The feelings of worthlessness persisted, triggering her post-traumatic stress disorder. Horrible memories of being brutally sexually abused as a child haunted her. And the black-and-white thinking of her borderline personality disorder made her feel unwanted, unlovable, alone.

"It's like a domino effect," she said.

When the last domino fell a few days after getting the pink slip, Hasna reached for a pair of scissors. She always cuts with scissors.

"My experience is that sometimes the emotional pain gets beyond. . . . It's too much. It's like emotional overload. It's so intense and you're so into it you feel like you're going to break up."

Then the sharp edge breaks her skin and she is bleeding.

"You just look at your arm. . . . It's like the emotional pain is distracted into 'Oh, no. I've got to take care of this.' "

But the blood just brings a new round of negative thoughts.

"Look what you did. You thought you were past it and now you do it again. You know better."

Hasna was awash in shame and guilt. "You beat yourself up for that backslide."

Recovery for cutters may take years.

"It means coming up with a new philosophy of life that works," said Waterbury, who specializes in post-traumatic stress disorder.

The person not only must redefine himself or herself but reframe the world so it becomes less threatening, he said.

Those who work with self-injurers disagree whether cutting is addictive. "I think it can become a habit but not an addiction," Mazelis said.

Some cutters experience a pleasurable almost euphoric feeling after hurting themselves. In response to injury, the body releases endorphins, which have a pain-relieving effect similar to morphine. Cutters come to crave that feeling much like a drug addict aching for a fix.

"I think it's both," Pramann said. "I have some cutters where it's a habit. I have some cutters where it's definitely an addiction."

Either way, quitting is extremely difficult, not unlike trying to kick a cigarette or drug habit.

"When you tell people to stop doing that, it's like telling us to stop breathing," Waterbury said.

Furthermore, cutting is just one symptom of many.

"It's never going to be their only problem," Mazelis said. "People who are hurting themselves are going to have a lot of different things going on."

Candace Lowry, a licensed clinical social worker at LDS Hospital, says cutting must not go unnoticed or overnoticed.

"It's a very tricky thing and always has to be evaluated in context," she said. "How does that one thing fit into the big picture?"