DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Dr Edgard A Sánchez Bernal Consultant Psychiatrist/Psychoanalyst Student Services KINGS COLLEGE LONDON / SOUTH LONDON AND MAUDSLEY NHS TRUST Edgard.Sanchez-Bernal@kcl.ac.uk

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS WHY LOOK AT DSH? “Deliberate Self Harm is the strongest risk factor for suicide” (Hawton et al; BJPsych 182:537-542, 2003) “30 to 47 percent of suicide completers had a prior history of parasuicide” (Gunnel D, Frankel S; BMJ 308: 1227-1233, 1994) BUT…… “Attempted suicide and deliberate self harm that is not suicidal in nature are very different behaviours, however, in research literature, they are often blurred together…” (Shaw Welch S, Psychiatric Services Journal 52: 368-375, 2001)

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS DESCRIPTIVE DEFINITIONS Self Harm: Deliberate and often repetitive destruction or alteration of one’s own body tissue, without suicidal intent. (adapted from Favazza 1987-89 & Walsh+Rosen 1989) DSH: An act with a non-fatal outcome in which an individual deliberately did one or more of the following: - initiated a behaviour (e.g. self-cutting, jumping from a height) which they intended to cause harm to the self; - ingested a substance in excess of the prescribed or generally recognized therapeutic dose; - ingested a recreational or illicit drug (which they intended to cause harm to the self);

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS DESCRIPTIVE DEFINITIONS(2) • ingested a non-ingestible substance or object (e.g. batteries, razor blades). (Hawton et al, 2002) OTHER NAMES: Self injurious Behaviour (the politically correct name for self mutilation) Favazza A, 1987. Parasuicide: Describes all non-fatal self-injurious behaviour with clear intent to cause bodily harm, reserving “attempted suicide” for situations in which intent is known. TYPES • Major: (e.g. eye enucleation and amputations) • Stereotypic: (e.g. head banging and self biting) • Compulsive: (e.g. severe excoriation of the skin and nail biting) • Impulsive: (e.g. skin cutting, burning and carving) Favazza A, Paediatrics, 117: 2283-84, 2006

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS COMPLEMENTARY DEFINITIONS OF DSH “For many self-harm is not so much about the inflicting of physical pain as the cessation of emotional pain” (Swales M, The Wellcome Trust. “Pain and Deliberate Self Harm”) “Self injurious behaviour itself is a morbid form of self-help and is usually effective in decreasing severe anxiety, depersonalisation, and other symptoms” (Favazza A, Paediatrics, 117: 2283-84, 2006)

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS EPIDEMIOLOGICAL PERSPECTIVE OF DSH -Registration studies v. Population surveys -findings in Registration studies: (WHO data 1989 -1992) Overall Rates from 2.6 per 100.000 to 542 per 100.000 (Lowest rates in Africa and Asia) (would imply at KCL 0.5 to 108 cases per year) • Rates of parasuicide varied substantially across sites. • Consistent higher rates of parasuicide for females • Higher rates found among younger people (in seven sites, females 15 to 24 years old had the highest rates, whilst in males highest rates in 25 to 34 years old) • Parasuicide rates in the WHO study seemed to decrease over time.

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS EPIDEMIOLOGICAL PERSPECTIVE OF DSH Population surveys: Overall rates of 300 to 1,100 per 100,000. (60 to 225 per year at KCL) • Women had higher rates than men • 6.9% of a school population of 15 and 16 year olds had engaged in an act of DSH in the previous year. Only 12.6% of these episodes had led to a hospital visit. (USA, 1990, Centres for Disease Control. Attempted suicide among High School Students) • 4% of representative sample of general population reported engaging in at least occasional instances of self-mutilation over the previous 6 months and 0.3% reported often engaging in such behaviour. (Briere J, Gil E. American Journal of Orthopsychiatry 68:609-620, 1998.)

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS RISK FACTORS(1) • Marital Status: “Single and divorced”: further studies suggest that it may have to do with interpersonal conflict. • Change in living situation from a stable environment. • Sexual abuse: “Sexual abuse as a child or adult is associated with later psychological problems. All forms of sexual molestation were predictive of DSH behaviour in men”. (King M, Coxell A, Mezey G. “Sexual molestation of males: associations with psychological disturbance”. BJPsych 81: 153-157, 2002) • Mental disorders • Mood Disorders: especially depression - Personality Disorders • Substance Abuse: Alcohol • Previous Attempts: highly predictive of future DSH

RISK FACTORS(2) Childhood experiences Neglect Emotional abuse Physical abuse Loss or separation Sexual abuse Parental mental health problems Parental substance abuse Current experiences Domestic violence Rape/sexual abuse Psychiatric diagnoses Substance misuse (both alcohol and drugs) ? Medication, ?SSRIs. (Donovan S, Madeley R, “Deliberate self-harm and antidepressant drugs” BJPsych 177: 551-556,2000) DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS

Psychiatric and Personality disorders in Deliberate Self-harm patients (Haw, C BJPsych 178: 48-54, 2001) A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12 to 16 months later. Results: ICD-10 psychiatric disorders were diagnosed in 138 patients (92%) - Most common diagnosis was affective disorder (72%) - Personality disorder was identified in 45.9% of patients interviewed at FU. - Comorbidity of psychiatric and personality disorder was present in 44.1% DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS AIM OF TREATMENT “Motivation to stop harming fluctuates, and it is easy to vow abstinence in the midst of a hangover but less so during the excitement of a party” (Bateman A, “Self-help books on DSH” BJPsych 185: 441-442 2004) - Psychosocial Interventions: Latest meta-analysis: (“Psychosocial interventions following self-harm Crawford M, Thomas O, Nusrat K, Kulinskaya E, BJPsych, 190:11-17,2007) “ The results of this meta-analysis provide little evidence to support the view that enhanced treatment following an episode of DSH substantially reduces the likelihood of subsequent suicide”

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS TREATMENT • Patients are referred to us or seek treatment due to • Have been seen at A&E and referred after an episode of DSH • In routine examination by GPs or nurses various scars are found • Some patients are not only aware of their need to get help but also know some of the reasons by which they self-harm • Feel frightened that the urge to cut is more powerful than their will • Re-start DSH behaviour that they thought had gone • Refer themselves for unrelated reasons, and only after a while the theme appears • Are made to come by friends, flatmates, partners, tutors

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS TREATMENT Findings: • Not uncommon to find them speaking of themselves as one would of a stranger. • They do frequently describe not feeling that much pain when they cut, and a sense of relief at the slightest sight of blood. • There is a powerful sense of shame and guilt that needs to be contained rather than re-enacted: at times they are told they are attention seeking, that they need to go on antidepressants, or simply by telling them off. The most common re-enactment is that the health professional dismisses the incident as not worth follow-up. • It is also quite frequent to observe in these patients an enormous difficulty to express outwardly negative emotions, especially anger, except if it is against themselves.

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Golden Rules • Patients will tell you as much as you can listen. • It is not about rushing them to inform you of why they keep on doing it. They may well not know. • DSH is a symptom, a coping mechanism, a defensive strategy, and still patients may not know why they do it. • The more we treat patients who DSH, the more we become aware that it is not a short-term process. • If the patient starts putting his life at risk, they will paradoxically be grateful to you if you delineate firm boundaries to the treatment. (You as the treating professional become the representative of reality in them)

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Golden Rules • With some frequency they may attempt to use you as you have heard them say others behave towards them, e.g. as if you become the one who should be protecting them from DSH. • Not to fall on role responsiveness, this is behaving as how their immediate relatives or friends are described. • They may be so used to being treated in a defined style, that before you know it they may be grudging of you being like all the others. At this point is always worth to reflect how much their perceptions are being contaminated by powerful experiences of the past. (“When one’s head is like a hammer, we tend to see everything like a nail”) • At some points they will try to tell their story, either willingly or in a cathartic episode, make sure you are willing to listen.

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Deliberate Self Harm in King’s College London March 2005-2007 Total Population: 192 Referrals to Psychiatrist Deliberate Self Harm: 37 Cases Sexual Abuse: 11 students= 29.7% Psychotic parent: 5 students= 13.5% Loss of parent (death, divorce) 2 students= 5.4% Psychosis in patient: 1 student = 2.7% Chaotic family situation: 7 students= 18.9% Undisclosed as yet: 8 students= 21.6% Anger management, bullying & others 3 students= 8.1%

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Treatment: Psychoanalytically orientated psychotherapy provided in a context of Dynamic Psychiatric orientation. • We cannot assume that people who self harm will never be suicidal. • Therapy can expand in patients to tolerate greater intensities of emotions without resorting to self harm Medication: • Antidepressants on their own may foster further dissociation from the painful “forgotten” memories. Paradoxically in a psychotherapeutic setting may allow painful feelings to be aired. Hospitalization: - We have found more benefit in liaising with Home Treatment Teams, that accompany patients during times of critical need.

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Treatment • “What good will I get of thinking about those things in the past that I just hate thinking about?” • I’d rather remember painful things, than have to keep on living them again and again in my present everyday life. • These kind of patients are suffering from reminiscences • At the age when this students arrive to College, the normal splits of childhood and adolescence are demanding to be integrated into one whole person. • This makes the professionals who see them, people who can make a huge difference for the course life will take in these young students.

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS Outcomes: • “I tried to cut myself yesterday, but couldn’t as it really hurts…” • “I’ve noticed that even if I cut myself, I still have the problem in front of me” • “It’s not fun any more” • “I just have not felt the urge for a while” • “I can’t believe that I haven’t done it again”

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS TREATMENT Anger Management: “For those who are not angry at the things they should be angry at are thought to be fools, and so are those who are not angry in the right way, at the right time, or with the right persons; for such a man is thought not to feel things nor to be pained by them, and, since he does not get angry, he is thought unlikely to defend itself; and to endure being insulted and put up with insult to one’s friends is slavish”. “The man who is angry at the right things and with the right people, and, further, as he ought, when he ought, and as long as he ought, is praised. This will be the good-tempered man,….” (“Ethica Nicomachea, Aristotle 1125b15 -1126a26. 322 B.C.”)

DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS