TORONTO - By any objective measure, the girl's upper arm was a mess. A painful, pus-filled swelling about the dimension of a paperback novel had brought the 16-year-old to hospital desperate for help.
X-rays and other imaging scans discovered the reason: buried just under her skin and into deeper tissues were 20 foreign objects, including a 16-centimetre-long straightened-out paper clip, a tiny screw from eyeglasses and 18 broken-off graphite pencil tips.
It was a wound the teen had inflicted herself.
“She made a cut and then just kept pushing these things in,” said Dr. William Shiels, head of radiology at Nationwide Children's Hospital in Columbus, Ohio. “And she had 20 fragments in her arm.”
Known as embedding, the behaviour is a severe form of self-injury - a particularly nasty notch up from the more common practices of cutting and burning.
Since 2003, Shiels and his colleagues have detected and treated self-embedded objects in 11 adolescents aged 14 to 18, two of them boys.
In a study published this week in the journal Radiology, the researchers describe removing 68 of 76 foreign bodies the 11 teens had burrowed into the flesh of their arms, hands, neck, ankles and feet.
The list of items reads like a hardware store's product line: metal, glass, wood, plastic and stone.
“One girl actually took the teeth from her comb, broke them off and embedded those,” Shiels said in an interview from Columbus. In other patients, the radiologists found chunks of crayon, a plastic fork tine and a nail-polish wand.
Beyond the obvious danger of infection, the presence of foreign bodies can lead to keloids - raised and red fibrous scar tissue caused by excessive tissue repair. And then there's the potential for unrelenting pain.
“A bee sting can be painful or just a small infected pimple can be painful, but magnify that 50 times,” said Shiels, referring to the 16-year-old with the severely infected arm.
When he asked the teen why she had embedded the unfolded paper clip and other objects, she explained she was “just having emotional difficulties with life,” said Shiels.
“The most common reason that we hear for this is it's a way to release the pain that's inside. So they have emotional pain inside, they have emotional trauma in their lives.”
Often these children have suffered physical or sexual abuse and are unable to deal with the psychological fallout, he said. “So they have a need to externalize or concretize the pain, and they make it real.”
“They convert emotional pain into physical pain.”
Dr. Wendy Lader, a psychologist who co-founded a treatment program for cutters and other self-abusers called S.A.F.E. Alternatives based in St. Louis, Mo., agreed with the authors that adolescents who practise embedding tend to have serious mental health issues.
“In my experience of people I have worked with who tend to embed, they do seem to have more psychological disturbances ... than kids who are self-injuring in general, who are doing delicate cutting, so to speak,” she said.
The study found the teens exhibited symptoms of one or more of a variety of psychological illnesses, among them bipolar, anxiety and borderline personality disorders, and clinical depression.
Doctors aren't sure how common embedding is, but one study of U.S. college students found a staggering one in five had engaged in some form of self-injury on at least one occasion. Seventy-five per cent of those were repeat self-abusers.
When Shiels's team first reported on their cases at a medical meeting in late 2008, some people thought self-embedding was a sporadic occurrence that didn't go much beyond Columbus.
But that's far from the case, he said. “Every city we've spoken to health professionals in has had at least one or two cases. When we started reporting it, we started getting people from Saskatchewan that said, 'Oh, we've had cases of this before,' or we've had people from Toronto. So we know that it is occurring in other cities.”
Like other forms of self-injury, embedding is not a new phenomenon, said Lader, noting that there were cases in the mid-1890s of women diagnosed as hysterics sticking pins in their bodies.
What has changed, it seems, is the age at which such behaviour begins.
“I think we are starting to see more of these things in younger populations,” she said. “Self-injury itself used to be an obscure psychiatric symptom and now it's becoming a more mainstream way of coping.”
“My concern is the more something becomes more mainstream, then people need to find more graphic or outstanding ways (of self-harm): 'Self-injury doesn't work very well any more, maybe I'll try embedding.'
“It is still a pathological way of dealing with feelings.”
Lader speculates that rapid changes in society in the last several decades - higher divorce rates, more blended families, the Internet and digital communication - have left many young people feeling alienated.
“They want to believe that somebody cares about them, that they have a connection. And I don't know that kids today are sure that anybody cares about them. And this is a way of coping with that.”
Shiels believes that for most adolescent embedders, seeking treatment is a cry for help beyond their physical injuries.
Pediatric psychologists or psychiatrists can provide counselling and mediations to help teens deal with the emotional wounds underlying their compulsion for self-inflicted harm, he stressed.
Using X-rays and other techniques, radiologists can detect foreign bodies and use guided ultrasound imaging to remove the objects that leave scars “no bigger than the size of a freckle” and don't damage surrounding nerves, blood vessels or tendons.
He said parents, teachers and primary-care physicians should be on the lookout for signs of cutting or embedding - the sharpest knife is missing from the kitchen or an adolescent wears long sleeves in summer.
“If the child comes down and has unexplained cuts or unexplained scratches, instead of just assuming that your child couldn't be cutting, dig into it and engage. If we're aware, we can engage with our children in the process of healing and that process can occur.”