department of psychology audience poll question #1 · audience poll question #2 2. true or false...

SELF-INJURY IN ADOLESCENTS AND

ADULTS

Edward A. Selby, Ph.D.

Assistant Professor

Department of Psychology

Rutgers, The State University of New Jersey

Rutgers Institute for Health, Healthcare Policy, and Aging Research

Families for Borderline Personality Disorder Research Investigator

Brain and Behavior Research Foundation

Licensed Psychologist, New York, NY#020331

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

2 Self-Injury

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

3 Audience Poll Question #1

1. Why do people engage in self-injury (without suicidal intent)?

a) To get out of doing something unpleasant.

b) To feel a rush of excitement.

c) To get attention from someone they love.

d) To escape feelings of emotional distress.

Answer:

d is the most typical reason reported, though b is very common too.

a & c happen, but are less common.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Nonsuicidal Self-Injury

• Direct and deliberate destruction of one’s own body tissue

in the absence of lethal intent (Nock, 2010)

• Often given different names in the literature:

• Deliberate self harm

• Self mutilation

• Parasuicidal behavior

• The term “nonsuicidal self injury” is preferred because it

makes the distinction between self injury and suicidal

behavior

• Often abbreviated to: NSSI

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

5 Nonsuicidal Self-Injury

• Most Common Methods:

• Skin cutting (70%)

• Head banging or self hitting (20-40%)

• Burning self (15-35%)

• Also: scratching to the point of drawing blood, pinching, hair pulling

• Most people employ multiple methods

• Prevalence: 13%-40% adolescents, adults 4%-28%

• Mixed literature on gender differences, but appears more

common in women

• Only “official” place in DSM-5 is as a symptom of

borderline personality disorder

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

6 Health Consequences

• Treatment from emergency medical services

• Nerve damage

• Progressively more severe self injury

• Poor academic functioning

• Peer rejection

• Accidental death

• Suicidal ideation or behavior

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Video

• The Silent Epidemic

• Video documentary

• Part One on YouTube:

https://www.youtube.com/watch?v=IAcSeVCnJSA&feature=relmfu

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

8 Self-Injury and Suicide

• Primary distinction is presence of suicidal thoughts and/or desires (suicidal ideation)

• If suicidal ideation is present when injury occurs, may be better thought of as suicide attempt or gesture

• 70% of adolescents who engage in self-injury reported a lifetime history of suicide attempts (Nock et al., 2006)

• Presence of self injury increases suicide risk 7 fold (Guan et al., 2012)

• Self injury may erode fear of suicidal behavior by habituation to pain (Van Orden et al., 2010)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

9 Risk Factors

• Alcohol or other substance use disorder

• Disordered body image

• Low global sense of self-worth

• Poor coping skills

• Rumination

• Thought suppression

• High conflict family environments

• Minority sexual orientation

• Peer rejection

• Bullying

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Important Risk Factors, Continued

• Genetics

• Female sex

• Maternal depression

• History of physical or sexual abuse

• Maternal borderline personality disorder

• Major depressive disorder

• Anxiety disorder

• Eating disorder (Anorexia Nervosa, Bulimia Nervosa)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

11

Borderline Personality Disorder

TURBULENT EMOTIONS

DYSREGULATED BEHAVIORS

SUICIDAL BEHAVIOR/SELF-INJURY

STORMY RELATIONSHIPS

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

12 Self Injury can be Confused with other

Diagnoses or Conditions• Suicidal behavior

• Psychotic disorders or substance use

• Developmental disorders

• Trichotillomania

• Excoriation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Developmental Disorders and Self Injury

• Self-Injury often occurs in developmental disorders

• Stereotypic Movement Disorder

• Developmental Delays

• Autism Spectrum

• However, most NSSI occurs in developmentally normal

adolescents and adults

• In developmental disorders, it is difficult to tell if behavior

is deliberate, and it is often repetitive and invariable

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

14 Trichotillomania

• Recurrent pulling out hair, often resulting in hair loss

• Repeated attempts to decrease or stop hair pulling

• Behavior causes distress or impairment

• Can lead to bald spots, social stigma

• NSSI can include hair pulling, but:

• Hair pulling in trichotillomania is often a result of boredom, anxiety,

or stress, and does not necessarily seem to “regulate” emotion

• Trichotillomania is often more compulsive than impulsive and often

involves playing with the hair

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

15 Excoriation

• Recurrent skin picking resulting in lesions

• Repeated attempts to decrease or stop picking

• Causes distress or impairment

• Not due to a substance or other condition

• NSSI can include skin picking, but:

• Excoriation is often focused on skin imperfections

• Picking can take place in short bursts or extended sessions

• Excoriation is often compulsive, rather than impulsive

• Self injury skin picking should involve a common self-injury

motivaiton

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Self-Injury In Adolescence

• Turbulent time for human development

• Family and peer problems are prevalent

• Unique and often challenging social context

• Bullying often serves as a trigger for suicidal ideation

• Social Media – Worsens many social problems

• Problematic online communities

• Online communities promoting self-injurious behavior

• Pro-anorexia websites

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

17 Online Promotion of Self Injury

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

18 Self-Injury In Adolescence

• Turbulent time for human development

• Family and peer problems are prevalent

• Unique and often challenging social context

• Bullying often serves as a trigger for suicidal ideation

• Social Media – Worsens many social problems

• Problematic online communities

• Online communities promoting self-injurious behavior

• Pro-anorexia websites

• However, important to remember that self-injury is most

common in adolescence, but the majority cease self-

injurious behavior once adults!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Self Injury Assessment

• Self Report

• Inventory of Statements About Self-Injury (ISAS; Klonsky & Glenn,

2009)

• 12 different methods of self-injury

• Rate functions of self-injury from 0 (never) to 2 (frequent)

• “releasing emotional pressure that has built up inside of me”

• “calming myself down”

• “causing pain so I will stop feeling numb”

• “doing something to generate excitement or exhilaration”

• “trying to feel something (as opposed to nothing) even if it is physical pain”

• Clinical Interview

• Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock et al.,

2007)

• http://harvardmagazine.com/sites/default/files/SITBI_LongForm.pdf

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

20 Nonsuicidal Self-Injury Disorder

• NSSI Disorder

• New DSM-5 Disorder for Further Consideration

• Not “technically” considered an actual disorder yet

• But finally giving self-injurious behavior the recognition of

importance necessary!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

21

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

NSSI Disorder Research

• Already much evidence to support this disorder (Selby et al.,

2015; Clinical Psychology Review)

• Fewer than 50% of self-injuring individuals have BPD

• NSSI causes significant clinical impairment (Selby et al., 2012)

• Important to distinguish from related behaviors (e.g.,

trichotillomania, excoriation)

• People with NSSI disorder appear to have much more

severe self injury, may be more reluctant to seek

treatment, but seem responsive to treatment (i.e., good

prognosis; Ward, Selby et al., 2013)

• However, there are still concerns about if NSSI disorder

would be clinically useful

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

23 Major Functions of Self Injury

• Social motivations

• Biological functions

• Anti-suicide function

• Self-punishment function

• Anti-dissociation function

• Feeling generation function

• Affect regulation function

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

24 Biological Contributions to NSSI

• Genetic factors account for 37% of the cause for self-injury in men,

and 59% in women, which means that familial and genetic factors

likely contribute much to the development of self-injury, especially for

women (Maciejewski et al., 2014)

• Opioid Hypothesis

• Self injury causes release of natural endorphins, which lead to feelings of

euphoria and can give self injury “addiction” like properties

• Role of opioids still unclear, as naloxone (opiate blocker) doesn’t prevent

self injury

• Increasing evidence that genes involved in serotonergic

neurotransmission may be linked to self-injurious behavior

(Groschwitz & Plener, 2012)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Vulnerability Psychopathology

Genetic

Biological

Social/Familial

Borderline Personality

Disorder

Self-Injury/Suicide

Eating Disordered

Behavior

Emotional Mechanisms!

?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

26

Emotional Cascades

Selby, Anestis, & Joiner, 2008, Beh Res Ther

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

27

Increased Emotional Intensity

EMOTIONAL CASCADE

Emotion

Rumination

Behavioral Dysregulation

Physical

Sensations

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Increased Emotional Intensity

EMOTIONAL CASCADE

Emotion

Rumination

Behavioral Dysregulation

Physical

Sensations

RELIEF

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

29

Selby et al. (2009)

J ABNORMAL PSY

10

12

14

16

18

20

22

24

26

28

BPD Control

Neg

ati

ve E

mo

tio

n

Group

Rumination Induction

Baseline

Post-Induction

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

30

Selby et al. (2009)

J ABNORMAL PSY

10

12

14

16

18

20

22

24

26

28

BPD Control

Ne

ga

tiv

e E

mo

tio

n

Group

Rumination Induction

Baseline

Post-Induction

p<.05

0

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Do Emotional Cascades

Predict

Future Dysregulated

Behaviors?

2007

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

32 Experience Sampling

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

33

Number Reported % Sample Reporting Behavior

Alcohol Use 50 45.30%

Reckless Driving 14 20.30%

Self-Injury 25 13.80%

Impulsive Shopping 21 25.60%

Marijuana Use 116 34.20%

Binge Episode 62 36.80%

Physical Fight 9 4.40%

Threw Object 20 29.00%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

High Lag-

Rumination

X

High Lag- Negative

Emotion

Predictive Validity

Immediate Future

Dysregulated Behavior

Signal 1

Signal 2

Selby & Joiner, 2013, PDTRT

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

35 Track It! Smartphone App

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

36

Kranzler, Selby, In Preparation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Audience Poll Question #2

2. True or False Question. Even though people who self-injure get very

upset, they should be able to control their emotions just as well as anyone

else if they put their mind to it.

a) True

b) False

Answer:

b – because of biological and psychological vulnerabilities, people with who

self-injure are likely to have very strong emotional responses, much

stronger than the average person. However, by learning skills and

practicing, they can learn to manage these emotions in a healthy way.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

38

Treatment Implications

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

39 Primary Treatments

• Research still very much lacking!

• Education about dangers and consequences of self injury

• Dialectical Behavior Therapy (Linehan, 1993)

• Emotion Regulation Group Therapy (Gratz et al., 2014)

• Cognitive Behavior Therapy (Stanley et al., 2014)

• Family Involvement in treatment is helpful for adolescents

(Stepp et al., 2012)

• Unfortunately no recommended or medication for self

injury as of yet!

• No conclusive study finding medication helpful for self injury

• Medication for co-occurring depression or anxiety can be helpful

though

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Mindfulness

Selby, Fehling, Panza, & Kranzler, in press, Mindfulness

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

41 Activities

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

42 Puzzles

Games

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

What Can Family Members Do?

• Knowing what is going on reduces negative reactivity and improves empathy, even in challenging situations

• Even being able to give a process a name, such as “emotional cascade” can help

1. Understand the emotion process of self-injury

• Work with them to come up with activities that they enjoy and are willing to do when distressed

• Develop a “coping card” of distracting activities, it is easy to forget strategies when you are distressed

2. Help your loved one distract when upset

• When we get frustrated, which can be easy at times, that can feed into the emotion dysregulation process

• Building emotion regulation skills takes time!

3. Try not to get frustrated

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

44 Reactions from Families and Friends

• Families, friends, educators often react with criticism,

discomfort, or horror when the behavior is discovered by

(Walsh, 2014)

• Important to respond to the disclosure of self-injury with

an understanding and supportive response

• However, do not minimize or trivialize the behavior

• Validates the individual’s emotional distress while at the

same time avoiding inadvertently appearing to approve of

the self-injurious behavior

• A “low-key, dispassionate demeanor” is recommended

when discussing self-injury (Walsh, 2014)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

45 Toolbox for Parents and Educators

• #1: Stay calm!

• Primary (and understandable) reaction is to become upset upon

discovery of Self injury.

• #2: Investigate – Don’t avoid

• Learn motives, triggers, interpersonal factors (home situation,

bullying)

• #3: Ask about suicidal thoughts

• Self injury is major risk factor for suicidal behavior

• Best thing to do is gently ask (again stay calm). Asking WILL NOT

cause one to become suicidal, and most people are relieve they

have someone to talk to about it

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Toolbox for Parents and Educators

• #4: Refer

• One self-injury picture is understood, adolescent should typically be

referred to onsite or outside mental health provider

• Team treatment approach is best, involving relevant teachers,

school nurse, mental health clinician/psychologist, and parents

• #5: Watch out for “contagion” phenomenon

• Sometimes adolescents encourage each other to self-injure, or

some students will hear about another student self-injuring and

then self-injure to get special treatment

• Social self-injury contagion more common in adolescent delinquent

settings

• #6: Remember that though self-injury is very serious,

majority of adolescents will mature out of this behavior, so

prognosis is good!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

47 Websites

• Adolescent Self Injury Foundation

• http://www.adolescentselfinjuryfoundation.com

• Self-Injury Outreach & Support

• http://www.sioutreach.org

• The Cornell Research Program on Self-Injury and

Recovery

• http://www.selfinjury.bctr.cornell.edu

• American Foundation for Suicide Prevention (AFSP)

• Because self-injury is so highly associated with suicide, it can be

important for clinicians, families, and patients to look into

foundations supporting suicide prevention and improving the

understanding of suicide.

• http://www.afsp.org

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide

48 Funding Acknowledgements and

Thanks to:

• Brain and Behavior Research Foundation (NARSAD) –

Young Investigator Grant

• Families for Borderline Personality Disorder Research

• National Institute of Mental Health

• Neil S. Jacobson Award for Outstanding and Innovative

Clinical Research

Contact: [email protected]

Website: www.edwardaselby.com

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

department of psychology audience poll question #1 · audience poll question #2 2. true or false...

Documents