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Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries
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
http://www.samhsa.gov/data/2k9/165/suicide.htm
8. 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
9. 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
10. 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
12. „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
13. 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
15. "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
16. 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
17. 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.
18. 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.
19.
20. 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
21. 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
22. 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
23. 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
24. 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.
http://consumer.healthday.com/Article.asp?AID=661301
Nationwide Children’s Hospital, Columbus, OH
25. Assessment for Ongoing Abuse
Professional Assessment of Suicide Risk
Treatment of Underlying Depression, Psychosis
Substance Abuse Rehabilitation/Treatment
Home Assessments/Family Therapy
PEER therapies
26. SOS@ High School Program
Suicide prevention
Training Trusted Adults
Professional development for school employees
ACT@ (Acknowledge-Care-Tell)
Peer-to-peer help-seeking model
http://www.mentalhealthscreening.org/
27. 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).
http://www.mentalhealthscreening.org/programs/youth-prevention
28. 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.
29. 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
http://www.witnessjustice.org/health/siv_whitepaper.pdf