Why is non-suicidal self-injury (NSSI, such as cutting, pill overdose, wrist banging) and bullycide (suicide that results from cyber or school bullying) so prevalent among victimized adolescents? Psychological research suggests that there is a kind of perfect storm that takes place in this age range that makes suicide the second leading cause of death for individuals aged 10-24 (see Center for Suicide Awareness).
To begin with, anxiety disorders, eating disorders, and depression regularly emerge during adolescence (Giedd, Keshavan, & Paus, 2008). It is at this vulnerable time that bullying tends to peak, with rates of school bullying (thankfully) falling across the high school years, and rates of cyber-bullying never changing (Eisenberg & Aalsma, 2005; and Schneider, O'Donnell, Stueve, Coulter, 2012). This is the perfect storm our youth face:
It is when they are the most vulnerable for depression/anxiety/eating disorders that they are the most likely to be the victim of bullying.
There is a third layer to this perfect storm: Disorders like depression and anorexia are associated with what are referred to as ego-syntonic symptoms. Ego-syntonic symptoms (like someone with depression cutting their body or a person with anorexia engaging in self-starvation) are particularly difficult to treat because the individual sees their behavior as consistent with and helping them achieve a particular goal (ego-dystonic symptoms, in contrast, would be those of PTSD). This can be understood intuitively with anorexia, as the act of self-starvation results in a salient, explicit outcome of weight loss, which the anorexic individual desires (despite anorexia having the highest mortality rate among psychiatric disorders). It is less intuitive to see how cutting is ego-syntonic, but this can be understood by marrying two seemingly unrelated lines of research: the physical-emotional pain overlap and pain offset relief.
Dr. Naomi Eisenberger, a social neuroscientist at UCLA, has found that social pain activates the same neural regions that are implicated in physical pain process. By having her participants play a game of Cyberball, she found that those who were eventually left out of the game by the other participants showed greater activation in their dorsal anterior cingulate cortex (dACC). The dACC is known to register physical pain/injury, but Naomi's research revealed that it processes our emotional injuries too. In essence, our brain lights up the same way when we step on a piece of glass in our kitchen as it does when our friend or lover says something inconsiderate or hurtful.
You may be wondering about the extent of this physical-emotional pain overlap. Well, Naomi found that individuals with a higher threshold for physical pain also had a higher threshold for emotional pain. Moreover, as part of the same study, she found that individuals who experienced social rejection during the cyberball game felt more physical pain (controlling for their initial pain threshold). Finally, when assigning one group of subjects to take Tylenol (a physical pain killer) for three weeks and another to take a placebo, the Tylenol group consistently reported fewer hurt feelings on a daily basis while the placebo group didn't change (this is in line with the use of antidepressant medication to treat physical injuries).
In the Tylenol study we see that something developed to remedy one kind of pain helps to attenuate the other. This is in line with Dr. Franklin Joseph's research on NSSI and Pain Offset Relief. Franklin's team found that the feeling of relief following the end of a physically painful stimulus was associated with temporary increases in positive emotions and temporary decreases in negative emotions.
Once again, something happening to us physically is associated with something happening to us emotionally. This is why exercise (while not necessarily painful) can help us feel better emotionally after a stressful day, why Tylenol for physical pain can help reduce social-emotional pain, and why antidepressants for social-emotional pain can help with physical pain. In essence, we see Naomi's research and Franklin's research working in a contrapuntal fashion.
So what makes cutting (or other NSSI) ego-syntonic?
Imagine someone you have watched harm themselves (if you you've never witnessed self-harm then picture a TV or movie character; perhaps Mia Kirshner as Jenny in The L Word). A gay student is bullied by gaycist peers at school and their dACC registers the emotional injury. When the student gets home, he cuts himself, which creates physical pain, and the ensuing relief (just as in the Tylenol study and with antidepressants) gives him a temporary increase in positive emotions and reduction in negative emotions. This is a very reinforcing outcome for the cutter, making it ego-syntonic in nature, and so difficult to treat that one clinical psychologist I questioned said she allows her patients to continue cutting during therapy. (She argued that, like smoking, it's more effective to discourage the behavior gradually than attempt to "cure" it overnight.)
Advocates for anti-bullying legislation have a strong case to make on mental health grounds, especially with ObamaCare finally providing mental health parity in 2014. There should be parity in disciplinary action for any kind of bullying, whether it results in physical injuries or emotional injuries. Emotional injuries don't heal with Neosporin. They can lead to self-perpetuating conditions (self-starvation, cutting), a hypo-cortisol awakening response (Ouellet-Morin et al., 2011), and more reports of pain disability and health problems for bullied kids (Knack, Iyer, & Jensen-Campbell, 2012). In short, "sticks and stone may break my bones but words will never hurt" is one of the most scientifically inaccurate phrases.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
If you're struggling with an eating disorder, call the National Eating Disorder Association hotline at 1-800-931-2237.
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