However, in the present context, we must also see agency as a fundamental human process that is no less fundamental for being challenged by illness . Specifically, self-cutting is a crisis in the agentive relation between adolescent bodies and the surrounding world, or put another way, a crisis of their bodily being in the life-world that they inhabit. In understanding embodiment as an indeterminate methodological field, this relationship between body and world is defined by three modes or moments of agency: the intentionality of our bodies in acting on the world or being-toward-the-world, the reciprocal interplay of body and world embedded in a habitus, and the discursive power of the world upon our bodies to establish expectation and shape subjectivity . To be precise, approaching the interpretation of cutting from the standpoint of agency in these troubled adolescents’ body-world relationship has the immediate effect of shifting interpretive attention from the wounded flesh to the relation between the active hand of the cutter and the self-inflicted wound. It is then not just a matter of the pain, the relief, or the blood that originates at the violated boundary between self and world, and the concomitant breach in bodily integrity. In the first mode of agency, regardless of the implement used to cut with, the cutter’s hand is an agent of self, and the opening of the wound and flow of blood are an emanation of personhood into the world. Cutting is a form of active being toward-the-world whether understood as a form of projecting outward or as a kind of leaking and draining into the world. This mode of agency is epitomized in the statements of identity such as “I am a cutter.” In the second mode or moment of agency, hand and flesh together instantiate the reciprocal relationship of body and world.

The cutting hand interpellates the part of the animal and material world that is one’s very own body,cannabis grow equipment and that precise fragment of the world responds with the opening of the flesh . In this way cutting highlights the simultaneity of body as both self and other. The flow of blood marking not only the violation of a boundary but the opening between body and world. The reciprocity between body and world is highlighted in the simultaneous infliction of pain and the granting of relief. The cutter’s body is also the locus of an anguished subjectivity that elicits the application to itself by an agentive hand ambivalently cruel and kind, of an otherwise inert implement from the material world, whether it is a razor blade or a piece of glass. In the third mode of agency, both hand and flesh are no longer part of an inviolate self but conscripts of the world’s oppressive agency, and one’s body may as well not be one’s own but just a body, any body, “the” body as an object rather than a subject. The cutter’s hand is now the hand of the other, the wound is world-inflicted, and structural violence is incorporated at the most intimate bodily level. That is, it is inflicted by an anonymous oppressive world or the world dominated by the cruelty of others, and one’s flesh becomes an inert object alienated not only from self hood but from the trajectory of a possible life, isolated from others and immersed in the immediacy of present pain and unproductive bodily transformation. We must take care to distinguish what is specific to each young person and what is fundamental to their bodily experience in the account we have just given. Attending to the immediate life worlds of individual youth reminds us that each has a distinct experience of cutting under distinct circumstances. Gender, ethnicity, and socioeconomic status matter to define these circumstances, while family relations and especially family instability are particularly insistent and frequent themes.

Insofar as all the youth we have discussed were psychiatric inpatients, they can be counted among the more extreme instance of adolescent self-cutters, while exhibiting varied diagnostic profiles, levels of functioning, regimes of psychiatric medication, and phases of treatment and recovery. The combination of individual uniqueness and shared extremity across their situations has allowed us to elaborate a multilayered crisis of agency in the relation between body and world and highlights the existential profundity of cutting as a function of its mute immediacy in practice. The possibility for this kind of embodied existential analysis is that cutting is not an idiosyncratic occurrence but a culturally patterned act. Yet it cannot be accounted for just because other kids do it, and this is why it has been important to examine it in the lives of afflicted adolescents rather than simply as an element in the ethnography of “Emo” culture. The interpretive point is that the trajectory of our argument from experiential specificity on the individual level to the fundamental human process of agency does not define the ends of a continuum. We must instead understand the extraordinary conditions of suffering as simultaneous with the enactment of fundamental human process, because the relation between body and world is always embedded in a specific instance, and each specific instance points to our shared existential condition of embodiment. Identifying the wounded flesh as locus of agency at the intersection of body and world as we have done brings to the fore a particular configuration of relations between self as active and passive, strategy and symptom, subjectivity and subjectivation. The moment of cutting is a fulcrum or hinge between the self as agent or as patient, with an intended pun on the medical sense of patient.

From the standpoint of individual experience, cutting in the first sense is a strategy that is part of the self as agent, while in the second sense it is a symptom that is part of a disease process. As a cultural phenomenon, cutting in the first sense exhibits the body as existential ground of culture and wellspring of agentive subjectivity , while in the second sense cutting identifies the body as a site at which cultural practice and structural violence are inscribed and have the effect of subjectivation . In this respect, the distinction between subjectivation and subjectivity in the cut/cutting body is substantively parallel to the distinction between symptom and strategy in the afflicted person. Perhaps the analysis we have presented suggests that self-cutting may indeed be sufficiently complex to serve as the core of a distinct diagnostic category and too problematic with respect to agency to be defined as a symptom in the ordinary sense. Whether or not this proves to be the case, the existential complexity to which we have pointed is precisely what one would expect by bringing attention to bear on cutting as a crisis of agency with its locus at the intersection of body and world. Despite viral suppression on combination antiretroviral therapy , people with HIV suffer from depressed mood and chronic inflammation. Depression is the most common psychiatric comorbidity in HIV . Depressed PWH show poorer medication adherence ,cannabis drying racks lower rates of viral suppression , greater polypharmacy , poorer quality of life and shorter survival . A sub-type of treatment-resistant depression in the general population is associated with chronic inflammation . The potential clinical significance of this is high, since the anti-inflammatory TNF-alpha blocker tocilizumab and other drugs such as the antibiotic minocycline, the interleukin 17 receptor antibody, brodalumab, and the monoclonal antibody, sirukumab, have been shown to be effective treatment for this depression sub-type , but these have not been studied in the context of HIV. Inflammation is associated with greater symptom severity, differential response to treatment, and greater odds of hospitalization in patients with major depressive disorder . Chronic inflammation persists in virally suppressed PWH and predicts morbidity and mortality . There also is an extensive literature on showing that depression correlates with markers of inflammation and immune activation in PWH , but most of these studies were performed in individuals who were not virally suppressed. We hypothesized that inflammation in virally suppressed PWH would be associated with poorer mood.HIV disease was diagnosed by enzyme-linked immunosorbent assay with Western blot confirmation. HIV viral load in plasma was measured using commercial assays and deemed undetectable at a lower limit of quantitation of 50 copies/ml. CD4 T cells were measured by flow cytometry and nadir CD4 was assessed by self-report. Inflammatory biomarkers measured in blood plasma at the 12-year follow-up visit using immuno assays were neopterin, soluble tumor necrosis factor alpha type II , d-dimer, interleukin-6 , C-reactive protein , monocyte chemoattractant protein type I , soluble CD14 and soluble CD40 ligand . We selected these markers based on previous studies linking them to depressed mood . Biomarkers were measured only at the 12-year follow-up visit, and correlations were assessed with BDI-II at the same visit, and secondary at the initial visit.Current mood at baseline and 12-year follow-up was assessed using the Beck Depression Inventory -II . Lifetime major depressive disorder and substance use disorders were assessed using the computer-assisted Composite International Diagnostic Interview , a structured instrument widely used in psychiatric research. The CIDI classifies current and lifetime diagnoses of mood disorders and substance use disorders, as well as other mental disorders.

Additional assessments measured activities of daily living, disability, employment and quality of life. Quality of life was assessed using the Medical Outcomes Study HIV Health Survey Short Form 36 , a reliable and valid tool for assessing overall quality of life, daily functioning, and physical health . The MOS-HIV contains 36 questions that assess various physical and mental dimensions of health. Items are grouped into two overall categories , with 11 subcategories . These are scored as summary percentile scales ranging from 0 to 100, with higher scores indicating better health. Disability was assessed using the Karnofsy Scale . Dependence in instrumental activities of daily living was assessed with a modified version of the Lawton and Brody Scale that asks participants to rate their current and best lifetime levels of independence for 13 major IADLs such as shopping, financial management, transportation, and medication management . An employment questionnaire asked about job loss, decreases in work productivity, accuracy, and quality; increased effort required to do one’s usual job; and increased fatigue with the usual workload. Neurocognitive function was assessed using a comprehensive, standardized battery described in detail previously . The battery covered 7 cognitive domains known to be commonly affected by HIV-associated CNS dysfunction. The best available normative standards were used, which correct for effects of age, education, sex, and ethnicity, as appropriate. Test scores were automatically converted to demographically corrected standard scores using available computer programs.Demographic and clinical characteristics were summarized using means and standard deviations, median and interquartile ranges or percentages, as appropriate. Log10 transformation was used to normalize the biomarker distributions for parametric analysis. Factor analyses with oblique Equamax rotation were employed to reduce the dimensionality of the biomarkers. Factor analysis is a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved variables called factors. Thus, factor analysis is a method for dimensionality reduction and can help control false discovery.To validate the factors, we examined intercorrelations between the biomarkers assigned to each factor. Pearson’s r and Spearman’s rho were calculated to compare factors with BDIII scores. Secondary analyses evaluated correlations with quality of life , neurocognitive function, and employment status. We used multi-variable linear regression models to test interaction effects. In the absence of an interaction, additive effects were tested. Analyses were conducted using JMP Pro® version 15.0.0 .We found that higher concentrations of a specific panel of markers of inflammation in blood were seen in PWH with worse depression. Additionally, PWH with depressed mood had markedly reduced quality of life and were more dependent in IADLs. In addition, higher inflammation associated with worse scores on numerous life quality indicators. Chronic HIV-associated inflammation and immune dysfunction have emerged as key factors that are strongly linked to non AIDS complications . Our findings confirm those of previous investigations , and extend them by evaluating a more comprehensive panel of biomarkers and more extensive evaluation of impact on daily functioning and quality of life.