The first time she did it, Heather slipped off to her grandmother’s empty beauty shop. She was 13, overwhelmed and struggling with the death of her grandfather, one of the few people in her life she could trust.

She had been closer to “Pepe” than to her own parents and watched for 16 days as he degenerated after heart surgery, eventually to the point where he could no longer talk.

The morning that the family agreed to turn off Pepe’s life support machines, Heather returned to her grandmother’s house and stole away to the attached beauty shop while family members congregated in another room.

She selected a razor blade from a box that her grandmother used for cutting hair, sat in the shop’s swivel chair, and ran the edge along the underside of her arm until blood surfaced on her skin.

“It seemed like it made everything better,” Heather, now 17, said in a recent interview, her blue eyes heavy with black eyeliner.

She asked that her last name not be used.

“It really didn’t hurt. It stung a little bit,” she said about her first time cutting.

Heather had made a discovery that teens across Maine and the country are making with alarming prevalence: Cutting herself was a way to relieve emotional pain, at least temporarily.

The troubled teenager was practicing self-injury, a behavior that is not new but seems to be on the rise, particularly among teenage girls.

“This is an exploding phenomenon,” Barent Walsh, co-author of the book “Self-Mutilation: Theory, Research and Treatment” and executive director of The Bridge of Central Massachusetts Inc., a nonprofit human service agency, said recently.

Walsh has written and lectured on the topic of self-injury throughout the nation. He spoke to local professionals last November in Bangor.

“Self-injury is an epidemic right now,” Walsh said. “It’s definitely on the rise.”

Experts estimate that habitual self-injurers represent nearly 1 percent of the population, according to the National Mental Health Association.

Many experts agree with Walsh that self-injury is on the rise, though some argue that because the disorder is now better identified and understood, it’s suddenly getting more attention.

Add to that the admissions by celebrities, including Princess Diana, actor Johnny Depp and rock star Marilyn Manson, that they bear the scars of self-injury.

Local mental health professionals cite media influence among the reasons for a rise in cutting among teenagers, including graphic Internet sites that glorify the behavior. Increasing pressure from parents and peers to be thin, popular and successful drives many to self-injury, professionals say.

Characteristic of many who self-injure, Heather is a white female who began cutting during puberty. She also is a survivor of abuse; she was sexually assaulted at 15 by a former boyfriend, she said.

Nearly half of those who self-injure report having been physically or sexually abused during childhood, according to the National Mental Health Association.

Though men do self-injure, females are much more likely to engage in the behavior. Men tend to express emotions outwardly, sometimes with violence, while women have been socialized to direct their feelings inward, experts note.

Even outwardly successful girls sometimes resort to hurting themselves, Pam Braley, a clinical therapist and licensed social worker at New Horizons for Young Women, a camp near Lincoln for troubled adolescent girls, said in a recent interview, adding that cutting has surpassed eating disorders as the epidemic of female adolescents.

“The ones at the top get missed,” she said. “Nobody thinks they have a problem. They look fine, they’re getting good grades.”

Yet they cut themselves.

Self-injury: the disorder

Though cutting one’s wrists and arms often is associated with a suicide attempt, self-injurers rarely want to die. In fact, they use the behavior to regulate mood.

Some call self-injury the “opposite of suicide.” Instead of giving up, those who do it are at least making an effort to cope with their pain, they claim.

Self-injury is defined as the act of deliberately harming or altering the body to the point of causing tissue damage, without the conscious intent to commit suicide. Along with cutting, self-injury includes picking, scratching or rubbing off the skin, bone breaking and trichotillomania, or compulsive hair pulling.

Other commonly used terms for the disorder are self-harm, self-mutilation, self-abuse and self-inflicted violence.

In the psychiatric community, the behavior generally is considered a symptom of other disorders – particularly borderline personality disorder – rather than a diagnosis in itself.

For that reason, updated statistics on the prevalence of self-injury are hard to come by. Experts agree that the disorder is pervasive, and in recent years its victims have become younger and spread throughout the general population.

In years past, self-injury primarily was the province of patients with serious psychiatric disorders, according to the experts.

Statistics on self-injury in Maine are all but nonexistent – lumped together with data on suicide – and local information is anecdotal at best. In Massachusetts, however, some figures are available.

There, 18 percent of high school students reported in 2003 that they had intentionally injured themselves at least once in the previous year, according to that state’s Youth Risk Behavior Survey, part of an annual national study performed by the Centers for Disease Control and Prevention.

The national survey includes questions on smoking, sex and suicide, but Massachusetts is the only state to include a question on self-injury in its survey, according to the most recent information available.

In Maine, interviews with anyone who deals with teenagers, including school and mental health professionals, suggest self-injury is happening everywhere.

Guidance counselors, school social workers and nurses from high schools in Bangor, Belfast, Houlton, Calais, Newport and Millinocket all have reported dealing with students who harm themselves.

The principal of Great Salt Bay School in Damariscotta in May sent a letter to parents of seventh- and eighth-grade pupils notifying them of an increase in reports of cutting at the school. Later that month, the school convened a public discussion about cutting.

A conference held Friday in Augusta by KIDSLAW, a gathering of Maine professionals who work with youths, with support from the Maine Attorney General’s Office, included a presentation on self-injury.

“We see lots of it, lots of it. More girls than boys by a pretty wide margin,” Donald Mendell, a school social worker and guidance counselor at Nokomis Regional High School in Newport, said recently.

Students at Nokomis have been caught using hairpins and paperclips to hurt themselves, he said.

“Anyone working with adolescents has been up to their waist in it for a long time,” Mendell said.

In Old Town, school resource Officer Debbie Holmes said that over the course of this spring, four or five girls have told her their friends are cutting themselves.

“I’m hearing so much more about it,” said Holmes, an Old Town police officer. “It just seems like it’s much more prevalent, more accepted, like it’s the thing to do.”

Why some hurt themselves

Peer pressure can play a role in self-injury, particularly among prepubescent youths and teenagers eager to fit in and please their friends. The behavior has even begun to creep into the lives of children as young as 11 or 12.

“It’s so prevalent in middle schools,” Walsh said, adding that half of the attendees at his self-injury seminars in Bangor, Freeport and Portland are from public schools. “There’s definitely a major issue in middle schools right now.”

Those who hurt themselves to please others, however, cause the least concern for mental health professionals.

“That’s in a sense almost the mildest form, because it’s something that they simply don’t want to engage in, and they’re engaging in it because of a peer group,” Eric Kuntz, a child and adolescent psychologist at Acadia Hospital in Bangor, said in a recent interview.

People who self-injure as a way to cope with difficult emotions are most at risk, Kuntz said. Underlying trauma motivates their behavior, and they are prone to other dangerous behavior, such as eating disorders, substance abuse and risky sexual behavior, he said.

Also of concern is the ever-present risk of infection from unsanitary cutting tools and accidentally cutting too deeply, Kuntz said.

Of patients who use self-injury as a coping mechanism, two distinct groups exist: those who self-injure to relieve emotional pain, and those who do it to escape a sense of numbness or loss of touch with reality, Kuntz said.

Their motivations for attacking their bodies are opposite.

The former group tends to use pain as a way to release feelings of anger and frustration, Kuntz said.

“They say that if it did not hurt, they wouldn’t do it. So they recognize the pain, it does hurt, and they will say, ‘That’s why I cut,'” he said.

The latter group, those who regain touch with reality through cutting, say they don’t even feel the pain. For them, seeing their own blood proves that they still exist, when otherwise they feel numb and disconnected from the world.

“In the act of cutting, they’re actually establishing where they stop and the rest of the world starts,” Kuntz said. “A lot of them will say, ‘If it hurt, I wouldn’t do it.'”

Heather suffered both facets of the self-injury experience, cutting herself both to relieve tension and, later, to escape a feeling of numbness.

“It hurts, but it doesn’t hurt,” she said. “I really didn’t know how I was feeling. It was kind of an adrenaline rush.”

Heather’s state of tension was intense, she said, worsened by a bad day at school or a fight with her parents. She described feeling like a potato cooking inside a hot oven without holes to release the stream.

Cutting for her was pricking that potato with a fork, she said.

Feeling the release gave Heather a high, she said. Many cutters describe becoming dependent on the rush of endorphins released into their brains when they hurt themselves, said Braley of New Horizons for Young Women.

“It becomes almost addictive. They like to look at the blood, they like to look at the cuts. They like to compare stories with their friends. They get on the Internet and find a lot of support,” Braley said.

Though some cutters swap “war stories” about their wounds with friends, many are embarrassed by their behavior, Braley said.

“Some of them have great shame and they don’t let anybody know. Then their parents find out and then they freak.”

Finding out

It wasn’t until her freshman year at Old Town High School that Heather’s parents found out what their withdrawn and sometimes violent daughter was doing to herself. By that time, Heather’s grades had slipped and she had become a heavy drug user, using cocaine, Ecstasy and taking prescription drugs, such as OxyContin and Percocet.

By that point, Heather was cutting herself deeper and more frequently, sometimes every other day, she said. She began using anything she could get her hands on; knives, broken glass, mirrors. Usually, she did it alone in her bedroom at night, she said.

“If I had a bad day, I’d go home and do it again,” Heather said.

In eighth grade, the year after her grandfather’s death, Heather started burning her hands and arms with the hot metal on her pocket lighter, she said.

“I was scared that I wasn’t going to stop,” she said.

In one incident that year, Heather cut herself while in the bathtub, she said. Startled and frightened by the sight of her blood spreading through the water, she got out of the tub, dressed herself and finally told her parents about her secret ritual.

“I said, ‘I think I have to go to a hospital,'” Heather said. “At first my dad didn’t believe me. I had to show him my arms.”

Heather was rushed to Eastern Maine Medical Center in Bangor, treated and sent to a rehabilitation program in Waterville. After participating in three weeks of therapy, and being diagnosed with bipolar disorder, she returned home.

“It took a good six to eight months before she could spend time alone,” Heather’s mother, Laurie, said in a recent interview.

Though they’d witnessed her violent temper, Heather’s parents had no idea about her cutting or the extent of her drug use. Two days after she left, they searched her room and found marijuana, empty pill bottles, razor blades and cigarette butts stuffed into porcelain figurines.

“I was devastated,” Heather’s mother said, looking weary as she sat next to her daughter at the kitchen table in their home. “I bawled. I cried for days.”

Though she was aware of Heather’s temper and grief over losing her grandfather, Laurie never suspected her daughter was cutting herself. Her husband thought Heather must have accidentally scratched her arms with her long fingernails.

Looking back, the signs were there, Laurie said. Her words of advice to other parents: Look for any changes in behavior, from attitude to appetite to dress. Heather wore long sleeves even in warm weather, Laurie recalled.

“She stayed in her room all the time,” the mother said.

Just after she returned home, Heather’s father removed her bedroom door from its hinges as his daughter slept. It was gone for the next year, allowing Heather’s parents to look in on her whenever they pleased.

Now, the bottom half of the door stands as a tangible reminder of the days when trust between parent and child was strained almost to the point of nonexistence.

“She’s earned back half a door,” Laurie said, her daughter laughing alongside her.

The road to recovery

Last year, Heather decided to stop counseling and taking her medications. In stressful situations when she once would have hurt herself, Heather now goes to her room to listen to music, usually rap by artists such as 50 Cent and Trick Daddy.

“If I’m just left alone, I’m fine,” she said.

Finding a coping mechanism to replace the cutting, such as listening to music or talking with loved ones, is key to the successful treatment of patients who self-injure, said Kuntz of Acadia Hospital.

“You never take away a patient’s defense unless you give them something back,” he said. “If you remove the cutting, you give them a more effective way of dealing with what’s going on inside of them.”

Treatment for cutting and other forms of self-injury varies, depending on the severity and the root of the emotional trauma, Kuntz said. Psychotherapy may be necessary for some, medication for many, and family therapy for patients whose environment contributes to their behavior, he said.

Much depends on the willingness of parents to work with mental health professionals to deal with the inner pain driving their child’s outward actions, Kuntz said.

“Some parents are absolutely enraged at their children [when they find out about the self-injury] and just want us to make it go away, make it stop,” he said. “Other parents are aware that there is some kind of pain that the child is feeling. They might not be able to figure out what it is, and they are absolutely desperate.”

The prognosis for those who self-injure depends on the nature of the emotional trauma driving the behavior, Kuntz said. Outpatient therapy helps many to adjust to the stresses of life outside the supportive atmosphere of the hospital, he said.

“Once they leave the hospital, these problems are still going to be waiting for them,” Kuntz said.

Heather never again cut herself after she returned from rehab, she said. As she talks longingly about her plans to move to California after graduation, the old scars on her arms are barely noticeable.

She doesn’t think she’ll ever cut herself again, though she’ll always struggle to deal constructively with life’s inevitable stress and pain.

“I still think about it,” Heather said. “But I mean I think anybody that’s cut themselves will always think about it. Because of the feeling you get, kind of like just doing drugs. You’re always going to have the urges.”

Now, when she sees the evidence of cutting on other girls’ arms, she feels repulsed, Heather said. She no longer hides her scars under long sleeves, though the once violently angry teenager does her best to keep her grandmother from seeing the old wounds.

“I was just sick of living that way,” she said.

Self-injury is defined as the act of deliberately harming or altering the body to the point of causing tissue damage, without the conscious intent to commit suicide.

Cutting is the most common form of self-injury, which also is known as self-harm, self-mutilation, self-abuse and self-inflicted violence.

Where to find help and information

Statewide crisis intervention

number: 1-888-568-1112; Open 24 hours a day, 7 days a week; Funded through the state department of Behavioral and Developmental Services

SAFE Alternatives:

www.selfinjury.com; 1-800-DONT-CUT; Web site and information line of Self-Abuse Finally Ends, a national self-injury treatment program

Web sites

Healthy Place: Self-Injury Community:

www.healthyplace.com/communities/selfinjury/site; An online community for people seeking support and information.

Self-Injury – You are not the only one: www.palace.net/~llama/psych/ injury.html; Includes information about causes and treatment for self-injury, and suggestions for parents and friends of those who self-injure.

Books

“The Scarred Soul: Understanding and ending self-inflicted violence,” by Tracy Alderman

“A Bright Red Scream: Self-mutilation and the language of pain,” by Marilee Strong

“Bodily Harm: The breakthrough healing program for self-injurers,” by Karen Conterio and Wendy Lader

Warning signs of self-injury

Wearing long-sleeved shirts or pants in warm weather

Blood stains inside clothing

Bandage wrappers, bloody tissues or razor blades in the bathroom or bedroom

Making poor excuses for how the injuries happened

Wanting to be left alone