Blocking endorphins helps prevent self-mutilation

THE BALTIMORE SUN

Years ago, Boston University psychiatrist Dr. Bessel van der Kolk tried a simple experiment to understand one of the most disturbing, and bizarre, of all psychiatric disorders: self-mutiliation, or more simply, cutting.

He asked his cutters, mostly young women, to come see him when they felt the urge to scratch, slash or burn themselves. When they came, he asked them to put their hands in ice water. They were able to keep their arms buried in ice much longer than normal people, he found, because they didn't feel the pain.

Then, when he gave them an injection of a drug that blocks endorphins, the body's natural painkillers, they felt pain again "and with that, a sense of feeling alive," van der Kolk says.

To the uninitiated, cutting may seem like a suicide attempt or a cry for attention, and in rare cases that's true. In reality, cutters and psychiatrists say, the urge to self-mutilate is a coping behavior triggered by an inner sense of numbness or deadness. Far from a wish to die, cutting is a terrible urge to feel something, even physical pain, rather than nothing at all. And far from flaunting their cuts to get attention, cutters usually hide them.

The numbness that these teen-agers -- and some older cutters -- feel usually is triggered by overwhelming trauma, family conflict, sexual or physical abuse, emotional neglect and, perhaps, genetics.

No one knows how prevalent cutting is, nor why it seems to be on the rise, though in some schools, contagion -- kids copying one another's behavior -- may be involved. Nor do researchers know why roughly 75 percent of cutters are female, though one theory is that girls turn their feelings against themselves while boys attack others.

But researchers do know far more than they did a few years ago about what triggers cutting and how to help kids stop.

Cutting often overlaps with anorexia or bulimia. Roughly half of girls who cut themselves with pins, knives and razors start out with eating disorders, says New York psychotherapist Steven Levenkron.

Levenkron says most of his patients are white, perfectionists and, contrary to outward appearances, filled with self-loathing. "I never met a cutter who liked herself."

One way to help cutters is to teach them how to talk about their emotional pain so that they don't express it nonverbally. "I teach cutters a full vocabulary for feelings and mental pain," Levenkron says.

Cutting may produce transient good feelings by triggering a flood of endorphins, the endogenous opiates. In fact, many doctors do what van der Kolk did in his experiments -- give opiate-blocking drugs such as Naloxone or Naltrexone. By blocking the good feelings that cutting stimulates, cutters often stop because cutting no longer has the desired effect, says Dr. Alan Langlieb, a psychiatrist at the Johns Hopkins School of Medicine.

Some cutters, such as Lydia Gibson, 38, of Baltimore, who has been cutting herself off and on for 25 years, must take several drugs simultaneously. Gibson, who says she "had to hurt myself because I had to get the anger out somehow," now takes Buspar for anxiety, Paxil for depression, Naltrexone to blunt the positive effects of cutting, Depakote, a mood stabilizer, and Seroquel, a tranquilizer.

Not only do drugs and psychotherapy often work, cutting, perhaps surprisingly, is less dangerous than anorexia. Long-term outcome studies suggest that the mortality rate for anorexia is about 10 percent, says Dr. David Herzog, a psychiatrist at Massachusetts General Hospital. Long-term mortality data from women without anorexia who cut themselves is scant, but doctors say that, except for accidentally deep cuts, the risk of death from cutting is minimal.

Judy Foreman is lecturer on medicine at Harvard Medical School and an affiliated scholar at the Women's Studies Research Center at Brandeis University. Her column appears every other week. Columns are available on www.myhealthsense.com.

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