But he always had a steely friend to soothe his empty soul. He carried a razor blade in his wallet.

"It's like having a tool kit in the back of your car," Howell said. "If you need it, you got it."

For most people, injuring themselves to feel better is incomprehensible. Usually a bowl of ice cream or a favorite movie will provide comfort. Occasionally, a traumatic experience like the sudden death of a loved one may cause a person to punch a wall or pull his hair. But those episodes are isolated, and the triggers are obvious.

There is no easy answer to why someone chooses to purposefully bruise, burn or cut his own flesh over and over again.

"That's a really good question. It's one that's with me all the time," said Pamela Sorensen, whose daughter has cut in the past. "I can't imagine anyone cutting themselves or hurting themselves in any way unless they have some kind of mental illness."

Mazelis answered the question this way in one of her newsletters:

"So, why do people cut their arms, burn their stomachs, punch their faces? Because they hurt. Hurt more than the cut, the burn or the punch. It is all relative. And when those who wish to be helpful understand this, and attend to the deeper pain, to the much more tragic wounds, then great possibilities for healing become available.

A certified nursing assistant, Kristin Hasna spends her days caring for others. She is always looking to improve her life, including time at a renowned California retreat offering a path to inner peace, clarity and happiness. She is kind and gentle, except when it comes to herself.

"I wouldn't hurt another person, but I hurt myself," she said. "When I feel hurt, when I feel angry, when I feel not real, that's when I do things to myself."

The wounds from the last time Hasna cut her own flesh are scabbing over. They will eventually turn to scars like the dozens of others on her upper left arm. And on her right arm. And on her thighs.

She had gone about 18 months without putting a blade to her skin. Therapy, medication and enjoyable diversions like visiting her nephews or helping someone kept her mind off cutting.

But getting fired from a job recently was more than she could handle. Co-workers, she said, whispered about her and told the boss things that weren't true. Whatever the circumstances, Hasna felt rejected.

Though she is learning to handle her anxiety-panic disorder, that was too much for the 40-year-old who has cut on and off for about 25 years. Her stress meter shot to the top. She went home, took a Xanax and climbed in bed.