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SELF HARM & ITS HIDDEN TRAUMA
Mary Nan S Mallory MDProfessor 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 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.
The Self-harm Spectrum
Suicidality
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
The Self-harm Spectrum
Methods of Self-Harm
Methods of Self-Harm
Posterior Left Shoulder view
Perspectives on Self-Harm
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
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)
Perspectives on Self-Harm
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
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.”
Perspectives on Self-Harm
fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders, June 2013
diagnostic Labels forSelf-Harm (SH)
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
Definition of Self-Harm
‘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
Methods of Self-Harm
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
"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
Psychodynamic of Self-injury
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
Psychodynamic of Self-injury
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.
Psychodynamic of Self-injury
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.
Risk Factors for Self-injury 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
Psychological Signs 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
Recurrent Self-harmers report:
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
Family of Disabled Youth report:
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
Sobering Stats:
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
Referral & Treatment Strategies
Assessment for Ongoing Abuse
Professional Assessment of Suicide Risk
Treatment of Underlying Depression, Psychosis
Substance Abuse Rehabilitation/Treatment
Home Assessments/Family Therapy
PEER therapies
Gatekeeper Strategies
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/
The SOS High School Program
Only school-based suicide prevention program on SAMHSA’s National 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
Immediate Relief Strategies
Go to a public placeWait 5 minutes and reassessYell aloud, listen to calming music, write in a journal Eat spicy foodRub an ice cube onto wristSnap a rubber band that is around your wristDraw with a red marker/pen at the site insteadCall 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.
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——Amy3http://www.witnessjustice.org/health/siv_whitepaper.pdf