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Am Fam Physician. 2005;72(7):1172

to the editor: I reviewed with interest the article on screening for suicide risk1 from the U.S. Preventive Services Task Force department inAmerican Family Physician, especially the association with deliberate self-inflicted harm. I have been confronted with this phenomenon repeatedly through my work in college health and in my supervisory role in our Family Medicine Teen Clinic. There appears to be a lack of information in the medical literature on deliberate self-inflicted harm and some misunderstanding about this disorder in the medical community. It is receiving more attention in the popular media and literature, however, with television shows and movies addressing this topic and Web sites devoted to self-inflicted harm.

I am concerned by one of the Clinical Quiz questions related to this department: “Which of the following is/are risk factors for attempted suicide?” Answer B, “cutting oneself,” might support the mistaken belief that cutting is a suicide attempt or the first step on a continuum toward suicidal behavior. However, self-inflicted injury is a coping mechanism, albeit not a particularly healthy one, used by those who want to live and are struggling to control their emotions. This behavior was documented previously in persons with comorbid depression, obsessive-compulsive disorder, borderline personality disorder, substance abuse, or pervasive developmental disorders. Designations have now been proposed to classify the increases we are seeing in adolescent populations not associated with these disorders. In 1983, Pattison and Kahan2 proposed a diagnostic entity, “the deliberate self-harm syndrome,” as a distinct category that excluded suicidal behavior. In 1993, Favazza and Rosenthal3 proposed the diagnosis of “repetitive self-harm syndrome,” in which patients repeatedly harm themselves without intent to kill but with the purpose of relieving mental and emotional pain. I believe we will see a greater push in the psychiatric and medical literature toward developing a separate diagnostic entity to address self-injury in adolescents who are using this method to regulate emotional distress and who do not have suicidal intent or an associated personality disorder.

Reactions by parents, health care professionals, friends, or teachers to episodes of self-inflicted injury can be highly variable, ranging from dismissal of the behavior as simply a phase to disgust, anger, and fear, or to misinterpretation as suicidal behavior with subsequent inappropriate admission to a psychiatric facility. I am concerned that this latter option will be overutilized if those reading the article or quiz were to presume cutting was equated with suicidal behavior. If the patient does not exhibit suicidal intent or more severe psychopathology, and the method is of low lethality, they would likely be much better served by being linked with a therapist who is experienced in treating this disorder and trained to help them develop more healthy and effective methods of coping with their emotions.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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