Peer Reviewed

Case In Point

An Adolescent With a Self-Inflicted Forearm/Wrist Cutting Injury

Volume 57 - Issue 11 - November 2017

Authors:
Alexander K. C. Leung, MD, and Benjamin Barankin, MD

Citation:
Leung AKC, Barankin B. An adolescent with a self-inflicted forearm/wrist cutting injury. Consultant. 2017;57(11):656a,656h.

 

A 15-year-old girl came in with her mother for a routine annual physical examination. She did not have any concerns, but her mother was concerned for her. On examination, the girl looked unhappy, anhedonic, and withdrawn. Multiple horizontal, hyperpigmented scars were present on the girl’s left forearm. The rest of the physical examination findings were unremarkable.

The girl admitted that she had cut her left forearm, but not other parts of her body, with a knife on 2 separate occasions. She was right-handed. She did not seek medical attention on those 2 occasions because she thought the cuts were trivial.

A detailed history revealed that her parents had divorced and that she had been living with her 62-year-old grandmother. She had broken up with her boyfriend a year ago and was depressed. She smoked 2 to 3 cigarettes a day and was an occasional drinker. There was no history of other substance abuse.

A diagnosis of self-inflicted forearm cutting injury was made. She was referred to a psychiatrist for assessment and a psychologist for psychotherapy.

DISCUSSION

Self-inflicted forearm cutting injury and self-inflicted wrist cutting injury have many features in common, and they will be discussed together.

Prevalence

The exact prevalence is not known, since a significant number of self-cutters do not need or seek treatment in an emergency department or a hospital setting. Rather, they either self-treat or seek treatment in a private facility. The lifetime prevalence of self-cutting is estimated to be 11.5%.1 The condition often begins in adolescence and young adulthood, with a peak age of onset between 14 and 24 years.2 The female to male ratio is approximately 3 to 2.3,4

Etiopathogenesis

The exact etiopathogenesis is not known. Self-inflicted forearm/wrist cutting is often used as a coping mechanism, which provides temporary relief of intense feelings such as anxiety, emotional stress, and depression, or as an attempt to communicate distress.5 Others may use it as a means to obtain cathartic release, responding to peer pressure, or inflicting self-punishment.1 At times, it may be used as an attention-seeking device to elicit sympathy. On the other hand, self-inflicted wrist cutting is more often involved with suicidality.6

Studies have shown that serotonin and endorphins are released in response to the act of self-cutting, which induce pleasant feelings and reduce emotional distress and tension.1,7,8 Also, one study has shown that there is a down-regulation of cannabinoid receptor mRNA in patients with wrist cutting, which might account for desensitization of pain perception in these patients.9

self injury

Predisposing factors for self-inflicted forearm/wrist cutting include depression, anxiety, peer rejection, recent breakup, unstable family relationship, bullying in school, impulsivity, substance abuse, low self-esteem, history of sexual/physical abuse, serious medical illness, unemployment, poverty, poor coping strategies, borderline personality disorder, posttraumatic stress disorder, conduct disorders, autism spectrum disorders, eating disorders, bipolar disorder, and schizophrenia.1,2,7,9

Clinical Manifestations

The typical self-inflicted forearm/wrist cutter is a young single woman who is under emotional stress and who often has a history of self-cutting.3,7,10 Despite having a history of self-cutting, the majority of these patients have not undergone psychiatric assessment.11 The object used for the cutting is usually a razor, a metallic or plastic knife, a broken bottle, or a safety pin.12 Because most of the population is right-handed, the majority of cuts are on the left forearm and/or wrist, opposite the side of a person’s handedness.13

A delicate cutter usually makes multiple superficial horizontal incisions on the forearm that are associated with slight bleeding.7,13 On the other hand, a coarse cutter often makes a single, deep horizontal incision on the wrist, and less commonly, the forearm close to a vital structure such as an artery or a nerve.7,13 In one study, all of the delicate cutters and two-thirds of the coarse cutters were female.2

The self-cutting act is usually performed in private. Many self-cutters have a high baseline threshold for pain and report feeling very little or no pain during the self-cutting.7,14 Rather, some of them may feel fascinated at the sight and warmth of their blood.7

Complications and Prognosis

Injury to an artery may result in fatal bleeding.14 Injury to a tendon may result in impaired or loss of function of the muscle connected to the tendon, while injury to a nerve might result in loss of motor and sensory functions supplied by that nerve.14 The resultant scars from self-cutting are often cosmetically unsightly and socially embarrassing. Although suicide might not be the initial intent or motivation, especially for forearm cutting, self-cutters are at higher risk of suicide and premature death.1,7

The prognosis depends on the underlying cause; the severity, duration, frequency, and progression of the self-cutting behavior; the patient’s desire to change, and whether proper treatment is offered.7 Even with proper treatment, the self-cutting behavior often continues, because such behavior can be addictive.1,14

Management

Any active bleeding should be stopped with pressure or, less commonly, with sutures if necessary. Proper wound care is important; the wound should be washed and cleaned. Tetanus toxoid should be administered if indicated.

The underlying cause of the self-cutting should be treated if possible, and a nonjudgmental, supportive, and sympathetic approach should be adopted.1 Treatment consists of psychiatric assessment, psychotropic medications (eg, olanzapine, selective serotonin-reuptake inhibitors), and psychotherapy, all of which have been used with some success.7,15,16 Various lasers (eg, vascular, ablative) may be tried to blend and fade the scars. For hyperpigmented scars, sun protection and possibly a bleaching cream in the night can be considered. For hypertrophic or keloid-type cutting scars, intralesional cortisone can be particularly helpful to flatten the scars. Referral to a dermatologist should be considered for cosmetic improvement. 

Alexander K. C. Leung, MD, is clinical professor of pediatrics at the University of Calgary and a pediatric consultant at the Alberta Children’s Hospital in Calgary, Alberta, Canada.

Benjamin Barankin, MD, is a dermatologist and the medical director and founder of the Toronto Dermatology Centre in Toronto, Ontario, Canada.

References:

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  2. Fujioka M, Murakami C, Masuda K, Doi H. Evaluation of superficial and deep self-inflicted wrist and forearm lacerations. J Hand Surg Am. 2012;​37(5):1054-1058.
  3. Clendenin WW, Murphy GE. Wrist cutting: new epidemiological findings. Arch Gen Psychiatry. 1971;25(5):465-469.
  4. Weissman MM. Wrist cutting: relationship between clinical observations and epidemiological findings. Arch Gen Psychiatry. 1975;32(9):1166-1171.
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  6. Matsumoto T, Yamaguchi A, Chiba Y, Asami T, Iseki E, Hirayasu Y. Patterns of self-cutting: a preliminary study on differences in clinical implications between wrist- and arm-cutting using a Japanese juvenile detention center sample. Psychiatry Clin Neurosci. 2004;58(4):377-382.
  7. Ahluwalia J, Lowenstein EJ. Case study: delicate skin cutting: management beyond the skin and implications of superficial habitual self-mutilation. Skinmed. 2005;4(3):190-192.
  8. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27(2):226-239.
  9. Schroeder M, Eberlein C, de Zwaan M, Kornhuber J, Bleich S, Frieling H. Lower levels of cannabinoid 1 receptor mRNA in female eating disorder patients: association with wrist cutting as impulsive self-injurious behavior. Psychoneuroendocrinology. 2012;37(12):2032-2036.
  10. Maloney C, Shah S, Ferguson DG. Acute management of the self-cutter. Arch Emerg Med. 1987;4(1):39-45.
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  12. Rosenthal RJ, Rinzler C, Wallsh R, Klausner E. Wrist-cutting syndrome: the meaning of a gesture. Am J Psychiatry. 1972;128(11):1363-1368.
  13. Takeuchi T, Koizumi J, Kotsuki H, Shimazaki M, Miyamoto M, Sumazaki K. A clinical study of 30 wrist cutters. Jpn J Psychiatry Neurol. 1986;40(4):​571-581.
  14. Ersen B, Kahveci R, Saki MC, Tunali O, Aksu I. Analysis of 41 suicide attempts by wrist cutting: a retrospective analysis. Eur J Trauma Emerg Surg. 2017;43(1):129-135.
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  16. Hayakawa M. How repeated 15-minute assertiveness training sessions reduce wrist cutting in patients with borderline personality disorder. Am J Psychother. 2009;63(1):41-51.