My Thoughts

Thank you for this. It’s a really good question. First off, I’m glad that you are getting treatment. Given that you’ve been in therapy for over a year and now you are trying medication, you are clearly trying really hard to make something happen for yourself. I’m proud of you for that and I’m sorry to hear that you are not quite in a comfortable place yet. It sounds like you are basically saying that you have always had a tendency toward self-harm and have tried to stop, but the way the antidepressant is making you feel, which is somewhat numb or disconnected, is a trigger for you to cut. I definitely see the concern here and I think it’s great that you’ve been able to recognize this pattern. I think that the work you are doing is paying off in terms of self-awareness. So, I’m glad you’re bringing this up. There’s a good chance that you need to adjust or discontinue the medication, but let’s make sure you are not doing this on your own. I’m not trying to give you medical advice here – you need to work with your providers.

Can antidepressants have a negative impact?

There are a small subset of people that have increased risk of suicide as a side effect from taking antidepressant medications. It’s not totally clear why, but it might have something to do with the fact that people who have been depressed and suicidal suddenly have energy and motivation to “do something about it.” Your case is a little different. I’m not sure if your self-injury is typically tied to suicidality, but there are a lot of people that engage in non-suicidal self-injury where the intention is actually to cope with life rather than to escape from it. From the way you phrased your question about self-injuring due to feeling numb, it sounds like you might fall into this camp. Rather than trying to exit the world, self-injury can be a way for you to ground yourself and return to reality when you are feeling dissociated. Unfortunately, it’s not a sustainable coping method and there is so much risk for serious harm or accidental death. If you are not working with a psychiatrist, I would highly suggest you do so. No offense to primary care physicians, but this would likely be out of their depth. A psychiatrist has specialized training to know the nuance and have a more comprehensive approach to medication management. At this point, you are getting the full effect of the antidepressant. You said that you’ve been taking it for a few months. It takes about one month to ramp up. So, what you’ve got is probably what you will continue to experience.

I took a guess at the function of your self-harm, but I do think it’s important for you to consider that. Why do you self-harm? What is the purpose or intention behind it? If I was wrong and you are feeling imminently suicidal, you need to talk to your providers right away or if it’s urgent, call your local resources. Your feeling that antidepressants are not for you could be correct. However, there is more than just a yes or no answer here. For example, an SSRI might not work well for you, but an SNRI or other type of medication might. It could be that some trial and error is necessary.

Finding the right combination

One of symptoms of depression that may be contributing to the feelings of numbness might be anhedonia, or inability to feel. If you are feeling unmotivated, disconnected, and blank, it could be that the anhedonia is the primary symptom to target. As I mentioned, there are different kinds of medications. One is called Wellbutrin or bupropion, which tends to help people feel more energy and motivation. There is also a therapeutic approach called behavioral activation, which focuses on action and getting you to re-engage with things that should be pleasurable or fun for you. The therapeutic approach and medication go hand in hand. A lot of times, people are too depressed to get the ball rolling with behavioral activation and they require the assistance of the medication to relieve some of the burden of their symptoms, allowing them to actually engage and do the work on their own.

I also wonder what therapy has been like for you. I’m proud of your for sticking with it. Has it been helpful? This is always an important question to ask. Being committed to therapy and having a good rapport with the therapist is great, but if it’s not getting you anywhere, that is sometimes worth considering. In therapy, you probably want to be working on coping skills such as breathing and grounding exercises. You need alternatives to cutting to bring you back down to earth when you are feeling dissociated or numb. Mindfulness as well. These are things that you can practice on your own and within the context of therapy to serve as tools to allow you to better endure the strange feelings that would otherwise cause you to self-injure.

Stay connected with the world

I’m also curious about whether you are going through all of this alone. I know that you have your therapist, but does anyone in your daily life or anyone close to you understand what has been going on? I know that you feel a great deal of shame for struggling with self-harm at your age. This is a good reminder that mental health concerns don’t discriminate based on age. Of course, a given disorder will have different prevalence rates across different age groups, but it’s super important to not assume someone does not suffer from a specific issue just because of their age. Anyways, you may be inclined to hide your struggles with self-harm at any cost from the people in your life. It totally makes sense why you would want to keep that hidden, but doing the opposite and dragging the issue out into the light could serve as an important protective factor. So many times, just being honest and open about what you are going through creates an important feedback loop that allows you to better adjust your behavior.

If the issue here is indeed feeling dissociated and disconnected, there are alternatives to cutting to bring you back to earth and into your body. Ideally, in therapy and in your own self-reflection, you are also going deeper and looking at why the dissociation and numbness is happening in the first place. But when it comes to coping with it on a day to day basis and keeping yourself safe from self-injury, there are grounding exercises such as gripping ice cubes in your hands, taking a cold shower, playing “sensory bingo”, or mindfulness exercises. None of these are a panacea and your mileage may vary, but trying these first could be a good option. I think that we also want to pay attention to what you are doing with yourself on a day to day basis. If you are essentially isolating and spending time doing the same things over and over, this lends itself to anhedonia and feelings of being disconnected. Keeping busy isn’t a direct solution, but it can help to have other things going on so that you don’t just have a ton of time and space to stew in your feelings and allow the temptation of self-harm to build up until you can’t resist anymore.

For a lot of people, self-harm is almost like an addictive behavior. The mental image of self-harm and the release of it builds and builds until you have to engage in the behavior for that temporary sense of relief. Just like other addictive behaviors, they are harder to cope with when you are just in your box by yourself trying to rely fully on your willpower without other things to put your attention toward. The more connected you can be to the world the better. If you have the opportunity to engage with people that you care about, be involved in activities, participate in groups, volunteer… anything. All of this is going to be helpful because you will feel less alone in the world.

Give yourself credit

I also think that it’s important for you to celebrate your victories. You have had a silent struggle for a long time, which I get. We don’t often think about self-harm as an adult issue. But issues like self-harm thrive as secrets. If you can own the process and celebrate your victories, that puts a different spin on it. You don’t necessarily have to shout it from the roof tops unless you want to. But realistically, what’s the difference between someone celebrating not biting their nails or pulling their hair and them not cutting? Again, the more connected and open you are, the better off your are likely to be.

In your question, you suggested that antidepressants might not be for you. That’s totally a possibility. As I mentioned before, there are other options within the medication world. But even if you decide to not take medication, there is so much work that can be done without them. You’re already in therapy, which is great. The research also suggests that vigorous physical exercise is also comparable to antidepressants. There are also non-medication options for depression, such as TMS that could be available to you. This is all about making sure that you embrace the opportunity to do the work, keeping your providers closely in the loop, and opening up as much as possible so that you don’t have this dirty little secret eating you alive.