneath their skin. None of those patients reported leaving the objects there, however, and only two out of 12 patients who reported doing so had to seek medical treatment as a result. "The fact that kids are inserting things under their skin is not necessarily new," Nock says, adding that those who leave the objects embedded are probably in a very small minority.

The dangers of this form of self-injury are obvious, and serious. Creating any wound in the skin can lead to infection, but when foreign objects are inserted deep into tissue, the risk is amplified. "The infections aren't just at the site," Shiels says. "You can get a deep muscle infection or a bone infection," or if you hit arteries, veins, nerves or tendons while driving something into the soft tissue, you can cause tears or other damage. Beyond those risks, there is also the possibility that objects can travel once inside the body, approaching vital organs. "They pose significant risk, not only during insertion, but also if they're not removed," Shiels says.
The other major concern among mental-health specialists is that publicizing the behavior could exacerbate the problem. In a study of self-injury among adolescents conducted earlier this year, Nock found that 38% of teens who injured themselves learned of the practice from friends, while 13% first heard about it through the media. It's a bit of a catch-22, says Nock. "On the one hand, it's very helpful and useful for health professionals to communicate with each other and learn how to proceed when they see [these cases]," he says, "but we know that media coverage of self-injurious behavior influences rates of self-injurious behavior."

As studies show a surge in self-injury in recent years, "we've also seen increased media reports," Nock says. "It could be the media is catching up, but the opposite is also true: as kids hear more about it, it enters into the realm of behaviors in which they can engage."