'Cutting' Elevated From Symptom To Mental Disorder

Cutting has been around for centuries and is best understood as a form of self-help, however misguided. People who cut, or intentionally injure their skin, often say it helps them relieve tension.

Up until now, cutting has been categorized as a symptom of borderline personality disorder — an illness marked by unstable moods, impulsive actions and chaotic relationships. The problem is, the majority of those who cut don't have borderline personality disorder. And under the current diagnostic guidelines, sometimes a doctor who first sees the patient, say in the ER, might confuse cutting with a suicide attempt.

Reworking The Book Of Mental Disorders

When clinicians see a patient with mental health issues, part of their job is to determine if the patient is experiencing temporary emotional struggles or if the patient has an illness. To do this, doctors rely on the bible of psychiatry, a book called the Diagnostic and Statistical Manual of Mental Disorders. The DSM lists all the mental disorders recognized by the American Psychiatric Association.

The book is also used by insurance companies to decide which treatments they'll pay for, and by courts to help determine insanity or other mental conditions.

The APA is releasing a new draft of the DSM Wednesday, the first major revision since 1994. This latest version of the book, the DSM 5, proposes some significant changes to the following disorders:

But cutting is rarely related to suicide, and researchers haven't been able to trace it to any one disorder. For instance, it can show up among those who have eating disorders, substance abuse problems, anxiety or depression, says Dr. David Shaffer, chief of the division of child and adolescent psychiatry at Columbia University Medical Center.

That's why the working group behind the latest draft of the psychiatric community's diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders, wants to elevate cutting from a symptom to a disorder, which would be called nonsuicidal self-injury.

The conflation with suicide is perhaps one of the most harmful misconceptions surrounding the behavior.

"We know that cutting accounts for far fewer than 1 percent of all suicides," says Shaffer. "And one of the characteristics of this disorder is that it's repeated very, very frequently, so presumably a young person knows it's not going to kill them."

The behavior is commonly, though not always, done by children and teens, and most grow out of it, says Shaffer. Cutting drops off dramatically when the kids reach age 16 or 17, he says.

"The main reason we worry about it being regarded as a suicide attempt is that it often leads to quite inappropriate management," says Shaffer. For example, a common response is to admit a teen who is cutting to the hospital. But there's not much evidence this does any good in most cases, says Shaffer. And psychiatric admission to the hospital exposes the child to other youths with more serious conditions, is costly, and will give the teen a lasting record of having a psychiatric admission, he says.

Making cutting a disorder and giving it a category in the DSM could help clarify the condition. It also could bring more attention to the disorder, and more research, says Shaffer.

"On the whole, treatment [for cutting] is ... unsystematic and really quite poorly developed, partly because it's been so cloaked in other diagnoses," says Shaffer.

He says the new categorization will be a way to separate out kids whose behaviors are of greater concern.

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