“Veronica” is a 15-year-old Caucasian girl who presented as a volunteer for a study of nonsuicidal self-injury. Veronica began cutting herself at age 13 in seventh grade after learning about this behavior from friends. After trying it once or twice, she said, she “was hooked.” Initially she cut herself on her forearms, but then switched to her upper thighs to conceal the injuries. Veronica’s primary reason for engaging in self-injury was to release built-up emotional pressure. Episodes typically occurred after an emotional conflict with her parents or a perceived rejection by a peer. The frequency of self-injury episodes ebbed and flowed, ranging from daily to monthly.
The diagnostic evaluation revealed that for Veronica, depressive symptoms began insidiously during middle school, and rose to meet criteria for a moderately severe episode of major depression when she was in eighth grade. Around that time, Veronica’s parents sought a mental health evaluation for her, where it was recommended that she begin weekly supportive counseling. However, Veronica did not feel “connected” to her therapist and attended only a few sessions. Her parents then brought her to their family physician, who prescribed fluoxetine. Veronica and her parents agreed that the medication led to a significant improvement in her overall depressive symptoms. However, she continued to engage in self-injury about twice a month.
Veronica’s medical and early developmental history was unremarkable. Her family history was notable for a history of depression for her mother and a history of alcoholism (with 3 recent years of sobriety) for her father. Her social history was notable for environmental stressors throughout childhood. Veronica’s parents described periods during her early childhood when the household was chaotic, characterized by shouting and occasional physical altercations between the parents or toward the children. There was no clear history of child abuse or neglect. Veronica’s parents divorced when she was in the fifth grade; since then, they have had joint custody of Veronica and her two siblings. Conflict between parents persisted even after the divorce. Additionally, Veronica described her older brother as being “mentally abusive” toward her, and reported that she argued almost constantly with her younger sister. Veronica’s history of peer relationships was characterized by instability and uncertainty, marked by occasional turmoil, which she referred to as “drama.” Veronica is now in the tenth grade at a large high school, where she has maintained a B average and currently has a moderately sized peer group consisting of relatively recent friendships.
Physical examination revealed an average height and weight and was notable only for scarring and some recent self-inflicted superficial wounds on her arms and legs. Veronica was pleasant and cooperative, forthcoming and direct in her communication style. She denied current suicidal thoughts. Results from a battery of self-report psychological assessments indicated only a mild level of depressive symptoms but significantly elevated levels of alexithymia, egocentrism, hostility, and interpersonal sensitivity. Several disturbances in emotion regulation were noted, including nonacceptance of emotional responses, lack of emotional awareness, and limited access to emotion regulation strategies.
Veronica was referred to the child and adolescent psychiatry clinic at the University of Minnesota. She was continued on fluoxetine and began participating in weekly individual, family, and group sessions in the dialectical behavioral therapy program. The initial focus of therapy was to address safety concerns. Nonsuicidal self-injury declined substantially within the first month of treatment, and ceased 2 months later. Veronica made significant gains in her ability to identify her emotions and to tolerate emotional distress. She utilized a variety of techniques to reach these goals and found that self-soothing strategies were particularly effective for regulating her emotions. Her interpersonal relationships matured, with an improvement in perspective-taking and an accompanying decrease in interpersonal sensitivity and hostility. However, family conflict persisted, so a referral was made for family therapy.