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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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ShrinkTime (TM)


Question:
My 17 year old daughter has been offered anti-depressants, but she doesn’t want to take them but wants me to help her stop cutting herself. What she really wants is for me to take away the feeling of wanting to–I don’t know how to help her. Any advice? G.

Answer:
My first piece of advice is that we need to tease apart several different issues that are woven together in your question: 1) your daughter is cutting herself, 2) she has been offered or prescribed antidepressants, 3) she doesn’t want to take them, 4) she wants you to change how she feels, and 5) you have an intense feeling of wanting to help her but don’t know how. Let’s address these one at a time.

First of all, cutting is not a psychiatric illness, it is a behavior that usually indicates that a person feels distress of some type. I am assuming from your question that your daughter’s cutting is not life threatening and is not an effort to kill herself – if it is or becomes so she will require emergency assessment and intervention immediately. Cutting can occur in the context of many different psychiatric conditions and stresses, and the roles of medication and other therapeutic interventions will depend upon those conditions and stresses. Therefore, the first step that is needed is a thorough assessment of the situation to include when this behavior started; what are her inner experiences and thought before, during, and after cutting; what behaviors on the part of her or others reinforce it; whether or not your daughter has a diagnosable psychiatric disorder; what are the current stresses in her life; whether she is using alcohol or drugs; and whether she has medical problems that are relevant to her emotional state. Such an assessment requires a mental health professional.

With regard to taking medications, it makes a big difference whether one has been prescribed medications, or whether medications have been merely “offered.” To me, prescribing a medication means that there is a diagnosis of a disorder to be treated and evidence supporting the use of the prescribed medication for that disorder. Prescribing a medication means strongly recommending taking the medicine based on the likelihood that the medicine will relieve symptoms being significantly greater than the likelihood that it will make symptoms worse or cause problematic side effects. Antidepressants of different types have been demonstrated to be effective in several conditions, including depressive disorders, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, and certain disorders of impulse control. There are also psychotherapeutic interventions for these conditions that may be very reasonable therapeutic alternatives for these conditions. Thus, my advice to you regarding medication issues is to first clarify whether your daughter has been diagnosed to have a psychiatric illness, and whether the drug has been prescribed as likely to benefit that condition, or whether the drug has been merely “offered,” as in “try this, it might help.”

There is no specific drug that stops cutting or takes away the feelings and thought patterns that lead to it. Antidepressants sometimes help relieve inner feelings of depression, frustration, and tension that can drive some people to cutting and other self injury behavior. Also, certain antidepressants can decrease obsessional thought patterns that may lead to self-injury. But because self injury occurs in many conditions, I cannot comment on the appropriateness of antidepressants for your daughter without more information.

With regard to your daughter not wanting to take the antidepressant, there are various reasons people don’t want to take such drugs, which include fears of side effects, stigmatization, the hope one can overcome one’s illness by other mean, and fear that medication will “control” one’s thinking and emotions. One of the dynamics sometimes seen in people who self injure is that they feel a lack of control in key areas of their life, and the self injury becomes something they can control. If this is the case, getting into a power struggle with someone about whether they take a medication will only be counter-productive. If someone with such control issues sees taking medications as others imposing control upon them, they will resist, and the medications are unlikely to be of benefit.

I would like to address next your comment that “what she really wants is for me to take away the feeling of wanting to (cut),” and that you don’t know how to help her. Your language indicates that you and/or your daughter wish for you to change how she feels and acts. I may be reading too much into your short letter, but if this is the case, your taking on the responsibility of trying to change her feelings and behavior is a prescription for failure, as it would be for trying to take on the responsibility for any behaviors by a 17 year old. In order for your daughter to change her patterns of behavior and thinking, she will have to take responsibility for them. You can only be responsible for your responses to her behavior, such as getting her into treatment and how much and what kind of attention she gets for this behavior. Parents and professionals need to find a balance of acknowledging and attending to a person’s distress on the one hand, yet being careful not to inadvertently reinforce self injury behavior by responding in a manner that rewards this behavior. Because finding this balance is often difficult, it is usually necessary for patients with self injury to have this problem treated by mental health professionals with experience in this area.

Please feel free to follow-up with more detailed information in response to my questions about diagnosis, medication offered, and your daughter’s reasons for not wanting to take medications.

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Disclaimer: The information contained here is not intended nor implied to be a substitute for professional advice relative to your specific medical or mental health condition or question. ALWAYS seek the advice of your physician or other health provider for any questions you may have regarding your medical or mental health condition. Information provided here DOES NOT constitute a doctor-patient relationship between you and the column author.

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