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

Familiar Faces

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 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