Self Injurious Behaviors: Trends and Treatments

1. Self Injurious Behaviors: Trends and Treatments Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children’s Hospital and Regional Medical Center

2. Revisiting Definitions Recent Statistics: Prevalence Methods Trends Adolescent vulnerability Controversies Talking about suicide/self-harm Medications as a trigger Influence of the internet Causal Models Vulnerabilities to Self-Harm Biological Behavioral Biosocial Theory of Emotional Dysregulation Intervention Approaches Assessment Prevention Strategies Treatment Strategies Roadmap

3. Definitions: Suicidal and Self-injurious Behaviors

4. Self-Harm: Definition • Non-fatal, intentional self-injurious behavior resulting in actual tissue damage, illness or risk of death; or any ingestion of drugs or other substances not prescribed or in excess of prescription with clear intent to cause bodily harm or death.* • Intent may vary. Self-harm: • without intent to die • with ambivalent intent • with intent to die • * Some make distinction between DSH and SHB bec of behaviors that occur during dissociative states

5. Self-Harm vs. Suicide • Self-harm is major risk factor for completed suicide, either by accident or habituation • The higher the frequency of self-harm, the higher the risk for completed suicide • Self-harm is not a suicide prevention strategy!

6. Suicide and Suicide Attempts 3rd leading cause of death among adolescents 15-25 5th leading cause of death among youth 5-14 Multiple attempts for every completed suicide Self-harm Behaviors Community samples: 14% to 39% Psychiatric inpatient samples: 40% to 61% 25,000 ED visits yrly for self-harm related events Prevalence Adolescence is period of increased risk for self-harm behaviors as well as suicidal thoughts and behaviors

7. Recent Trends • Suicide • Declining rates 1992-2000 • Changing methods • Changing patterns w/i ethnic groups • DSH • Prevalence • Increases in frequency • Associated factors

8. Prevalence: Adolescent Suicide Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources:Anderson, 2002;CDC, 2002;National Center for Health Statistics, 1999. (prior to 1979, African-Americans not broken out.From:   GOULD: J Am Acad Child Adolesc Psychiatry, Volume 42(4).April 2003.386-405

9. Changing Trends in Methods 10-14 year olds FR: MMWR, CDC, 2004, 53:22

10. Changing Trends in Methods 15-19 year olds FR: MMWR, CDC, 2004, 53:22

11. Changing Trends • May reflect issues of access • Rapid shifts in youth suicidal behavior can occur • Differential profiles of risk, motivation, behavior, intent

12. Hispanics in US-1997-2001 • 2020 17% of populations • Rates of suicide lower overall but still 3rd leading cause of death among 10-24 yr olds • Methods: firearms, suffocation, poisoning • Growing risk: Hispanics in grades 9-12, particularly females, report more sadness, hopelessness and suicidal ideation and attempts than while or black non Hispanics • Hyp risk factors: mental illness, substance use, acculturative stress, family issues, low SES

13. Associated Factors: Exposure to self-harm in friends, family Smoking (fewer than 5 cigarettes/wk) Boyfriend/girlfriend problems Amphetamine use Self-prescribing medications Coping by blaming self **Living with one parent was associated with lower rates of DSH (as opposed to step parent or other family members) 4000 teens; mean age 15.4 8.4% (6.2%) DSH w/i yr 11.1% females 1.6% males Methods: 59.2% cutting 29.6% overdose of meds 3% illicit drugs 2.2% self-battery 1.7 sniffing/inhalation DSH--Recent community based studies: Australia

14. Associated Factors: Exposure to self-harm in friends, family Drug use Depression/anxiety/impulsivity Low self esteem Sexual orientation worries Trouble with police (girls) Hx of being bullied Hx of sexual abuse 6020 teens; 15-16 yrs 13.2% lifetime hx of DSH 8.6% (6.9%) w/i yr 11.2% females 3.2% males Methods: 64.6% cutting 30.7% overdose of meds 54.8% reported multiple acts 12.6% presented to EDs 15.0% suicidal ideation w/o DSH DSH--Recent community based studies: England

15. Why are Adolescents So Vulnerable??

16. Why are Adolescents so Vulnerable? Adolescence represents one of the healthiest periods in life span with respect to physical illness BUT • 200-300% increase in mortality and morbidity rates between mid childhood to late adolescence • Problems related to control of emotions and behavior: • Accidents, homicides • Suicide, depression, anorexia, bulimia • Alcohol and substance use • STDs, unwanted pregnancies

17. Why are Adolescents so Vulnerable? Adolescence period of rapid changing in CNS • Structural changes occurring in this time period: • Completion of brain cell genesis, nerve myelination, dendrite pruning in the frontal cortex • These developments in turn lay the foundation for more sophisticated “executive function” problem solving skills

18. Why are Adolescents so Vulnerable? Pubertal development assoc with changes in brain: • Changes in Brain assoc. with behavioral changes • Animal models--sensation seeking • Adolescents—mood regulation, romantic interests, changes in sleep/wake cycles, risk taking (DAHL, 2004) • Exploring mechanisms: Dahl, et al, 2005 MECHANISM: Rise in estrogen availability during puberty—may impact the functional integrity of the amygdala and prefrontal cortex

19. Why are Adolescents so Vulnerable? • Emotional changes associated with pubertal development (emotional intensity, romantic interests, risk taking) • Cognitive changes (inhibitory control, problem solving, long term planning) are more related to increasing age and experience

20. Why are Adolescents so Vulnerable? • Asynchrony between physical and emotional changes and cognitive maturation • During this period of rapid change, adolescents are not yet able to make rational decisions in the face of intense emotional and motivational states • Prone to biased interpretations of experiences, self-criticality, low inhibitory control, and emotion-focused coping . “Starting the engines with an unskilled driver” (Dahl, 2005)

21. Controversies: Asking about Suicide • Gould et al (2005)--? does asking about suicidal ideation or behavior create distress or increase SI among HS students generally or among high-risk students reporting depressive symptoms, substance use problems, or suicide attempts • 2342 students in 6 high schools in New York State • Classes were randomized to an E group (n = 1172), which received the first survey with suicide questions, or C group (n = 1170), which did not receive suicide questions. • Exposure not assoc. w diff in distress, depression or suicidal ideation; not for hi or low risk students Gould, et al: Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1635-43.

22. Controversies: Medications as a Trigger • 3 to 8 fold increase in the use of antidepressants in children and adolescents from approx 1990-2000 (Zito, et al., 2002; Rushton, et al. 2001) • Efficacy: • Fluoxetine (Prozac) – efficacious • Up to 40% are “non-responders” • Resistance/Adherence: Adolescent Attitudes (Gray, 2003) • 69% stopped taking meds by end of 4 weeks • 58-61% report bias against meds • “Medicine might…change my personality, control my thoughts, not let me be myself” • Issues around belief in efficacy of meds and stigma about MI

23. Duration of Antidepressant Use Richardson, et al, 2004

24. Medications Considerations: • BLACK BOX Warning • Providers to monitor weekly for four weeks, monthly for approx three months • Monitor for anxiety, agitation, panic, insomnia, irritability, hostility, impulsivity, severe restlessness, mania as well as suicidal ideation • Meta analyses of 23 studies with 9 agents: • 2:1 increase risk of documented suicide attempts active med vs. placebo • NO suicides completed

25. Medication and Suicide • Hammad, 2004 meta-analysis: • No completed suicides--monitoring • No evidence for med association with emergence • No evidence for med association with worsening • Meds associated with activation in 10-20% of cases • TADS • 6 of 7 attempts youth had clear suicide “flags” at entry into the study • Combined tx or CBT best for reduction of suicidal ideation

26. Controversies: Medications as a Trigger • Large scale studies of youth and adults suggest that communities with higher rates of antidepressant use have lower suicide rates (Simon, 2006, NEJM) • Difficulty of completing studies to resolve issue—need for large samples (6000) (Simon, 2006, NEJM) • Fact that emergent suicidality is a factor in any treatment of depressionor related adolescent problems(Bridge et al., 2005, Am J Psychiatry) • Psychotherapy only study—emergent suicidality in 11 of 88 (12.5%) pts who had not reported current suicidality at intake • Self-reported suicidal thoughts at intake were sign predictor

27. Controversies: Medications as a Trigger • Management: (Simon, 2006, NEJM) • Efficacy only est for those with current MDD—careful dx evaluation • Fluoxetine only proved and approved med—therefore it should be first choice medication • Patients and families need to be clearly warned that suicidal ideation might increase and that aggression and agitation are also signs of possible increased risk • Regular follow-up with active outreach • Factors that can increase compliance with tx: • Monitoring and targeting specific behaviors • Trial period—CBT “experiment” approach

28. Controversies: Medications as a Trigger Are we at risk for increases in suicidality? • 2004 FDA advisory regarding increased risk of suicidal thoughts and behaviors in patients treated with newer antidepressant meds • 25% drop in antidepressant prescriptions • No change in follow-up care as recommended by FDA • Now some concerns about increases in suicide rates but NO DATA to support at this time

29. Controversies: Influence of the Internet • 80% of 12-17 yrs. report use of internet; half log on daily • Primarily for social reasons—may be advantageous for shy, socially anxious, marginalized youth • Depressed youth more likely than others to engage on line—therefore concern that self injurers may be drawn to internet • Could provide positive support BUT also could serve to spread of deepen practice among adolescents • Studied role of internet in spreading DSH info and influencing help seeking: • Prevalence and nature of self-injury message boards • Coded 2,942 messages over a 2 mos period (10 boards) Whitlock, Powers, Eckenrode, 2006. Developmental Psychology, 42:407-412.

30. Controversies: Influence of the Internet Findings: • 28.3% informal support—”just relax and take a breath” but also apologizing beh—”I’m so sorry to lay this on you”, “I hate myself for doing this” • 19.2% triggers—conflict with others, depression, school/work stress, most common, loneliness, sexual abuse/rape • 9.1%--anx re concealment, managing scars, dishonesty • 8.9%--addictiveness of behavior • 7.1%--help seeking—largely positive • 6.2%--techniques—”how to cut w/o having it bleed so much?” Conclusions: • Internet is providing powerful vehicle to bring DSH youth together • + These youth engage in typical social discourse--exchanging stories, voicing opinions, providing support • - Exposure to subculture that normalizes and encourages self-harming beh contributing to a social contagion effect

31. Causal Models: Vulnerabilities to Self-Harm • Depression (emotional lability, irritability, loneliness, isolation, hopelessness) • Anxiety (weak coping and/or social skills) • Impulsivity • Low self-esteem • Perfectionism • Confused sense of self (including sexual orientation) • Internal locus of control (self-blaming)

32. Causal Models: Vulnerabilities to Self-Harm • Awareness of self-harm by peers/family (contagion) • Impaired family communication • Hypercritical parents • Violent/dysfunctional family • Use of cigarettes, alcohol, & drugs • Criminal history

33. Causal Models: Functions of Self-Harm Behaviors • Categories: interpersonal (personality disorders) versus intrapersonal (trauma) • Motivational Factors: • Affect modulation (dec anger, fear) • Desolation (stop feeling empty) • Punish self • Influence others (express anger) • Magical control (prevent one from hurting others) • Self-stimulation (provide excitement) • Additional reasons: • To feel relaxed • Something to do when alone • To get control of a situation • To get attention/help • To feel more a part of a group

34. Causal Models: Why do adolescents engage in DSH?

35. Causal Models: Why do adolescents engage in DSH?

36. Causal Models: Biological • Heritability—Offspring of parents with mood disorders Those who have attempted suicide 6X more likely to have a child who attempts suicide • Role of impulsive aggression –highly heritable • Lower levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in persons with suicidal behavior or impulsive aggression than dx controls • MRI studies—alterations in the number and function of serotonin receptors in prefrontal cortex—emotional regulation and behavioral inhibition (Brent et al., 2002, Arch Gen Psychiatry, 59; 2006 NEJM, 355)

37. Models:Brent et al. 2006 Familial Pathways to Early-Onset Suicidal Behavior.

38. Causal Models: Biological • Serotonin and DSH • Initial findings of some evidence that self-injury is associated with lower levels of presynaptic serotonin release—MORE RESEARCH NEEDED • Endogenous opioid system (EOS) hypothesis: • DSH associated with partial or complete analgesia during the act • Two hypothesis regarding involvement of the EOS in DSH: • Addiction hypothesis—EOS repetitively activated by DSH produces a elevation in mood • Pain hypothesis: • Indiv with DSH have an altered EOS, congenitally or 2nd to changes with repeated experience leading to neurochemical alternations • Mediates reduced pain sensitivity • MORE RESEARCH NEEDED (Yates, 2003, Clinical Psychology Review, 24)

39. Causal Models: Behavioral • Social learning hypothesis • Learned behavior—modeling • Behaviors maintained by reinforcement contingencies: • Negative reinforcement—avoid even more aversive consequences • Positive reinforcement—attention, inclusion, sense of relief, tension reduction (Yates, 2003, Clinical Psychology Review, 24)

40. Causal Models: Biosocial Theory • Emotional Vulnerability + • Invalidating Environment = • Pervasive emotional, behavior, interpersonal, cognitive, and self dysregulation Linehan, 1999 DBT

41. Emotion Vulnerability • High sensitivity • Immediate reactions • Low threshold for emotional reaction • High reactivity • Extreme reaction • High arousal dysregulates cognitive processing • Slow return to baseline • Long lasting reactions • Contributes to high sensitivity to next emotional stimulus

42. Invalidating Environment • “Poorness of fit” • Child’s expression of private experiences are not validated, but dismissed (i.e., “You can’t be hungry, we just had dinner”) • Child searches social environment for cues on how to act, think, and feel and learns to distrust internal cues • Child “ups the volume” to convince invalidating environment that what they’re feeling is real

43. Emotion Dysregulation Affective lability Problems with anger Interpersonal Dysregulation Chaotic relationships Fears of abandonment Self Dysregulation Identity disturbance/difficulties with sense of self Sense of emptiness Behavior Dysregulation Parasuicidal behavior Impulsive behavior Cognitive Dysregulation Dissociative responses/paranoid ideation “Hot” cognitions Domains of Dysregulation

44. Respondent Behavior Self-harm as “response to” past negative event/emotion Goal is emotion regulation Function is maladaptive coping mechanism Intervention targets improved emotion regulation and distress tolerance skills More common function Operant Behavior Self-harm as attempt to “operate on” (influence) future events/emotions Goal is attention or avoidance/escape Function is maladaptive attempt to influence behavior of others Intervention targets interpersonal effectiveness skills Less common function Summary of Self-Harm Functions

45. Intervention: Prevention • Population based suicide prevention approaches greater effect than those focused on youth at high risk • Public education: • Signs and symptoms • What to say and do • How to get help • Restriction of access to means: • Gun locks • Monitoring

46. INDICATED PREVENTION • Skill-building support groups Family support training • SELECTIVE PREVENTION • Screening programs with special populations Gatekeeper training • Crisis intervention services • UNIVERSAL PREVENTION State-wide public educational campaign on suicide prevention School-based educational campaigns for youth and parents Public educational campaign to restrict access to lethal means Education on media guidelines • EVALUATION AND SURVEILLANCE Evaluation of prevention interventions in each component Surveillance of suicide and suicidal behaviors among youth 15-24 years Intervention: Prevention • Current approaches and outcomes: • Signs of Suicide • TeenScreen • Prevention Models:

47. Assessment and Intervention • Assessment before making treatment plan • Assessment of changes in key symptoms/ behaviors during tx • Assessment of how things are going from family/youth’s persepctive

48. Transient/experimental: peer or media inspired Occasional: coping strategy for major events Persistent: standard coping/communication strategy (bad habit) Intractable: frequent and severe (life disrupting addiction) Associated with impulsive aggression/complex envir. Cognitive Behavioral Therapy (CBT) Case conceptualization Tx Choice • Dialectical Behavioral Therapy (DBT) • Multisystemic Therapy (MST)

49. Interventions: Other Concerns • Contagion • Curiosity, peer pressure, and risk-taking make teens more likely to try on various roles and try out various behaviors • Self-harm becoming more common, but do not normalize. “Everybody’s doing it”—NOT! • Clearly label self-harm as inappropriate coping/attention-seeking behavior • Respect privacy of those unable to cope effectively • Ignore those seeking attention in negative ways • Inadvertent reinforcement • Reinforce appropriate behaviors • Extinguish (ignore) inappropriate behaviors

50. Interventions: Referrals • Refer for assessment and treatment • Inform parent/guardian • Harm to self trumps confidentiality • Questions to ask potential therapists • How do you conceptualize self-harm? • What is your model for treating self-harm? • What is your experience level with these behaviors?