Cutting – Causes, Signs and symptoms

Cutting

Summary

Cutting involves making repeated, intentional wounds to one’s own skin with a sharp instrument. It is the most common form of self-injury, and is different from a suicide attempt because there is no intent to die.

Cutting may be performed in an attempt to reduce emotional tension. The person performing the act may believe there is no other way to obtain emotional release except through drawing blood or feeling sharp, physical pain. A private act, cutting is usually performed when an individual is alone, and the resulting scars are hidden from others.

Those who cut themselves may also engage in other methods of self-injury, including hair-pulling, head-banging, punching, scratching and burning with cigarettes. Of these, both cutting and burning are considered methods of self-mutilation, a specific type of self-injury that involves the deliberate disfigurement of skin tissue.

Cutting is a serious, harmful behavior that usually appears in conjunction with mental illnesses including borderline personality disorder, depression, anxiety disorders and psychosis. This type of chronic self-injury appears to affect more females than males and typically first occurs during adolescence. Cutting can develop into a pattern of self-destructive behavior that continues into adulthood. A thorough psychiatric evaluation is needed for a diagnosis of the problem. Treatment is often a combination of medication and psychotherapy, such as cognitive behavioral therapy and interpersonal therapy. Although cutting is not performed with suicidal intent, people who practice it have an increased risk of future suicidal behavior.

About cutting

Cutting is a form of self-injury. It is defined as an act performed to achieve immediate emotional relief and is not intended to end one’s life. By injuring their own bodies, people who cut themselves achieve the emotional release they feel is necessary to continue functioning.

The act of cutting involves creating superficial lacerations (e.g., cuts, scratches) on the body with a knife, razor, glass or other sharp object. Each episode of cutting is usually completed upon the sensation of pain or the drawing of blood.

Cutting is the most common type of various self-injurious behaviors, which can include scratching, picking scabs, punching, burning with cigarettes or hot irons, head banging, biting, hair-pulling and/or drinking harmful liquids such as bleach or detergent. It is sometimes classified as self-mutilation, a specific type of self-injury that involves damage to the body. The scars, burns or bruises of self-injury may be concealed and a high level of shame is associated with the behavior. Common areas on the body for cutting include the arms, legs and front of the torso – especially areas that can be hidden by clothing.

Research suggests that cutting is common among high school students. Also, as many as one in six U.S. college students have engaged in some type of self-injurious behavior, including but not limited to cutting, according to the largest survey to investigate the incidence among young adults. The survey was conducted by researchers from Cornell University in Ithaca, New York. Most of the students who reported injuring themselves (71 percent) said they had done so at least twice. On average, they had injured themselves for the first time at age 15 or 16. Repeat self-injurers were more likely to be female.

Some people who regularly cut report experiencing relief from stress, emotional pain, fear and/or anxiety after cutting. In such cases, the self-injurer comes to see cutting as necessary to restore emotional balance. Other self-injurers report feeling better and more in control immediately after cutting themselves. However, the relief is usually temporary and individuals who cut for such reasons may fall into a chronic pattern of reliance on the behavior.  

A common misperception about cutting is those who practice it are manipulating people around them or simply seeking attention. In some cases, attention may become an unintended consequence of the cutting – which can reinforce the behavior. However, cutting is almost always done in isolation and attention to the self-inflicted wounds is typically not desired. The primary goal of cutting is emotional release, not attention. Although cutting is performed without the intention of causing death, self-injury may be fatal in cases where the self-injurer miscalculates his or her own safety margin.

Types and differences of cutting

Cutting is described as a self-mutilating form of self-injury, meaning that individuals actually cause disfigurement by cutting or slashing their own skin. Self-mutilation can be broken down into three categories:

  • Superficial/moderate. The most common type of self-mutilation, involving superficial to moderate lacerations (cutting) or burns to one’s own skin. It is most often seen with borderline personality disorder and psychosis.

  • Stereotypic. Those types of repetitive, rhythmic self-injuries (e.g., head-banging) often seen with organic disorders such as autism or mental retardation.

  • Major. An extremely rare form of self-injury involving the severing of limbs and genitals. It is usually associated with psychotic disorders.

Tattoos and body piercing are sometimes considered a form of self-injury when they become excessive or if an individual is unable to stop. In general, however, these practices involve pain that is endured to achieve an end result that involves appearance – the tattoo or piercing. For those who cut themselves, pain is the intended goal.

Disorders related to cutting

Cutting is considered a symptom of a serious mental health problem. The behavior has been associated with the following mental illnesses:

  • Borderline personality disorder (BPD). Characterized by impulsive behavior, moodiness and problems with self-image and personal relationships. BPD is the condition most commonly associated with cutting.

  • Mood disorders. Cutting may be accompanied by depression (feelings of sadness and an inability to enjoy daily life) including severe (major) depression, or bipolar disorder (which involves alternating periods of mania and depression).
     
  • Anxiety disorders. Characterized by debilitating, disruptive fear or worry. Cutting has been reported in conjunction with diagnoses of obsessive-compulsive disorder, with its recurrent and intrusive thoughts and behaviors, as well as post-traumatic stress disorder, in which symptoms occur after a traumatic event.

  • Psychosis. Involves losing touch with reality as well as impaired thought and perception. Schizophrenia is a type of psychosis that involves an inability to think logically, have normal emotional responses or behave appropriately in social situations. Cutting can accompany this type of disorder.

Risk factors and causes of cutting

Statistics have revealed certain patterns regarding cutting. The reasons for these particular trends are not clearly understood. However, the following factors have been linked to an increased risk of cutting:

  • Age. Because cutting tends to begin during adolescence, teens and young adults are at greater risk. The behavior can last for five to 10 years, but may continue for longer periods of time if appropriate treatment is not obtained.

  • Gender. Cutting appears to be more common in females than in males.

  • Self-esteem. People with a low sense of their own value are at greater risk than those with healthy self-esteem.

  • Personal and or family history of self-injury. Those who have engaged in any form of self-injury in the past are likely to repeat the pattern, which may include cutting. Some evidence also suggests that self-injury is more common in people who have a family history of suicide or self-injury.

  • Past abuse. Approximately half of all self-injurers were subject to sexual, physical or emotional abuse including neglect as children, according to the National Mental Health Association.

Substance abuse also appears to be associated with cutting.

In addition, almost all cutters report feeling discouraged from expressing emotions, especially negative emotions such as anger or sadness.

Distorted thought processes support the cycle of cutting. For example, individuals may assume they cannot handle emotional pain and that cutting is the only way to relieve themselves of negative emotions. Or, they may have been taught not to express anger toward another person or that they deserve to suffer. Often, self-injurers report not being understood by others and feeling lonely.

Other possible reasons for cutting include:

  • Expression of emotional pain. Physical pain is perceived as being easier to bear than emotional pain. Cutting is seen as releasing overwhelming negative emotions to achieve a state of emotional equilibrium.

  • Distraction from emotional pain. Preoccupation with the ritual of cutting can become an engaging, self-absorbing activity that temporarily distracts one from distressing emotions and events.

  • Alleviating feelings of numbness. Many who self-injure report seeking relief from an internal emptiness or numbness, which can sometimes be the result of emotional overload. Cutting provides a temporary break from this uncomfortable state.

  • Validation of emotional state. Cutting produces visible physical evidence of emotional suffering. After-the-fact, it can provide a reason for negative emotions.

  • Exertion of control. When events and emotions are painful and seem out of control, cutting may provide a feeling of empowerment by allowing one to control the amount or intensity of pain experienced.   

In addition to psychological causes, cutting also appears to include a biochemical component. By stimulating the release of endorphins (biochemicals that act as a painkiller) within the body, it is believed that self-injurers may also be experiencing very real, physiological relief from pain after cutting.

Signs and symptoms of cutting

People who cut are often ashamed of their behavior, but feel unable to stop. They may seek help only after their secret behavior is exposed to others.

Those who believe someone they know may be cutting can look for several signs. The wounds themselves are likely to be small, straight cuts – cuts that appear more deliberate and precise than a cat scratch or accidental scrape. Besides the discovery of physical evidence or discussion of the problem, the following are some additional signs of cutting:

  • Frequent injuries with suspicious excuses
  • Inappropriate clothing worn to conceal the skin (e.g., long sleeves in warm weather)
  • Blood stains on clothing
  • Long periods of isolation, after which new injuries appear
  • Knife or razor in purse or book bag
  • Difficulty talking about feelings
  • Relationship problems
  • Poor functioning at home, work or school
  • Low self-esteem, extreme self-criticism

Diagnosis and treatment for cutting

The first step in diagnosing the problem is a psychiatric evaluation, which will likely include a mental status examination and patient history. In addition to looking for signs of mental disorders that can accompany cutting (e.g., borderline personality disorder), if possible it is useful for the mental health professional to identify and assess the following:

  • What function cutting serves for the self-injurer
  • The intent behind past cutting
  • Thoughts that contribute to cutting
  • Intended or unintended consequences that reinforce cutting

A physical examination may also be included, with particular attention paid to areas of the body where self-injury has occurred.

The next step is a recommended course of treatment. The treatment approach will depend on any accompanying conditions or underlying issues. Possible treatment methods for cutting include:

  • Medication. The type of medication used will depend on the accompanying disorder. For instance, treatment for cutting associated with depression may involve antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs).

  • Psychotherapy. The treatment of mental and emotional disorders using a variety of psychological techniques. Psychotherapy can be performed in one-on-one, family or group settings. The type of psychotherapy chosen depends upon the nature of the underlying mental disorder. Specific psychotherapy techniques include:

    • Cognitive behavioral therapy, which addresses a person’s thoughts in relation to their actions.

    • Dialectical behavior therapy, which focuses on coping skills, managing emotional trauma and tolerating distress. Both dialectical and cognitive behavioral therapies may help self-injurers to identify any possible underlying cause and better manage self-destructive thoughts and behaviors.

    • Interpersonal therapy, which focuses on human relationships. This type of therapy can help self-injurers develop better social skills to help decrease the likelihood of emotional and physical isolation from others.

  • Contracts, journals, behavior logs. These tools track thought and behavior patterns and can help the self-injurer regain self-control.

Whether or not to hospitalize an individual who engages in cutting should be carefully evaluated. At times, it may be felt that the individual does not appreciate the severity of the problem and family members may need to hospitalize (commit) the person against his or her will. However, hospitalizing a person immediately after cutting may come at a time when the patient is actually feeling her or his best and is actually less likely to engage in additional self-harm.

Before making the decision to hospitalize, it is important to identify whether the cutting was an act of nonsuicidal self-injury or an actual suicide attempt. A comprehensive psychiatric evaluation can help in making this decision. Many hospitals or mental health facilities offer programs that may help individuals with mental illnesses associated with cutting (e.g., BPD). These programs can include inpatient hospitalization or partial hospitalization (day treatment), which consists of remaining in a hospital part-time, for six to 12 hours per day.

Prevention and lifestyle issues for cutting

There are several things self-injurers may do to help reduce the likelihood of cutting. First, it is important that self-injurers recognize cutting as a detrimental behavior that they wish to discontinue. In order to help them accomplish this, it is recommended they seek help from a mental health professional who has experience dealing with cutting.

Once cutting is identified as a problem and steps are taken to address it, there remain various issues affecting the lifestyle of the self-injurer. These are adjustments to the way self-injurers conduct themselves once in treatment for cutting. Lifestyle issues may include:

  • Avoiding physical and emotional isolation

  • Making time for therapy sessions

  • Keeping a list of people to contact handy (for times of intense emotional distress)

  • Being aware of the side-effects of certain medications that may affect mood or energy level

  • Identifying how to treat or explain physical scars

Approaching loved ones about cutting

Parents or friends of a self-injurer can discourage cutting. The ways to do this include asking about the behavior, encouraging self-injurers to get help and letting them know they are not alone. It is very important when approaching the self-injurer to suspend judgment and negative responses. Some tips include:

  • Talking. Encouraging open discussion helps identify the problem and remove the secrecy that surrounds cutting. It also increases the opportunity for the self-injurer to engage in close personal relationships with others.

  • Offer support. Directly asking how to help will identify exactly what is needed by the self-injurer. It is important for those attempting to help to recognize their personal limits, whether regarding time available or ability to openly discuss cutting with the self-injurer. Many people have difficulty dealing with this subject since it involves willful self-mutilation. Sometimes it is most helpful to refer the self-injurer to resources available in the community.

  • Be available. Self-injurers usually only engage in cutting when they are alone. By offering to be physically in their presence, those periods of isolation where cutting may occur are reduced.

  • Withhold judgment and demands. Learn to listen without judging. Because those who self-injure may have difficulty expressing their emotions, or fear or embarrassment about others’ reactions, it is important to encourage them to do so without judgment or negative responses.

Questions for your doctor regarding cutting

Preparing questions in advance can help patients and their families have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about cutting:

  1. Do you have experience treating people who self-injure?

  2. What type of therapy is most appropriate for me?

  3. Can you recommend a mental health professional who may help me?

  4. Are there other treatment methods I might benefit from?

  5. How soon after beginning treatment will I see improvement in my behavior?

  6. What do you think is causing my cutting?

  7. Do I have an underlying disorder that is related to cutting?

  8. Are any of my lifestyle habits contributing to my cutting?

  9. How can I prevent a relapse?
  10. I suspect a loved one may be cutting himself/herself. How should I approach him/her about getting help?

  11. I recently discovered that a loved one has been cutting. Should I be concerned that she/he may attempt suicide?

  12. Where can I go for additional resources on cutting?
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