Self harm & its hidden Trauma

1. Self harm & its hidden Trauma Mary Nan S Mallory MD Professor and Residency Program Director Department of Emergency Medicine University of Louisville

2. …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.

3. The Self-harm Spectrum

4. 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

5. The Self-harm Spectrum

6. Methods of Self-Harm

7. Methods of Self-Harm Posterior Left Shoulder view

8. 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

9. Perspectives on Self-Harm 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) 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

10. Perspectives on Self-Harm 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.” fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders, June 2013

11. 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

12. 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

13. 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

14. Familiar Faces http://self-injury.net/

15. Adler & Adler, 2011- an ethnographical look "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.”

16. 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

17. 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.

18. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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/

27. The SOS High School Program • Only school-based suicide prevention programon SAMHSA’sNational 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

28. Immediate Relief Strategies Go to a public place Wait 5 minutes and reassess Yell aloud, listen to calming music, write in a journal Eat spicy food Rub an ice cube onto wrist Snap a rubber band that is around your wrist Draw with a red marker/pen at the site instead Call 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.

29. 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——Amy3 http://www.witnessjustice.org/health/siv_whitepaper.pdf