In a 1995 appearance on the BBC, Great Britain's Princess Diana disclosed that she was so unhappy with her marriage to Prince Charles that she cut her arms and legs.

Celebrities Fiona Apple, Johnny Depp, Angelina Jolie, Courtney Love and Marilyn Manson also admitted in magazine interviews that they deliberately hurt themselves by cutting or burning their flesh.

Mental health professionals call that self-injurious behavior, or SIB, and many believe that its occurrence rate is approaching that of eating disorders.

SIB is so prevalent in the area that registered nurse Judy Welty, coordinator of Child and Adolescent Inpatient Services at Latrobe Area Hospital, has given in-service programs at several schools and is developing a community service project to address the issue.


"About five years ago, self-mutilation was something that you would see occasionally," she said. "Now it's something that we see on a daily basis. I'm not sure if you would call that an epidemic, but it certainly is out of control."

Psychotherapist Robbie Greenfield, in practice since 1996, also has seen an increase in cases.

"That means that more people are coming for help, and more are doing it," she said.

At Beyond Therapy, in Greensburg, she and her partners, licensed social worker Elvira Fisher, and Brandie Stewart, a board-certified art therapist and licensed practical counselor, have treated a number of young people with SIB, some of them referred by school counselors or through foster-care agencies.

There are many degrees of self injury, from scratches inflicted with plastic forks or paper clips, to more damaging cuts with knives, pins, razor blades or other sharp objects.

Some people burn themselves with cigarettes or lighters, scrape their skin off, pick at healing wounds or pull out their hair.

While the injuries are not actual attempts at suicide, Dr. Douglas Ramm, a Greensburg psychologist who has worked with adolescents since 1974, cautions that SIB is serious.

"If a person who is doing this self-mutilation is not getting effective intervention in dealing with whatever the underlying problem is, they do become hopeless; and that's where they begin to become a suicide risk," he said. "If it's not dealt with appropriately at this level, it often does slide into a way of thinking that is much more dangerous."

SIB crosses all social and economic lines, usually begins in adolescence and may continue through the 20s or later. Females outnumber males, who are more likely to lash out aggressively to deal with despair or hostility.

"This whole business (with SIB) is that they're unhappy and that they're trying to get happy by cutting themselves, which is pretty self-defeating," Ramm said. "The underlying or interpersonal issues cause the unhappiness, and they'll continue to do it as a way of obtaining some relief.

It's an escape like any other addiction. It's a way of getting their minds or thoughts off of what's bothering them."

According to mental health professionals, people hurt themselves for many different reasons.

They may have experienced physical or emotional trauma, or have been physically, emotionally or sexually abused. There could be unbearable tension in the home, or the parents are negligent or overwhelmed. Some victims abuse themselves to protect against a more frightening dissociation experience.

Self-mutilation often is accompanied by other mental health issues such as depression, anxiety, eating disorders or borderline personality disorders.

Some victims just feel so unworthy that they want to punish themselves.

"Someone who was abused is reacting to previous abuse because they've been taught that certain behaviors are punishment," Greenfield said. "Even though they've been abused, they turn around and do it to themselves, and in this self-punishment, they are being critical of themselves. Or they may have never developed the ability to feel or express their emotions as others do, or they may not have been allowed to show their feelings. So the cutting, bruising and scratching allows them to have concrete evidence of intangible emotions."

While outsiders may trivialize the triggers, patients perceives the circumstances as significant because they can't deal with them.

"They may have problems in a romantic relationship, or difficulty with their peers, and that's especially true with girls where there's a fair amount of conflict and body issues," Ramm said. "You may get a reasonably bright kid who is failing academically and they start to feel guilty about that, or maybe they're around parents who are continuously disaffirming."

SIB patients who feel out of control may harm themselves as a way to gain control. Or they try to calm stress with the rush of endorphins the body releases in response to pain.

Ramm had one patient who cut herself hundreds of times with a razor blade. She told him: "This makes me feel better because at least now I know where I hurt."

Some patients injure themselves where it shows or inflict wounds serious enough to need medical attention. They may end up in a hospital emergency room and then be referred for mental health treatment.

Others hide their injuries under clothing and hurt themselves repeatedly long before anyone realizes what's going on.

"Parents are frequently surprised when they find out what's happening, though part of the intentions may be to get the parent's attention," Ramm said. "That's not to say that the parents are necessarily negligent, but the child may have no other way of communicating."

Many therapists blame that gap on contemporary lifestyles in which divorce, career commitments or overbooked schedules leave families little time to talk or to sit down together at the dinner table.

Some SIB patients admit to being influenced by celebrities who self-injure. There's also pressure to fit in with peers who are doing it.

"I think that kids are talking a lot about this in school, and in a way, it's a fad," Ramm said. "But you have to go into the psychodynamics of it, of why anyone would copy something like this. It's not like copying ear piercing. I think there's always an underlying problem, even when it's a copycat."

Ramm counsels patients with some of the same philosophy he uses in his "Facts of Life" program, aimed at teaching juvenile offenders how to make the right choices to improve their lives. That concept also is the focus of his recently released book, "The Formula For Happiness."

At the Latrobe Area Hospital program, patients are given a "No Harm Contract" in which they pledge to remain free of self injury.

"Then we give them grounding techniques, things to do that might help, like a card saying that they're not going to cut, and the reality that 'I am safe.' They can look at the card and say over and over again, 'I feel safe.' This makes the present moment more powerful. We also do some role playing in which they confront the person who maybe has neglected them. They need to be able to assert themselves and their needs and their thoughts."

Patients are encouraged to write in journals or listen to calming music. If the urge for a destructive act becomes overwhelming, they are advised to put ice on their hands for an extended period of time.

"That sensation of physical pain when they cut and burn themselves takes away the emotional pain they're feeling," Welty said. "Using ice takes the place of cutting and it won't do any permanent damage."

Greenfield also teaches diversion tactics.

"We may use imagery or hypnotism or have them carry something that makes them feel safe, and they can rub it instead of cutting themselves," she said. "We teach them how to handle anxiety and to understand the reasons that they're hurting themselves and what it does to themselves and everyone around them."

Underlying mental health issues may require extensive individual and or family counseling. Sometimes drug therapy is recommended, especially if the patient is causing great physical harm.

But even less serious incidents should be considered potentially dangerous.

"Self-injury," Ramm said, "is a cry for help."