1. Prof. Amany Haroun El Rasheed M.N.P., D.P.P., M.D. Master in Mental Hygiene (Johns Hopkins Univ.)Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.) APA Membership WPA Fellowship ISAM Fellowship FRC Psych
2. DSH is a behaviour and not an illness
3. Deliberate Self Harm Terminology and definition Diversity of terms: “parasuicide”, “self- poisoning”, “self injury”, “deliberate self harm”, “self harm” Common definition: ‘An act with non-fatal outcome in which an individual deliberately initiates a non-habitual behaviour, that without intervention from others will cause self harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage’ (Platt et al., 1992; WHO).
4. Deliberate Self Harm What is Self Harm? Terminology and definition ‘self-poisoning or injury, irrespective of the apparent purpose of the act’. (NICE, 2004) ‘Self-injury is a compulsion or impulse to inflict physical wounds on ones own body, motivated by a need to cope with unbearable psychological distress or regain a sense of emotional balance. The act is usually carried out without suicidal, sexual, or decorative intent.’ (Sutton 2005)
5. Key elements of an operational definition? • Self-inflicted • Deliberate • Alters body tissue • Purpose to cause harm – but not suicidal
6. Drugs used in self-poisoning: Trends in selected drug 1970-1992 Oxford, UK
7. DSH: the facts Such behaviors are found in about 75% of borderline personality disorder. The frequency with which self- destructive behaviors occur (e.g., unprotected sex with strangers, drinking while taking antabuse) would increase this rate into 90% range.
8. Incidence and Onset 4% in the general population = numbers of males and females (though more females present for treatment) Typical onset: puberty though can be seen in young children and adults Often lasts 5-10 years But can last longer without treatment
9. Background Factors in Teens who Self- Injure: Generalized Found in = numbers in all ethnic groups Nearly 50% report physical/sexual abuse (At least 50% have NOT reporting abuse) Many report that they were discouraged from expressing emotion, particularly anger and sadness Feelings of emptiness, over/under stimulated Unable to express feelings Lonely, fearful of intimate relationships or adult responsibility Feeling invalidated/disconnected from parents
10. PrevalenceCommunity Samples• Adolescents: 13-16% (Ross & Heath, 2002; Muehlenkamp &Gutierrez, 2004)• College Students: 17-36% (Gratz, 2001; Whitlock et al. 2006; Brownet al. 2007)• Adults: ~4% (Klonsky, et al., 2003; Briere & Gil, 1998)Clinical Samples• Inpatient adolescent: 24-82% (Taimenin et al. 1998; Rosen &Walsh, 1989; Nock & Prinstein, 2004)• Inpatient adult: 21-35% (Briere & Gil, 1998; Paul et al. 2002)• Inpatient BPD: 75-80% (Soloff, 1994; Shearer et al., 1988)
11. Deliberate Self Harm
12. Deliberate Self Harm
13. Self-Injury: Behaviors•carving•scratching•branding•marking•picking, and pulling skin and hair•burning/abrasions
14. Self-Injury: Behaviors•Ingestion of sharps/toxins•cutting•biting•head banging•bruising•hitting•excessive body piercing
15. Deliberate Self Harm
16. Behavior Patterns Cutting arm/legs most common practice May attempt to conceal injuries (long sleeves/pants) Often make excuses Significant number also struggle with eating disorders/substance/alcohol abuse Big difference between self decorating (tattoos/piercings) and self harm Teens who self harm are seeking relief from emotional distress
17. Warning Signs Unexplained, frequent injuries including cuts and bruises Wearing of long pants/sleeves in warm weather Low self-esteem Overwhelmed by feelings Inability to function at home, school or work Inability to maintain stable relationships
18. MethodsWhat is your primary method of self-injury? (choose one) [38728 votes total]Cutting (27436) 71%Burning (1750) 5%Hitting (Self/Object) (1619) 4%Head banging (455) 1%Skin picking/Scratching (4721) 12%Wound Interference (740) 2%Bone-breaking (196) 1%Biting (553) 1%Other (1199) 3% Self Injury Poll (2004) What is your primary method of self-injury (online) http:vote.pollit.com/webpoll2?ID=25897 (accessed: 25-02-08)
19. MethodsCutting 80%Bruising 24%Burning 20%Head banging 15%Biting 7% These are the most common symptoms by which people with borderline disorder come to the clinical attention. Such self-injurious acts occur in people who have histories of suicidal attempts (62%), with an average frequency of about three attempts.
20. Females vs Males More females cut More males punch More females report Males likely underreport Males hurt hands
21. DSH: Why?Emotion Relief (92%, at least one) To stop bad feelings (immediate relief) To stop feeling angry or frustrated or enraged To relieve anxiety or terror To relieve feelings of aloneness, emptiness or isolation To stop feeling self-hatred, shame To obtain relief from a terrible state of mind To control feelings (to exert control)
22. DSH: Why? Physical pain distracts from emotional pain To disassociate from intolerable feelings To transfer emotional pain into physical pain Physical pain is easier to deal with than emotional pain IT WORKS
23. DSH: Why? Not understood by others Means of communicating distress Make internal wounds external (visible) Event markers (memorial for traumatic events) Creates euphoria
24. DSH: Why? To punish yourself (63% of nonsuicidal self-injury) Replicates earlier abuse Only 13 % wanted to punish someone or make someone feel guilty Social modeling – 82% of responders say at least one friend self-injured in the last 12 monthsNock and Prinstein (2004) A functional approach to the assessment of self-mutilativebehavior. Journal of Consulting and Clinical Psychology 72: 885-890.
25. DSH: Why? Wanting to fit in Feeling emotionally dead inside Self harm feels alive and confirms existence Coping strategy
26. A patient struggling with herimpulse to cut wrote I want to cut. I want to see pain, for it is the most physical thing to show. You can not show pain inside. I want to cut, cut, cut, show, show. Get it out. What out? Just pain.
27. Immediate Consequences of SIB Feels alive, functioning, able to act Clears the mind, helps to focus Release of endorphins Tension reduction Relief from stress or feelings Calmness Relaxation Sleep
28. Later Consequences of SIB Guilt Shame Stigma Feelings of isolation and abandonment
29. Stigma Self-injury is not a behavior that “works” for someone who is not in acute emotional distress Important for caregivers to recognize that there is NO safe amount of self-injury Self-injury, like substance abuse and eating disorders, is a coping strategy used by people who are in emotional distress Those who self-injure feel great amounts of pain and often, shame
30. Deliberate Self Harm
31. Feelings Associated with Cutting Before During After Tension Pleasure GuiltWorthlessness Exhilaration ShameVulnerability Satisfaction Crushed Loneliness Numbness Pathetic Confusion Relief DisturbedDetachment Control Out of Control
32. Some Quotes (Look Beyond The Scars, 2002) “It’s something that needs to be done to get me living” (Vicky, over 25) “I didn’t want to kill myself. I just wanted some of the hurt and all of the pain to just go away” (Rachel, late teens) “Way of coping … when things get really bad. People deal with things in different ways and, unfortunately or not, this is my way” (Kirsty, early 20s)
33. Etiology of S.I.B. Biological Considerations and Neurochemistry Serotonin – Decreased levels correspond to increased aggression and self injurious behavior. Irritability is expressed as screaming or throwing things when serotonin levels are normal. Research correlates this by showing decreased platelet imipramine binding sites in self-injurers (Simeon et al. 1992) and linked to impulsivity and aggression (Birmaher et al. 1990)
34. Etiology of S.I.B. Biological Considerations and Neurochemistry Endorphin Model – Pain resulting from SIB may elicit release of endogenous opioids (endorphins) which acts as an analgesic on opiate receptors like morphine or heroin. (Thompson et al. 1994). Little or no pain seen in many self-injurers which is termed “blunted nociception”. Dopamine supersensitivity or hypersecretion of endorphins seen. Repetitive self-injurious actions my come under control of addictive reinforcers and these receptor effects.Thompson, T., Hackerberg, T., Cerulti, D., Baker, D., Axtell, S. (1994), Opioid Antagonist Effects on Self-Injury in Adultswith Mental Retardation. American Journal on Mental Retardation, 49: 85-102.
35. S.I.B. Culturally Sanctioned Pathological Ritual Practices Suicidality Self-Mutilation Major Stereotypic Superficial/Moderate Compulsive Impulsive (OCD spectrum) (Impulse Control D/O)Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Episodic RepetitivePsychiatry, 2nd ed. Baltimore: The Johns HopkinsUniversity Press.
36. Favazza’s Typology of Self-Mutilation (1988) Major Self-Mutilation Rare and typically seen in people with psychotic disorders, mania or severe drug intoxication. Includes severe self-mutilating behaviors such as eye enucleation or amputation of limbs, or self-castration. Explanations given are usually based in religious or sexual delusions, or delusions of sinfulness. Identification with Christ Biblical or demonic influence Commands from God Desire to be female Control of sexuality Favazza, 1988; Favazza, 1989, Favazza, 1998
37. Favazza’s Typology of Self-Mutilation (1988) Stereotypic Self-Mutilation Common among individuals with mental retardation and developmental disabilities (autism, Lesch-Nyhan disease, Tourette’s syndrom) Includes behaviors such as scratching, biting, head- banging, oral injuries (biting/picking of lips, gums) Hypotheses for this type of behavior Social reinforcement (behavior decreases in the absence of adults) Negative reinforcement (the behavior is used to end an aversive situation, such as classroom time) Self-stimulation: in the absence of adequate neurosensory stimulation, an individual will engage in self-harming behavior to stimulate himself (also found in normal-intelligence infants and animals).
38. Favazza’s Typology of Self-Mutilation (1988) Moderate/Superficial Self-Mutilation Most commonly seen in women, with onset in adolescence Most common form is skin cutting, though 75% use multiple methods Numerous, wide-ranging explanations for the behavior Tension release Anti-dissociation Interpersonal control/influence Social functions (identity formation, group membership)
39. Emotion Regulation Model of DSH (automatic-negative reinforcement) 96% of self-harmers (with BPD) reported that emotion release was the reason for the behavior. (Brown et al. 2002) Emotional dysregulation develops through a combination of individual risk factors (emotional reactivity and intensity) and environmental risk factors (invalidating environments that fail to teach strategies for emotion regulation).
40. Emotion Regulation Model of DSH (automatic-negative reinforcement) DSH may develop as a way to manage intense or out-of-control emotions. It may serve to: Reduce anxiety Release tension Release anger Provide a sense of control Relieve guilt, loneliness “Concretize” emotional pain Terminate dissociation Stop racing thoughts Gratz, 2003; Briere & Gil, 1998; Connors, 1996; Linehan, 1993
41. Experiential Avoidance Model Chapman, Gratz & Brown’s Experiential avoidance: any effort to avoid or escape internal experiences or the situations that produce them Experiences: thoughts, feelings or physical sensations Avoidance strategies: thought suppression, substance abuse, DSH. Avoidance is negatively reinforced since, when you avoid, immediate discomfort is reduced. This relationship becomes very strong after repeated experiences.
42. Experiential Avoidance Model Chapman, Gratz & Brown’s In the long term, thought suppression tends to increase distress, increase the frequency of distressing thoughts and increase the likelihood of a rebound effect from the suppressed emotional experience (ie temporary relief leads to greater anxiety) Avoidance decreases the likelihood of extinction of unwanted emotions and prevents the individual from learning that aversive emotional states, while unpleasant, are not threatening.
43. Methods of Experiential Avoidance Denial of problems (rather than problem-solving) Dissociation and emotional numbing Isolation Drug and alcohol abuse Suicide attempts (and suicide) Nonsuicidal self-injury Self-punishment, self-criticism Secondary emotions to avoid primary emotions Hospitalization to escape stressful circumstances
46. Risk Factors The most consistent risk factor for DSH is childhood abuse-- physical, sexual, emotional abuse and neglect. For men only, childhood separation from the father is a risk-factor Familial alcohol abuse Dissociation
47. Social Risk Factors Social circumstances are important:1. Isolation2. Socioeconomic deprivation3. Excess of life events (month before SH)4. Younger people : relationship difficulties5. Older people: health or bereavement6. War
48. What Isn’t Self- Injury Taking drugs to get high Tattooing Piercing Suicide Attention Seeking
50. Psychosocial assessment Principals : privacy, conduct interview safely and with adequate time, let patient tell their story Question relatives and friends about what patient has recently said Three main issues:1. Are there current mental health difficulties?2. What is the risk of further self harm/suicide?3. Are there any current medical or social problems?
51. Assessment Short term risk assessment Careful history of events surrounding self harm serious medical attempt/perception of seriousness ie in children/learning disability Precautions against being found Previous mental health problems (DSH)
52. Assessment Short term risk assessment Harmful use of alcohol or drugs Social circumstances and problems – loneliness and lack of network Forensic history – impulsive or aggressive traits MSE – symptoms of depression, suicidal thoughts , plans or intent to self harm
53. Circumstances and Comorbidity Interpersonal conflicts in 50 % who self harm Unemployment and physical illness Most common diagnosis – depression (50 – 90%) Substance use (25 – 50 %) Personality disorders common , particularly young people BUT 56 % will have 2 or more psych diagnosis Thus, what looks like another “borderline” might also have an underlying bipolar disorder etc
54. Help seeking behaviour in adolescents before and after the deliberate self harm actPercentage of adolescents who engaged in DSH and whosought help or talked to someone before and after theevent: Help source Before DSH After DSH (%) (%) Friend 43.7 49.8 Family 7.8 20.5 Health Service 11.1 15.3 Teacher 5.8 6.5
55. The epidemiology of suicidal behaviour: The iceberg phenomenon Suicide Deliberate self harm medically treated “Hidden” cases of deliberate self harm and related mental health problems
56. The majority of deliberate self harm patients are “hidden” from the services
57. Challengesfor Research and Prevention - Research into specific risk factors of suicide - Explaining cross-cultural differences in suicide rates - Implemenation of evidence based suicide prevention programmes in all countries Suicide - Standardised assessment and treatment referral - Research into the Deliberate self effectiveness of treatments for DSH patients harm medically treated “Hidden” cases of Evidence based deliberate self harm and mental health Promotion related mental health problems
58. Differentiating SIB from Suicide Attempts Assessment Suicide Attempt SIB (Walsh & Rosen, (Schneidman, 1985) 1988)1. What was the To escape pain; Relief fromexpressed and terminate unpleasant affectunexpressed intent? consciousness (e.g., anger, tension, sadness, etc.)2. What was the level Serious physical Little physicalof physical damage damage; lethal means damage and/or non-and potential of self-harm lethal means usedlethality?3. Is there a chronic, Rarely chronic Frequent, chronicrepetitive pattern and repetition; some high-rate patternpotential lethality? overdose repeatedly
59. Differentiating SIB from Suicide Attempts Assessment Suicide Attempt SIB (Walsh & Rosen, (Schneidman, 1985) 1988)4. Have multiple Usually one method Usually more thanmethods of self- one methodinjury been used overtime?5. What is the level of Unendurable and Uncomfortable andpsychological pain? persistent intermittent6. Is there Extreme constriction; Little or noconstriction of suicide is the only way constriction; choicescognition? out; seeking a final available; seeking a solution temporary solution
60. Differentiating SIB from Suicide Attempts Assessment Suicide Attempt SIB (Walsh & Rosen, (Schneidman, 1985) 1988)7. Are there feelings of Hopelessness and Periods of optimismhopelessness and helplessness are and some sense ofhelplessness? central control8. Was there a No immediate Rapid improvement;decrease in improvement; rapid return to usualdiscomfort following treatment required cognition and affectthe act? for improvement9. What is the core Depression and/or Body alienation;problem? rage about exceptionally poor inescapable body image (in unendurable pain clinical populations)
61. Similarities Between SI Addiction and SA Addiction Unhealthy, unsafe way of “coping” Numbing or avoiding emotional pain Distraction from pain The “rush” The secretiveness/illicitness “Stress” reliever You cannot force someone to stop self- injuring, just like you cannot force someone to stop abusing substances
62. Clinical Tip – the Dos and Don’ts of CuttingDo… Talk openly about it – If you are comfortable talking about, clients will be too Take this very seriously and explore the issue of suicidal ideation Ask about other forms of self-injury Be supportive Help clients identify the factors that lead to cutting and the feelings behind it Help clients identify healthy alternatives to dealing with their feelings
63. Clinical Tip – the Dos and Don’ts of CuttingDon’t… React with anger, fear, or revulsion Assume this is a phase that they will outgrow Assume that they are not thinking about suicide Tell them to stop – getting into a power struggle does not stop the behavior, serves to increase resistance, and impairs the therapeutic relationship Assume self injury is manipulation
64. What To Look For Unexplained cuts, scratches, burns, or bruises Excuses such as, “my cat scratched me” Clothing inappropriate for the weather Reluctance to dress out for physical education class or swimming Dressing to fit in
65. Clinical Tip – Use Pop Culture Use pop culture like movies, music, scripted TV shows, reality TV shows, You Tube, blogs, etc. in therapy to facilitate discussion of difficult topics like self injury Clients are not only very likely to connect to movies, songs, etc., but they are also more likely to address delicate issues and feel more comfortable discussing “characters” than discussing themselves directly
66. Prognosis Subsequent risk of suicide – at least 3% and up to 10 % after 10 or more years DSH is an ominous sign for repeated acts 40 % will repeat self harm 13 % will do this within the first year
67. Dangers Can become desperate about lack of self- control and addictive-like nature of acts May lead to true suicidal attempts Self-injury may cause more harm than intended. Can result in medical complications or death Eating disorders/AODA intensifies threat to overall health and quality of life
68. Self-Injury: Interventions• Accept reality and find ways to make the present moment more tolerable.• Identify feelings and talk them out rather than acting on them.• Distract themselves from feelings of self- harm (for example, counting to ten, waiting 15 minutes, saying "NO!" or "STOP!”
69. Self-Injury: Interventions• Stop, think, and evaluate the pros and cons of self-injury.• Soothe themselves in a positive, non- injurious, way.• Practice positive stress management.• Develop better social skills.• Hospitalization
70. Reducing Self-Mutilation Viewed as means of replacing emotional pain with “fake pain”, or physical pain that is under control of patient Non-adaptive approach to distraction To replace anger: Engage in physical task. Punch doll, crush aluminum cans, make doll cut or tear instead of self.
71. Reducing Self-Mutilation Feeling depersonalized: Replace self- mutilation with something that hurts: Squeeze ice-cube for 1 minute. Put ice on spot you want to burn. Slap tabletop hard. Snap wrist with rubber band. Take cold bath Wanting focus: Do other task (cleaning room, play computer game) that requires focus. Find simple object (paper clip) and try to name 30 uses for it
72. Reducing Self-Mutilation Wanting to see blood: Draw on self with red felt pen. Use food coloring bottle (red, naturally) and draw it across area you want to cut as if it were a knife. Wanting to see scars, pick scabs: Use henna tattoo kit. Put henna on as paste. Picking it off when dry feels like scab, leaves red mark like a scar
73. Case Scenario Called by A/E to see a 28 year old female who has presented after ingesting 25 paracetamol and 20 fluoxetine after the break up of a relationship. Used to be a regular attender with self harm a few years ago. You are requested to do a psychosocial assessment. What are you going to do?
75. Case Scenario Had the tablets at home Boyfriend left her that day Thinking about it for a few hours Drank half a bottle of vodka Took the tablets but vomited afterwards Didn’t expect mother to come round Wanted to die but now not sure No suicide note Similar episode 3 years ago
76. AssessmentSuicidal Intent Method Premeditated Suicide note Wanted to die at time of attempt Tried to avoid discovery Alcohol/ Drug use Precipitant of self harm Previous self harm
77. “I got the impression that [thepsychiatrist] wanted to get it overand done with as quickly as hecould and get on with whatever it ishe had to do next. There wasnothing personal about it”
78. “O.K. The first interview was just „so tell uswhat happened‟ and he wrote it up and said„um hm, um, hm‟ and wrote notes and he didn‟tlook at me but he was nodding and looking atthe other guy. And they looked at each otherand exchanged nods. It was very factual like„So what did you take?‟ and „What happened atthe house?‟ Um, you know I felt like saying „Ican understand English, doctor.‟ It was justvery factual. They filled out their little form andthat was it”