Study details little-known form of self-harm in teens
NEW YORK (Reuters Health) - A new study of children undergoing radiology treatment at one U.S. hospital points to what seems to be a little-recognized form of deliberate self-injury where kids embed objects ranging from glass to needles to wood under their own skin.
In a report published today in the journal Radiology, researchers describe the cases of 11 teenagers treated at their hospital to remove foreign objects that the teens had deliberately implanted through cuts in their skin.
The patients had implanted a total of 76 objects -- including paper clips, staples, pencil lead and glass fragments -- in what the researchers term "self-embedding behavior."
In recent years, the problem of "self-harm," particularly among teenagers, has received increasing attention in the media and in medical studies. Self-harm refers to deliberately self-inflicted injuries that are not intended to be fatal -- though there is evidence that people who self-harm have a significantly higher-than-average risk of eventually attempting suicide.
The spotlight has mainly been on the practice of "cutting," where a person uses a razor or knife to make cuts in the skin -- often, research suggests, with the goal of regulating unwanted thoughts and feelings (the physical pain may distract from emotional pain, for example).
There have, however, been some case reports in the medical literature of adults who perform self-embedding, as well as two reports of the problem in teenagers, according to the researchers on the new study.
This latest report, they say, appears to be the first to describe a series of teenage patients with self-embedding behavior -- and the first to detail the successful removal of the implanted objects with the help of ultrasound and/or fluoroscopic imaging.
Most parents are unlikely to know that self-embedding behavior exists, and the same is true of most doctors, said Dr. William E. Shiels II, one of the researchers on the new work and the chairman of radiology at Nationwide Children's Hospital in Columbus, Ohio.
The goal of reporting on this series of patients, he told Reuters Health, is to bring self-embedding behavior to the attention of parents and teachers, as well as pediatricians, ER doctors and radiologists -- the latter of whom may have a key role in diagnosing the problem, according to Shiels.
The findings come from a review of 600 patients at Nationwide Children's who were part of a long-term study of using imaging technology -- "real-time" ultrasound and/or fluoroscopy (a form of X-ray that provides continuous images on a monitor) -- to help remove small foreign bodies embedded in patients' soft tissue.
Most of these children had been involved in accidents. But Shiels and his colleagues identified 11 patients -- nine girls and two boys between the ages of 14 and 18 -- who were self-embedding.
In most cases, no one had known that the injuries were self-inflicted at the time the teens were referred to a radiologist for evaluation -- usually by an ER doctor or pediatrician who had seen the child for symptoms like skin inflammation and infection.
Conventional X-rays and ultrasound were used to identify the embedded objects; ultrasound, Shiels noted, can pick up materials that X-rays cannot, such as small fragments of plastics and wood.
Nine of the 11 teens had the objects removed via tiny incisions with the help of ultrasound and fluoroscopic imaging. The procedure was successful in all cases, according to Shiels, and left little to no scarring.
The study illustrates a "clear role" for radiologists for spotting self-embedding behavior, Shiels said. "We may become the first provider to make a clear diagnosis of it."
Of course, removing the objects is only the first step in treatment. The children's underlying mental health issues must then be addressed, Shiels said.
The 11 teenagers in this study had an established history of mental health conditions, including bipolar disorder, depression, and anxiety disorders like panic disorder and post-traumatic stress disorder. Ten of them admitted that they had at least thought about suicide.
Shiels said that parents, teachers and doctors should be aware of the potential signs of self-embedding, such as a pattern of unexplained cuts on the skin or a child's insistence on wearing long sleeves even in hot weather (as the arms are the most common site of the injuries). These behaviors should raise flags particularly if a child has a history of mental health disorders, he said.
There are not yet any estimates of how common self-embedding might be, according to Shiels.
There are, however, some figures on self-harm in general. According to a recent research review, studies suggest that 1 percent to 4 percent of adults have deliberately injured themselves, most often by cutting their skin. But up to 23 percent of teenagers admit to trying self-harm, again most commonly by cutting.
It is unclear, researchers say, whether self-harm is actually becoming more common, or whether adults are more reluctant than teenagers to admit to past or current self-harm.
Radiology, online September 7, 2010.
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