COPING WITH SELF-INJURY
Stephanie Larsen, Psy.D. Clinical Psychologist Palm Beach Behavioral health & wellness DISCLOSURE STATEMENT
There is no conflict of interest or commercial support for this presentation. LEARNING OBJECTIVES
To be able to identify types of self-injury
To understand common reasons for onset of self-injurious behaviors
To understand how self-injury is perceived by the injurer as helpful
To be able to differentiate between self-injury and suicide attempts
To identify potential ways of treating self-injurious behaviors NON-SUICIDAL SELF INJURY (NSSI)
Non‐suicidal self‐injury (NSSI) has been defined as the deliberate, self‐inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned (ISSS, 2007) DSM-5 SECTION 3: EMERGING MEASURES & MODELS (AREAS OF FURTHER STUDY)
(A) In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm. The behavior is not a common one, such as picking at a scab or nail biting.
(B)The intentional injury is associated with at least 2 of the following: (1)psychological precipitant: interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act, (2)urge: prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist (3)preoccupation: thinking about self-injury occurs frequently, even when it is not acted upon (4)contingent response: the activity is engaged in with the expectation that it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterwards C)The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. (This criterion is subject to final approval on the use of criteria that relate symptoms to impairment.)
(D)The behavior does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior cannot be accounted for by another mental or medical disorder (i.e., psychotic disorder, pervasive developmental disorder, mental retardation, Lesch–Nyhan syndrome, stereotyped movement disorder with self-injury, or trichotillomania).
(E)The absence of suicidal intent has either been stated by the patient or can be inferred by repeated engagement in a behavior that the individual knows, or has learnt, is not likely to result in death COMMON FORMS OF NSSI
Cutting (70%)
Burning
Scratching
Hitting/ Punching Self
Biting
Pulling out hair
Choking
Interfering with healing of wounds
Ingesting harmful toxins or substances WHO IS SELF HARMING?
This Photo by Unknown Author is licensed under CC BY-SA-NC It’s very difficult to have clear prevalence due to varying definitions
We CAN agree that onset is most frequently between 13 and 15 - 25% before the age of 12
7-8% of children 15% of teenagers 17% of College Students 1-4% of - Ranges: 14-38% -Ranges: 17- 35% Adults - NIMH(2015) estimates 9-16% with increase over last two decades MALE VS. FEMALE
Many studies suggest no difference between male versus female
Differ in type of self injury
Females seen more frequently in treatment
Boys seen more comorbidity with substance use 2x to be under influence of alcohol 5x to be under influence of drugs DON’T FALL INTO STEREOTYPES
WHY SO POPULAR IN OUR TEENAGERS?
Some individuals are contributing the increase in reported self-harm to be related to:
Increased violence and self-destructive themes in media
Increased choices and adult responsibilities placed on adolescents
Demand and intensity of peer groups (effects of social media)
Stress Overload
Focus on quick fixes, immediate gratification
Societal shift to thinking things should be painless and easy
Selekman, 2009. (#4) 2:10 TO 3:53 SIB AND CULTURE
http://www.selfinjury.bctr.cornell.edu/resources.html#tab6 NEUROBIOLOGICAL MATURATION
Prefrontal Cortex, including frontal lobes, goes through significant changes in adolescent Correlated with significant behavioral change: learning to regulate emotions, make plans, and control impulses
Animal Studies indicate highest density of dopamine receptors during adolescence Correlated with significant responsiveness to reward signals Risky choices and processing emotional information create much higher activation in amygdala and dopamine receptors than children or adults
Adolescents display exaggerated stress response due to increased steroid hormone, cortisol, released from the Hypothalamic-Pituitary-Adrenal (HPA) axis Increased activity in the HPA and increased cortisol contributes to high emotional reactivity
Ballard, E., Bosk, A., & Pao, M. (2010) Invited Commentary: Understanding brain mechanisms of pain processing in adolescents’ non-suicidal self injury. Journal of Youth and Adolescence, 29 (4) WHAT WERE YOU DOING AT 15? WHAT DO TEENS HAVE TO WORRY ABOUT?
Homework College Frenzy (2016)
1 to 5 hours a night for middle 69% high school seniors enroll AND high school students directly into college 65% acceptance rate at a “typical school”. 71% in Average high school student 2001 with 5 classes= 17.5 hours per week 19.9 million students projected (2018) > 15.3 million students in fall 2010 Ivy League school acceptance rates fell approximately .5-1% from last year Bullying (CDC, 2015)
• 35% of 12-18 –year-olds report traditional bullying • 15% have been cyber-bullied in last year
Sex and Relationships (CDC,2015)
• 41% of high school students have had sexual intercourse • 30% have had sexual intercourse in the last three months; 43% of these individuals did not use a condom • (2013) 15% of high sexually active high school students have had sex with four or more partners • (2014) 22% of girls and 18% of boys have sent nude pictures or semi-nude pictures to others • (2014) anonymous online undergraduate study indicates over 50% reported sending nude pictures during high school
24 Hour Media Exposure
Importance of Peer Acceptance/ Interpersonal Relationships
• Self Identity is developed by peer feedback in early adolescents
Sport Performance or Extracurricular Activities
• 66% of students
LOGIC- 1-800-273-8255
• September 24, 2018 = 292, 114,170 YouTube views • 50% increase in calls following VMA performance • In the last year it has remained 25% higher usage • https://www.youtube.com/watch?v=Kb24RrHIbFk DESENSITIZATION IN MEDIA CONTINUED…
YouTube 8.5 million “Cutting” videos (two year’s presentation) 19.6million “cutting” videos (last years presentation) 1.2 million “self harm” Suicide Prevention hotline and text line provided - FACEBOOK
YOU CAN FLAG PICTURES OR STATUSES THAT SUGGEST SUICIDAL IDEATION OR SELF HARM BEHAVIORS AND FACEBOOK WILL PROVIDE OPTIONS FOR RESOURCES FOR BOTH INDIVIDUALS INCREASING THE ODDS…
Being Female (for cutting)
Being an ‘early teen’
Having friends that self-harm
Traumatic Life Events Death, abuse, questioning identity, unstable home
Mental Health Issues
Use of Alcohol or Illicit Substances
Less Parental Supervision/ Involvement ATTEMPTING TO UNDERSTAND… HTTP://WWW.YOUTUBE.COM/WATCH?V =ZVB3M4Z8ZHC FUNCTION OF SELF INJURY
Primarily, an attempt to COPE and a physical expression of being OVERWHELMED
It is continued because to many it is an effective coping mechanism AFFECT REGULATION
Many adolescents report anxiety, depression, feeling “sad,” “lonely,” and “alone” prior to engaging in self-harm 63-78% for emotional distress
Attempt to escape from trapped feelings of psychological and emotional distress which they cannot find a way to solve or cope with
Temporary distraction from anxiety, depression, rejection, or distress PAIN
Our brains use the same two areas to sense physical and emotional pain the anterior insula and the anterior cingulate cortex. Pain relievers also act in these two areas seamlessly: Tylenol will relieve distress associated with emotional distress and physical pain. Pain causes inhibition of the amygdala and emotional centers of the brain. Physical pain acts as an emotional regulation mechanism since emotional and physical pain are interpreted in the same area SOCIAL DISTRESS AND PAIN
“Social Pain” primarily perceived by adults demonstrates significant activation of the ACC and decreased activation of Prefrontal Cortex. In adolescents activation in the insula and Prefrontal Cortex AND differential activation in the subgenual ACC and ventral striatum Decoded: Adolescents experience social pain in different regions of the brain than adults Pain causes inhibition of the amygdala and emotional centers of the brain. PAIN AND SELF INJURY
Those that engage in NSSI experience heightened emotional distress Heightened activation of limbic circuitry to both positive and negative emotions Heightened amygdala activation correlating to more emotion regulation problems Experience higher physiologic reactivity Higher pain threshold under both stress and non-stress conditions Less sensitive to thermal stimuli and laser radiant heat pulses Pain thresholds increase when distressed Associated with changes in system moderating affective responses: Anterior Cingulate Cortex (ACC) and amygdala Demonstrate difficulties social problem solving Select more maladaptive responses and report lower self efficacy in ability to perform solutions
Less distress tolerance abilities FIGHT OR FLIGHT #1 (5:06-7:30)
http://www.selfinjury.bctr.cornell.edu/resources.html#tab6 CHANGES COGNITION
Effective in distracting from thoughts: Mindfulness
Re-focuses problems
Temporarily stops suicidal thoughts FORM OF SELF-PUNISHMENT
“ I deserve to be in pain”
“I deserve to be punished”
“I’m bad and evil”
Related to Trauma
Failed perfectionism
Validation of perceived trauma STOPPING DISSOCIATION
To discredit feelings of numbness or emptiness
“To Feel”
To increase self-awareness
Can be one of the most dangerous reasons for NSSI
Cold Pressure Test– Measuring Pain tolerance NSSI tend to be double the pain tolerance as non NSSI numb to physical AND emotional INTERPERSONAL/ COMMUNICATION/ CONTAGION
Often falsely labeled as attention seeking
Communication of distress 33-56% interpersonal functions
Communicating insecure attachment or validation from family
Secondary gain of escaping from negative situations
An extension of self identity HIGHLY REACTIVE INDIVIDUALS
Urge to physical express all feelings
Highly reactive individuals experience more affect and emotion
Some research suggests not necessarily the highly reactive individuals, but Highly Reactive Individuals who tend to suppress their emotions
greater emotional sensitivity, greater emotional reactivity (increased amygdala activity) and a slower return to baseline arousal SUICIDE VERSUS SELF INJURY
Although distinct from suicidal behavior, NSSI frequently co-occurs in adolescents who have contemplated or attempted suicide in the past.
Joiner’s Theory suggests that habituation to fear and physical pain, such as that associated with suicidality, increases the desire and the capability to engage in lethal self-injurious behaviors (Nock, Joiner, Gordon, et al, 2006). THE POTENTIAL RISK FACTORS..
Research has identified correlations with increased suicide attempts in individuals who self injure and….
Develop absence of pain during self-injury
Have a longer history of self-injury
Number of self injury methods DIFFERENCES
Differs in intent Self-Injury does not hold the intent for death NSSI desires more control over feelings; whereas suicide is attempt to not feel
Differs in Means 98% of individuals who completed or attempted suicide do not do so by cutting (guns, overdose, jumping, hanging, etc) Cutting accounts for 1.2% of suicidal deaths (CDC, 2005)
Discomfort following the act
Self‐injurers are nine times more likely to report suicide attempts than non self‐injurers. (Whitlock et al, 2006) ASSESSING FOR SELF-INJURY ASSESSING SELF-INJURY
Clearly ask direct questions
Assess immediate harm self-injury poses Severity and extent Intensity and frequency
Motivation for SI/ Function of SI
Location on the body Alarming areas: face, eyes, breasts, genitals
Determine outpatient vs. inpatient
Assess suicidal ideation, plans, and intent Self-Injury Assessments
-Self Harm Inventory (Sansone & Sansone, 2010)
-Suicide Attempt Self-Injury Interview (SASII) -Formerly PHI (Linehan et al. 2006)
-Deliberate Self Harm Inventory (DSHI; Gratz, 2001)
-Functional Assessment of Self- Mutilation (FASM; Lloyd et al. 1997) FIRST THINGS FIRST IN TREATMENT…. What is the function of the behavior? You are treating the underlying cause NOT the self-injury
- Depression - PTSD - Anxiety - Interpersonal Difficulties - Eating DO - Invalidating Environment - Substance Abuse - Poor Coping Strategies - Borderline Personality - Adjustment DO THERAPEUTIC INTERVENTIONS
Therapy Individual Therapy Family Therapy Research indicates group therapy can be detrimental
Potential Inpatient Hospitalization
Psychopharmacology
12-step programs
Stress Reduction and Management Skills COMMON TREATMENT ORIENTATIONS
Dialectical Behavioral Therapy Emotional Regulation Self invalidation Distress Tolerance Interpersonal Effectiveness Self-Awareness
Cognitive Behavioral Therapy Automatic thoughts/ Core Beliefs Cognitive Distortions and collaborative evaluation of thoughts Cognitive Restructuring WALKING THROUGH CBT
1.) Identify the situation 2.) Recognize the feelings 3.) Identifying the thoughts - Thinking leads to feelings…How did you get to this feeling? - 4.) Evaluate your thoughts - What evidence do I have for and against this thought? How might others think in this situation? Is this a distortion? - 5.) Take Action - What new thought might we want to introduce/ combat distortion - Note any change in distress FAMILY THERAPY
Assess for validation and distress tolerance within the family Begins with validation, psychoeducation, family DBT, and communication Structure is important and therapist neutrality Family chain analysis can help each person understand their contribution to the problem and role in resolution Body Image Work
Motivational Interviewing How is the behavior ineffective at resolving real underlying issues Readiness to change and improving therapeutic alliance
Meditation and Mindfulness Training http://www.selfinjury.bctr.cornell.edu/resources.html#tab6 Example MEDITATION CHANGES BRAIN 9:14 TO 14 (#1) 3:50 TO 5:37 (#4) THERAPEUTIC ALLIANCE
3 main components Therapist-client bond Agreement on therapeutic tasks Agreement of therapeutic goals
Most effected by client’s perception of collaboration on treatment goals and commitment to change
Client rated commitment and client-rated therapist’s understanding were significantly related to decrease in NSSI KEY COMPONENTS
Support, Validation, and aid in Understanding Behaviors
Learning to Correctly Identify feelings Depolarization
Coping Skills
Building Self-Esteem
Treat the underlying root of the problem ACTIVITIES
Identify feelings and express in some way Journal, Draw, Paint, Write music lyrics, dance, art
Distract yourself for 15 minutes
Talk to someone
First Aid Therapy Kit
Relaxation
Problem solve- create a pro and con list
Music- inspirational
Exercise TREATMENT MYTHS
Be CAUTIOUS: Negative Replacement Behaviors i.e. Hold an ice cube, red pen, rubber band, BenGay/ IcyHot Allows continued fixation on self-harm and not on distress tolerance Some argue beneficial during transition period
Only focusing on cutting acts of self-injury
Self Harm Contracts
Attention Seeking Ignore and punish HOW TO HELP OTHERS…
If episode is severe seek immediate medical assistance (hospital emergency room)
Obtain professional therapeutic help
Provide nurturing support
Listen without judgment
Manage your reaction
Get Informed
Role model coping strategies THOUGHTS FOR RESIDENTIAL PROGRAMS
Contagion Factors Competition Affiliation Communication
Manage Reactions Focus on emotion and motivation, not behavior
Identify Community Protocol
Intervene during “war stories”
Wear long sleeves or jewelry after recent injuries to hide bandages– avoid bandage only PsychologyToday.com or Selfinjury.com to find local therapists
http://www.selfinjury.bctr.cornell.edu
H ttp://www.selfinjury.com/ (S.A.F.E. Alternatives)
1-800-334-HELP (24 hour Self Injury Hotline)
1-800-273-TALK (24 hour crisis hotline)
1-800-SUICIDE (24 hour suicide hotline)
Text 741-741 REFERENCES
Bedics, J.D., Atkins D.C., Harned, M.S., and Linehan, M.M. (2015). The therapeutic alliance as a predictor of outcome in dialectical behavior therapy versus nonbehavioral psychotherapy by experts for borderline personality disorder. Psychotherapy, 52, (1), 67-77.
Center for Disease Control. 2014. National suicide statistics at a glance. Retrieved from http://www.cdc.gov/violenceprevention/suicide/statistics/self_harm.html on April 04, 2015.
Dahlstrom, O, Zetterqvist, M, Lundh, L., Svedin, C.G. (2015). Functions of nonsuicidal self injury: Exploratory and confirmatory factor analyses in a large community sample of adolescents. Psychological Assessment, 27, (1), 302-313.
Hamza, C.A., Willoughby, T., and Armiento, J. (2014). A laboratory examination of pain threshold and tolerance among nonsuicidal self injurers with and without self-punishing motivations. Archives of Scientific Psychology, 2, 33-42.
In-Alob, T., Burli, M., Ruf, C., & Schmid, M. (2013). Non-suicidal self-injury and emotion regulation: a review on facial emotion recognition and facila mimicry. Child and Adolescent Psychiatry and Mental Health, (7), 5. doi: 10.1186/1753-2000-7-5 International Society for the Study of Self-Injury. Fast facts about self-injury. Retrieved from: http://www.itriples.org/isss- fastfacts.html on February 27, 2014.
Jacobs, Bruce. (June 2010). Adolescents and self-cutting (self-harm): Information for parents. New Mexico State University Newsletter , I-104.
Kerr, P.L, Muehlenkamp, J.J., & Turner, J.M. (March-April 2010). Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. Journal of American Board of Family Medicine, 23 (2), pg 240-259.
Lader, Wendy. (10/2/2013). Once an obscure Psychiatric Symptom, Now and Alarming Mainstream Problem. S.A.F.E. Alternatives St. Louis, MO presentation.
Mayo Clinic Staff. Diseases and conditions: Self-injury and cutting. (2012). Retrieved from http://www.mayoclinic.org/diseases-conditions/self- injury/basics/definition/con-20025897 on February 27, 2014.
National Campaign to Prevent Teen Pregnancy. “Teenage Sexting Statistics.” Guardchild. Accessed April 2015.
Nock MK, Joiner TE, Gordon KH,et al. (2006).Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Res.144:65–72.
Peterson, J., Freedenthal, S., Sheldon, C., & Andersen, R. (2008). Psychiatry, 5(11) 20-26.
Selekman, M.D. (2009). Helping self-harming students. Health and Learning, 67 (4), 48-53.
Simeon, D., & Hollander. , E.(2008). (Eds.). Self-injurious behaviors; Assessment and treatment. Washington. DC: American Psychiatric Publishing.
Walsh, B.W. (2008). Treating Self-Injury; A Practical Guide.
Whitlock J, Eckenrode J, & Silverman D. Self-injurious behaviors in a college population. Pediatrics 2006; 117: 1939–48. THOUGHTS FOR RESIDENTIAL PROGRAMS Contagion Factors Competition Affiliation Communication
Manage Reactions Focus on emotion and motivation, not behavior Exposure
Identify Community Protocol Key Stakeholders Assessment for safety Medical Evaluation
Intervene during “war stories”
Wear long sleeves or jewelry after recent injuries to hide bandages– avoid bandage only Drugs and Alcohol (2015 National Institute on Drug Abuse) Alcohol By age 15= 35% of teens have had at least one drink By age 18= 65% of teens have had at least one drink Median age of drug and alcohol use is 14 SOURCE: JOHNSTON, L.D.; MIECH, R.A.; O'MALLEY, P.M.; ET AL. MONITORING THE FUTURE NATIONAL SURVEY: TRENDS IN 30-DAY PREVALENCE OF USE OF VARIOUS DRUGS IN GRADES 8, 10, AND 12, 2015. ANN ARBOR, MI: INSTITUTE FOR SOCIAL RESEARCH, UNIVERSITY OF MICHIGAN, 2015. AVAILABLE AT: HTTP://WWW.MONITORINGTHEFUTURE.ORG/DATA/15DATA/15DRTBL3.PDF. ACCESSED 01/06/2016.