A 16-year-old girl is brought to the emergency department by her parents after they found razor blades hidden in her room and noted several scratches on her forearms. The girl says, "My parents are always overreacting to stupid things and when I really need them, they're always busy. It wasn't like I was trying to kill myself or anything." The parents note that their daughter is always moody. They have noticed that she frequently wears long sleeves and don't know how long she has been cutting herself. They are also concerned that she frequently binges on junk food and then starves herself for a few days afterward. They suspect that she may be forcing herself to vomit. The girl has no medical problems and no prior psychiatric history. She has tried alcohol and marijuana at parties but does not use them regularly. When interviewed alone and asked about depression, she says, "I just hate everything in my boring life. I wasn't trying to kill myself. I just feel like cutting when I am upset about something. I know a lot of kids who do it." She has no thoughts of suicide currently, although she has previously wished that she were dead after breaking up with her boyfriend and sometimes thinks about how her parents and friends would react if she were dead. Vital signs are stable. Physical examination is normal except for multiple scratches and superficial lacerations in various stages of healing on both forearms. Her parents are very concerned. Which of the following is the most appropriate statement to make to the parents at this time?

Question

A 16-year-old girl is brought to the emergency department by her parents after they found razor blades hidden in her room and noted several scratches on her forearms.  The girl says, "My parents are always overreacting to stupid things and when I really need them, they're always busy.  It wasn't like I was trying to kill myself or anything."  The parents note that their daughter is always moody.  They have noticed that she frequently wears long sleeves and don't know how long she has been cutting herself.  They are also concerned that she frequently binges on junk food and then starves herself for a few days afterward.  They suspect that she may be forcing herself to vomit.  The girl has no medical problems and no prior psychiatric history.  She has tried alcohol and marijuana at parties but does not use them regularly.  When interviewed alone and asked about depression, she says, "I just hate everything in my boring life.  I wasn't trying to kill myself.  I just feel like cutting when I am upset about something.  I know a lot of kids who do it."  She has no thoughts of suicide currently, although she has previously wished that she were dead after breaking up with her boyfriend and sometimes thinks about how her parents and friends would react if she were dead.  Vital signs are stable.  Physical examination is normal except for multiple scratches and superficial lacerations in various stages of healing on both forearms.  Her parents are very concerned.  Which of the following is the most appropriate statement to make to the parents at this time?

Quizplus · Accepted Answer

Explanation: This patient exhibits cutting behavior, a form of nonsuicidal self-injury. Nonsuicidal self-injury is often used to cope with distressing affective states and is common in adolescents and young adults. It is seen in a wide range of disorders, including borderline personality, eating, and dissociative disorders, and in patients with developmental disabilities. It may also occur in patients who do not meet criteria for a major psychiatric disorder. It should be distinguished from suicidal behavior (an act performed with some intent to die); however, these patients are at increased risk for suicide attempts. Cutting behavior frequently occurs impulsively and is preceded by feelings of numbness or intolerable tension. The individual typically experiences a sense of relief and minimal pain when performing the act. The most appropriate intervention is to reassure the parents that their daughter does not appear to be in imminent danger but needs a thorough psychiatric evaluation to identify any underlying conditions. Although the patient exhibits some features of borderline personality disorder (impulsivity, mood lability, anger) and an eating disorder (binging and purging), making these diagnoses or recommending treatment is premature (Choices A and E). If psychiatric evaluation confirms the presence of these disorders, treatment interventions, including family therapy, dialectical behavior therapy, and fluoxetine for bulimia nervosa, should be considered. (Choice B) Although this patient has risk factors for suicide, she does not appear to have any active suicidal ideation (no thoughts of suicide currently), intent ("I wasn't trying to kill myself"), or plan that would require inpatient admission at this point. (Choice D) Although family therapy might be helpful in this case, she might need additional treatment, including individual therapy and/or medication. The first step is a psychiatric diagnostic evaluation that will help guide treatment. Educational objective: Although commonly associated with borderline personality disorder, cutting behavior is a nonspecific psychiatric symptom seen in adolescents coping with distressing negative affective states. Initial management of adolescents with nonsuicidal self-injury should include screening for suicidal ideation and comprehensive psychiatric evaluation. References: Non-suicidal self-injury: a review of current research for family medicine and primary care physicians. (http://www.ncbi.nlm.nih.gov/pubmed/20207935)

A 16-Year-Old Girl Is Brought to the Emergency Department by Her