«Nothing relaxes as quickly as self-inflicted pain»

Mr Köhnlein, self-harm among young people is on the rise in this country. How many boys and girls are affected?

One in four young people has experience of self-harm. That is a huge number. But you have to look at this phenomenon in a differentiated way. Many only do it once or twice. A boy or girl tries it out, cuts themselves with a razor blade or burns themselves with a cigarette, perhaps because the others in their circle of friends do the same - and soon stops doing it again because it doesn't help them. However, around a quarter of those who try it repeat it again and again. And these cases, which worry us, are on the increase. That's right.

What do you say to a mother whose ten-year-old daughter is constantly biting her fingernails? Is that the beginning of self-harming behaviour?

Without knowing the girl, I would say no. With a ten-year-old, nail biting may be nothing more than auto-stimulation - perhaps because she wants to generate more stimuli or because she is exposed to too many stimuli and nail biting calms her down. However, the boundaries are fluid.

I have a teenage patient who keeps scratching her whole body, even her face, and inflicts countless wounds. She says she can't do anything else, but doesn't have the impulse to hurt herself. In this case, the self-harm has a compulsive character. What is relevant for the distinction is whether there is an intention to harm oneself and inflict pain.

When do we start talking about self-harming behaviour?

In principle, everyone more or less injures themselves. Tattooing, piercing your ears or depilating your legs are also self-harming behaviour. However, by definition, four factors must be fulfilled in order to speak of self-harming behaviour.

What are these factors?

It must be an act that - unlike tattooing or ear piercing - is not culturally accepted, and there must be damage to the body. Furthermore, these acts must not be committed with the primary intention of killing oneself, otherwise it is a suicidal act.

Self-harm always fulfils a purpose, it is never unintentional.

It would therefore be correct to speak of non-suicidal self-injurious behaviour (NSSI). The fourth aspect is that self-harm always fulfils a purpose that supposedly cannot be fulfilled in any other way, so it is never unintentional.

What purpose can there be in inflicting pain on yourself?

We recognise two motivations: one is intrapsychic and the other is interpersonal. The intrapsychic motive is primarily about regulating emotions, for example to relieve pressure or stress. The pain is good for me, seeing the blood flowing grounds me. I have my life under control. Or I want to punish myself with the pain. It is no coincidence that bullying is one of the main motives for self-harming behaviour.

In what way?

As a victim of bullying, I am constantly being hurt and insulted by those around me. At some point, I make it my own and think: I'm just a failure and don't deserve it any other way. In this case, the scratching serves as self-punishment. With such intrapsychic motives, the behaviour is usually very shameful and the wounds or haematomas are hidden. These young people come to school wearing long trousers or sweatshirts, even in summer. The interpersonal motive is quite different, where a young person wants to communicate something to those around them by self-harming.

Please give us an example.

One of my patients was sexually abused by her father over a long period of time. She wanted to show him with her cuts: You did this to me! She also used them to make contact with her mother. She knew that when she came to her mother, a doctor, in the kitchen with her incisions, she would be cared for and lovingly looked after - in an otherwise emotionally cool parental home. She said: «In those moments, I could talk to my mum really well.»

Many young people who are in great need say it does them good when blood flows.

Another patient put her bloodstained bed linen in the laundry basket to draw attention to her emotional distress. Her mother washed and ironed them for weeks without mentioning it to her daughter. She was probably - as the teenager interpreted it - simply overwhelmed by the situation.

What are the most common forms of self-harm?

There is nothing that does not exist, but scratching or cutting is by far the most common. Many young people who are in great distress say that it does them good when blood flows. They therefore have to cut as deeply as they can until there is enough. But there are also other cases: Burns from soldering irons, irons, flames, cigarettes, injuries including broken bones from blows or bruises, and the most serious injuries from acid.

Cutting with sharp instruments - scalpels, Japanese knives - can lead to near amputations and other mutilations. I once had a patient who knew exactly how much painkiller she needed to take in order to get a headache but not end up in intensive care with liver failure. She didn't want any more scars on her arms and therefore found this «solution» of hurting herself.

So it's more about the pain than the permanent mark.

That's right, the mark is actually rather shameful. But the actual damage to the body, the generation of pain - preferably in connection with blood - is very important. Nothing else seems to relax so quickly. Afterwards, however, most young people quickly experience a feeling of shame and fear of being discovered.

Then the wounds are concealed.

Exactly, because the young people are overwhelmed by their own actions. What was I doing there? But it was remarkably good. A classic intrapsychic motive. But then the young people think: I definitely don't want it to be discovered. When asked about this, a typical explanation is: I fell into a bush or the cat scratched me.

After self-harming, most young people quickly develop a feeling of fear of being discovered.

But at some point they usually want it to be discovered in order to draw attention to their distress - that would then be the interpersonal motive. Or they simply don't care that the wounds are visible.

Is suicide the most extreme form of self-harm?

What is certain is that self-harm is a major risk factor for suicidal behaviour. Those who have repeatedly self-harmed in the past are up to 40 times more likely to commit suicide. On the other hand, self-harm often serves as a strategy to avoid killing oneself. This is referred to as partial suicide. Self-harm is a kind of protective compromise to avoid killing oneself. However, if this behaviour is not addressed and treated, it can ultimately lead to suicide.

So the self-harming behaviour increases.

At least that happens very often. Because you get used to the pain and it no longer relieves you as much as you would like, the injuries become more serious over time. This phenomenon is called tolerance development. We are also familiar with this from addictive behaviour - I need a higher and higher dose to feel an effect.

Is self-harming behaviour always associated with a mental disorder?

No, the causes are by no means always psychopathological. Around a third of young people who repeatedly self-harm are not mentally ill. But it depends on how you define «psychopathological». There is a state of tension that one cannot withstand, for example in stressful family situations.

When wounds are shown openly, that is already a message.

The parents are constantly arguing, the son sits in his room and can't stand the shouting any longer. Gaming no longer helps him, so he cuts himself. Of course, you could say that self-harm is a reaction to acute stress, but a real psychiatric illness, such as a personality or developmental disorder, obsessive-compulsive disorder, depression or anxiety disorder, is only present in around two thirds of cases. The causes are not always pathological.

But what?

For example, some young people want to show that they belong to a certain group or to set themselves apart from their parents: look, I'm no longer a baby, my skin is now damaged. This intention does not correspond to a mental disorder, but is part of development, even if the means chosen are not «normal».

At what age does self-harming behaviour begin?

The age shifts downwards a little, but not very quickly. Statistically speaking, the typical starting age is 13 to 14 years, peaking at around 15 to 16 years, with the rate dropping again from the age of 17.

What role do social media play?

Of course, Tiktok, Instagram, YouTube and others play a major role. Boys, and girls in particular, use these networks and see pictures or even videos of their peers scratching themselves, which may give them the idea to try something like this. And if it brings them relief, then they will most likely repeat it.

I once asked a teenager how she had come across the scoring, whether she had seen it anywhere. She denied my question. The idea had just come to her. I don't really think that was true. You need role models for this behaviour. And these are more easily accessible today.

So more girls are affected than boys?

Around a third of young people who self-harm are male. But you have to be careful. Boys often injure themselves in a way that is easier to hide. For example, they are more likely to bruise themselves and credibly explain to their parents that they have fallen. I have also seen some boys who have scratched themselves above the T-shirt arm line. Where you can't see it when they're dressed, even in summer. Boys are also less likely to seek help.

According to the Federal Statistical Office, 3124 patients between the ages of 10 and 24 were hospitalised for self-harm or attempted suicide in 2021, an increase of 26% compared to 2020. What do you attribute this development to?

We have already discussed the greater prevalence of self-harming behaviour due to social media. Many experts also see an increase in social pressure and the associated uncertainty. Against the backdrop of current crises such as the coronavirus pandemic, the war in Ukraine and global warming, this may be true. In principle, however, I would be cautious with this statement.

As a rule, I have a lot of faith in the intuitive expertise of parents.

Every generation has had its challenges and crises and has had to find a way to deal with them. Personally, I don't believe that today's young people are any more stressed than those 20 or 40 years ago.

Do you have another explanation?

Self-harming behaviour is another way of dealing with pressure, stress, trauma or anxiety - but all of these factors have also existed in the past. At the end of the 19th century, fainting was a way of expressing that one was in some way psychologically over-excited or stressed. After the economic miracle years, eating disorders emerged. And while the number of eating disorders - apart from the pandemic years - has only grown moderately in recent decades, self-harming behaviour has increased sharply since the 1980s and 1990s.

How do I react correctly as a parent if I discover scratches or even cuts on my teenager's forearms?

I would not address these injuries immediately, but I would observe them. Have these wounds healed after four to five days? Or are they still fresh or are new ones appearing? If such wounds are shown openly and not hidden, this is already a message and a request: Look! As a matter of principle, such behaviour must be addressed. Before I address it, I would think carefully about how I do it so that I don't just impulsively walk all over my teenager.

Let's say the wounds remain: How do you address this properly?

I would take the physical symbol, the wound or scar, as an opportunity to express my concern: «You, I've noticed for a few days that you are injured. What happened there? I'm worried about you, what's going on?» Then the teenager usually says: «Oh nothing, leave me alone.» - «Well, it's a bit difficult for a mum or dad to leave you alone when something like that happens, because I don't want anyone to hurt you, not even yourself.»

The depth of the wound correlates with the depth of the distress.

I would also insist that you show the injuries to the paediatrician: «I could imagine that the area could become infected and then it would look bad afterwards. Let the doctor have a look.» Or more emphatically: «I want a doctor to look at it.» The paediatrician will take the child aside and say: «How did that happen?» If the child admits to their behaviour, a sensitive doctor will say: «Maybe you sometimes feel under pressure, can you talk to someone about it?» Otherwise, the paediatrician may say: «Okay, please come back next week for a check-up.»

So parents should express their concerns.

Absolutely! But without judging or even condemning the child's behaviour. You always have to remember that: No matter what strange behaviour children and young people display, it is always the best possible behaviour from their point of view - and this is how parents should view and respect self-harming behaviour: As a solution approach, an intermediate step for something for which a better solution must be found.

When does self-harming behaviour need to be treated?

It is said that the depth of the wound correlates with the depth of the distress. If a child scratches itself superficially no more than three times a year, there is not much to worry about. More recent classifications even speak of five times a year. If it occurs more frequently or the damage becomes more serious and this behaviour cannot be plausibly explained, the paediatrician should be consulted. Further steps can then be discussed with the paediatrician.

The paediatrician is therefore always the first port of call for mental health problems.

That's right. Parents are sometimes much more alarmed than they should be. And paediatricians, unlike parents, don't just see one, two or three children, but three hundred to five hundred and are better able to assess what is normal. For example, it is also normal for a young person to get drunk or smoke pot from time to time.

Even if, as a psychiatrist, I don't think much of this behaviour, it is advisable for parents to be defensive and «watchful waiting» to a certain extent, i.e. to observe carefully and wait and see. As a parent, I can allow such behaviour to a certain extent, but I don't let it out of focus.

And when should you start to worry or seek a professional assessment of the situation?

Of course, this depends on the age of the child, but basically I would say: If the injury is serious, anyway. Otherwise, whenever I can no longer explain the behaviour or can no longer calm myself down - or if the behaviour is so deviant that I can no longer classify it in the broad area of «normality», even if this is of course quite subjective. As a rule, I have a lot of faith in the intuitive competence of parents, and if they are unsure, they should ask the paediatrician. And in many cases, the paediatrician can give the all-clear.