Mary Nan S Mallory MD
Professor and Residency Program Director
Department of Emergency Medicine
University of Louisville
…in a group of students at two Ivy
League universities who were
willing to respond anonymously to
a survey, nearly 20 perc...
Self-harm (DSH) Behaviors
Youth Prevalence Rate 15-20%
81% School Counselors impacted
Suicide
Completion
#3 Cause of
Death...
Of the adults who attempted suicide in the 2008:
62.3 % received medical attention for their
suicide attempts
46.0 % staye...
Burns
Cuts
Self-hitting
Self-poisoning
Object
Ingestion/Inserting
Tobacco
Excessive alcohol
consumption
Excessive risk-tak...
Posterior Left Shoulder view
Neurotic: nail-biters, pickers, extreme hair removal, cosmetic surgery
Religious – circumcision, self-flagellants and auto...
Ear-piercing, nail-biting, small tattoos, cosmetic
surgery
(not considered self-harm by the majority)
Piercings, saber sca...
Issues for DSM-V: Suicidal Behavior as a
Separate Diagnosis on a Separate Axis
Am J Psychiatry 2008;165:1383-1384. doi:10....
 Self-injury (SI)
 Self-mutilation
 Para-suicide
 Self Inflicted Violence (SIV)
 Non-Suicidal Self Injury (NSSI)
 Mi...
„a wide range of things that people do to
themselves in a deliberate and usually
hidden way, which are damaging’
Camelot F...
 Cutting
 (making cuts or severe scratches on different parts of the body
with a sharp object)
 Burning
 (with lit mat...
http://self-injury.net/
"A lot of people quit when they get out of the
situation that's triggering it, but not everybody
does."
”…there tends to b...
Trauma impacts one‟s sense of having power and
control, of being able to acknowledge and
guide internal and external exper...
 Our tardiness in acknowledging the prevalence of
self-harm is tied to our tardiness in coming to
acknowledge the prevale...
 Coping Strategy  Prevents Suicide (attempt) ?
 At the milder end of the spectrum, these
behaviors include mild to mode...
 History of self-harm and/or previous suicide attempt
 Mental or substance use disorders, especially
depression
 Physic...
 Obvious changes in mood, sleeping and eating
patterns
 Losing interest and pleasure in activities
 Decreased participa...
 To feel real, get a sense of physical boundaries
 To diminish intense emotions: despair, terror, self-hate,
rage, shame...
 A release of emotions
 As a means of communication
 To appropriate a reaction from someone
 There being a physical ca...
Most Teens Who Self-Harm Are Not
Evaluated for Mental Health in ER
(2/14/2012)HealthDay News
Most children and teens who d...
Assessment for Ongoing Abuse
Professional Assessment of Suicide Risk
Treatment of Underlying Depression, Psychosis
Substan...
 SOS@ High School Program
 Suicide prevention
 Training Trusted Adults
 Professional development for school employees
...
 Only school-based suicide prevention
programon SAMHSA‟sNational Registry of
Evidence-based Programs and Practices that
a...
Go to a public place
Wait 5 minutes and reassess
Yell aloud, listen to calming music, write in a journal
Eat spicy food
Ru...
Excellent and effective
An excellent worker—
The day flows by smiling and productive
with co-workers—
The night falls And ...
Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries
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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Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries

  1. 1. Mary Nan S Mallory MD Professor and Residency Program Director Department of Emergency Medicine University of Louisville
  2. 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. 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. 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
  5. 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. 6. Posterior Left Shoulder view
  7. 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. 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. 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. 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. 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. 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. 13. http://self-injury.net/
  14. 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. 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. 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. 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. 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. 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. 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. 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. 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. http://consumer.healthday.com/Article.asp?AID=661301 Nationwide Children’s Hospital, Columbus, OH
  23. 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. 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 http://www.mentalhealthscreening.org/
  25. 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). http://www.mentalhealthscreening.org/programs/youth-prevention
  26. 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. 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 http://www.witnessjustice.org/health/siv_whitepaper.pdf

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