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Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries
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Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries


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  • 1. Mary Nan S Mallory MD Professor and Residency Program Director Department of Emergency Medicine University of Louisville
  • 2. …in a group of students at two Ivy League universities who were willing to respond anonymously to a survey, nearly 20 percent reported self-injury, and more than a third of them had never told anyone about it. Whitlock, J., Eckenrode, J, Silverman, D. 2006. “Self-Injurious Behaviors in a College Population.” Journal of Pediatrics 117 (6): 1939–48.
  • 3. Self-harm (DSH) Behaviors Youth Prevalence Rate 15-20% 81% School Counselors impacted Suicide Completion #3 Cause of Death ages 14-25 Suicide Attempt 1.2 % ages 18-25
  • 4. Of the adults who attempted suicide in the 2008: 62.3 % received medical attention for their suicide attempts 46.0 % stayed overnight or longer in a hospital for their suicide attempts
  • 5. Burns Cuts Self-hitting Self-poisoning Object Ingestion/Inserting Tobacco Excessive alcohol consumption Excessive risk-taking behavior Insufficient exercise Over/under eating, Stress
  • 6. Posterior Left Shoulder view
  • 7. Neurotic: nail-biters, pickers, extreme hair removal, cosmetic surgery Religious – circumcision, self-flagellants and auto-sacrifice Puberty rites – hymen removal, circumcision or clitoral alteration Psychotic – eye/ear removal, genital self-mutilation, amputation Organic brain diseases – repetitive head-banging, hand-biting, finger- fracturing or eye removal Conventional – nail-clipping, trimming of hair and shaving beards. Menninger, K. (1935), "A psychoanalytic study of the significance of self-mutilation", Psychoanalytic Quarterly: 408–466
  • 8. Ear-piercing, nail-biting, small tattoos, cosmetic surgery (not considered self-harm by the majority) Piercings, saber scars, ritualistic clan scarring, sailor and gang Tattoos Wrist/body-cutting, Self-inflicted cigarette burns, Wound-excoriation Auto-castration, Self-enucleation, Amputation (psychotic decompensation) Adapted from Walsh, B. W., & Rosen, P. M. (1988), Self Mutilation: Theory, Research and Treatment, Guilford. of N..Y, NY., ISBN 0-89862-731-1
  • 9. Issues for DSM-V: Suicidal Behavior as a Separate Diagnosis on a Separate Axis Am J Psychiatry 2008;165:1383-1384. doi:10.1176/appi.ajp.2008.08020281 “Personal history of self-harm” is a new diagnostic category listed in what are called the V-codes. These diagnoses are not considered mental illnesses in and of themselves, but rather are “other conditions or problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder.” fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders, June 2013
  • 10.  Self-injury (SI)  Self-mutilation  Para-suicide  Self Inflicted Violence (SIV)  Non-Suicidal Self Injury (NSSI)  Misapplied Malingering, Munchausen‟s Syn, Borderline Personality Disorder  Misinterpreted as Child (or Date) abuse
  • 11. „a wide range of things that people do to themselves in a deliberate and usually hidden way, which are damaging’ Camelot Foundation/Mental Health Foundation, 2004
  • 12.  Cutting  (making cuts or severe scratches on different parts of the body with a sharp object)  Burning  (with lit matches, cigarettes or hot sharp objects like knives)  Carving words or symbols on the skin  Breaking bones  Hitting or punching  Piercing the skin with sharp objects  Head banging  Biting  Pulling out hair  Persistently picking/interfering with wound healing
  • 13.
  • 14. "A lot of people quit when they get out of the situation that's triggering it, but not everybody does." ”…there tends to be a natural turning point where people drop off. As you get older, there are fewer” “Teenagers who started in their early teens still constitute more than 50%...the next biggest group is people in their 20s, and then there's a drop off." “The people who self-harm to fit in with a social group – this became another curious part of her research – or see it as a passing fashionable rebellion fall off earlier. I think it will peak as a fad eventually, and then settle down.” Adler & Adler, 2011- an ethnographical look
  • 15. Trauma impacts one‟s sense of having power and control, of being able to acknowledge and guide internal and external experiences. Control is a crucial issue for many trauma survivors, and it is the thread that runs through the experience of self-harm
  • 16.  Our tardiness in acknowledging the prevalence of self-harm is tied to our tardiness in coming to acknowledge the prevalence of violent trauma in our culture and the tendency toward violence in ourselves. . . .  For many abused and traumatized people who have plenty to scream and cry about, self-harm is what happens when screams are not listened to.  —S.K. Farber Farber, S.K. 2000. When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments, Northvale, NJ, Jason Aronson p 107.
  • 17.  Coping Strategy  Prevents Suicide (attempt) ?  At the milder end of the spectrum, these behaviors include mild to moderate self-injury as a response to emotional pain and, at the more extreme end, attempted suicide Skegg K. Self-harm. Lancet. 2005 Oct 22-28;366(9495): 1471-1483.
  • 18.  History of self-harm and/or previous suicide attempt  Mental or substance use disorders, especially depression  Physical illness: terminal, painful or debilitating illness  FH: suicide, substance abuse, psychiatric disorders  History of sexual, physical or emotional abuse  Social isolation  Bereavement in childhood  Family disturbances  Rejection by a significant person e.g.relationship breakup  Mental health or substance use disorder
  • 19.  Obvious changes in mood, sleeping and eating patterns  Losing interest and pleasure in activities  Decreased participation and poor communication  Problems in social, work, intimate relationships  Hiding or washing their own clothes  Avoiding situations were exposure of arm and legs is required (e.g. swimming)  Strange excuses provided for injuries
  • 20.  To feel real, get a sense of physical boundaries  To diminish intense emotions: despair, terror, self-hate, rage, shame  To facilitate dissociation, to disconnect from oneself  To make pain visible  To communicate what cannot be said verbally  To express anger at someone else by directing it at one‟s own body  To avoid violence toward another  To feel part of a group of peers who self-injure  To stop flashbacks of abuse  To facilitate remembering  To punish oneself  To symbolize spiritual beliefs
  • 21.  A release of emotions  As a means of communication  To appropriate a reaction from someone  There being a physical cause  Low self-worth/self-efficacy  To obtain something tangible  A lack of choice and control  Being in disempowering circumstances  Having a lack of control within their living environment  Having the opportunity to do so
  • 22. Most Teens Who Self-Harm Are Not Evaluated for Mental Health in ER (2/14/2012)HealthDay News Most children and teens who deliberately injure themselves are discharged from emergency rooms without an evaluation of their mental health, a new study shows. The findings are worrisome since risk for suicide is greatest right after an episode of deliberate self-harm. The majority of these kids do not receive any follow-up care with a mental health professional up to one month after their ER visit. Nationwide Children’s Hospital, Columbus, OH
  • 23. Assessment for Ongoing Abuse Professional Assessment of Suicide Risk Treatment of Underlying Depression, Psychosis Substance Abuse Rehabilitation/Treatment Home Assessments/Family Therapy PEER therapies
  • 24.  SOS@ High School Program  Suicide prevention  Training Trusted Adults  Professional development for school employees  ACT@ (Acknowledge-Care-Tell)  Peer-to-peer help-seeking model
  • 25.  Only school-based suicide prevention programon SAMHSA‟sNational Registry of Evidence-based Programs and Practices that addresses suicide risk and depression, while reducing suicide attempts.  In a randomized control study, the SOS program showed a reduction in self-reported suicide attempts by 40% (BMC Public Health, July 2007).
  • 26. Go to a public place Wait 5 minutes and reassess Yell aloud, listen to calming music, write in a journal Eat spicy food Rub an ice cube onto wrist Snap a rubber band that is around your wrist Draw with a red marker/pen at the site instead Call upon a peer 1-800-273-TALK (8255): National Suicide Prevention Hotline, a 24- hour crisis line for if you're about to self-harm 1-800-334-HELP (4357): The Self-Injury Foundation's 24-hour crisis line.
  • 27. Excellent and effective An excellent worker— The day flows by smiling and productive with co-workers— The night falls And with it the façade— Terror, lost time, flashbacks— Burning off the filth— Cutting away the painful memories— Beating the offending parts— Whatever it takes To find a moment of Relief— Until tomorrow comes— And I begin again——Amy3