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adolescent self-injury

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adolescent self-injury

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  1. I intended to kill something in me, this awful feeling … So when I discovered the razor blade, cutting, was my gesture of hope. That first time, when I was twelve, was like some kind of miracle, a revelation…As swift and pure as a stroke of lightning, it wrought an absolute and pristine division between before and after. All the chaos, the sound and fury, the uncertainty and confusion and despair—all of it evaporated in an instant, and I was for that moment grounded, coherent, whole. I drew the line in the sand, marked my body as mine, its flesh and its blood under my command. --C. Kettlewell, Skin Game, 1999

  2. adolescent self-injury Dale Wisely, Ph.D. Director of Student Services Mountain Brook Schools

  3. What to call this? • Self-injury • Self-harm • Self-inflicted violence • Self-injurious behavior • Self-mutilation • Parasuicide • Autoaggression • “Cutting”

  4. Nonsuicidal Self-Injury NSSI

  5. Some assumptions Self-injury is often (mostly?) a coping mechanism to deal with psychological pain/distress. Most self-injury involves slight/modest physical damage that leaves little, if any, long-term scarring. Some, however, quite serious. Relationship between NSSI and suicidalityis not fully understood.

  6. What are we talking about? People hurt themselves. What’s distinctive about this form of hurting oneself?

  7. These teenagers! • Suicide rates are lower in teenagers than in their parents’ age group. • Substance abuse is more common in adults than in teenagers. • Workplace shootings more common than school shootings.

  8. Non-Suicidal Self-injury “Direct, deliberate, socially unacceptable injury of one’s own body tissue without intent to die.” • Lloyd-Richardson, E. E. Adolescent nonsuicidal self-injury: Who is doing it and why? J. of Developmental & Behavioral Pediatrics, 29, 216-218.

  9. Methods Cutting Hitting Punching/hitting walls Pinching Scratching Biting Burning

  10. Demographics How would we know?

  11. Classic (pre-1990 or so) understanding of who self-injures • Patients with serious, persistent disturbance/mental illness (outpatient, inpatient, day treat.) • Patients in psych emergency rooms • Incarcerated adults. • Youth in special education, residential treatment, juvenile detention. • Borderline Personality Disorder

  12. Beginning in the late 1980s… Seen in broader population outside of psychiatric/incarcerated groups. Youth in middle & high schools, regular ed, often high functioning College / University students Adults in general population

  13. State of the Research: Crappy • Research picking up, but still sparse. Lots of inconsistencies, differences in definition, etc.

  14. APA, 2009.

  15. Prevalance data 4 – 47% in community samples 12 – 82% in clinical samples. You’re welcome.

  16. Who? • Perhaps more in white adolescents. • Females > Males, especially in clinical settings. (method, bias?) • Perhaps more in gay, lesbian, questioning • In majority, begins ages 13-15. • Nothing useful known about course.

  17. Self-injury: Middle & high school Ross & Heath (2004). Studied 440 youth from urban and suburban Canadian high schools. • 14% reported self-injury • Of these, 64% were girls, 36% boys. • Higher scores for depression and anxiety. • 13%-at least once a day • 28%-a couple of times/week. • 19%-a couple of times a month

  18. Self-injury: Middle & high school Ross & Heath (2004). • 59% started in 7th or 8th grade • 25% started 6th grade or earlier • Good news: 64% had stopped

  19. The new self-injurers Barent Walsh’s observations • Both genders, females>males, 2:1 • No ethnic, racial, economic pattern • Start as early as 11-12. • Have considerable strengths and function adequately, or well. • Most: not special ed, not discipline problems, no history of psych treatment

  20. The new self-injurers • Often introduced to cutting by friend(s) • Quickly come to rely on it after trying it. • Lack healthy coping skills. • Body hatred (body alienation) not nearly as common. • Most deny (convincingly) history of sexual/physical abuse. • More prone to give up the behavior after awhile (highly influenced by peers.)

  21. Most agree… Previously commonly believed to be associated only with severe psychiatric illness, now it is too commonplace to be regarded as the product of severe psychiatric illness.

  22. Risk factors • Mental health problems • Depression • Conduct disorder • Personality disorder • Substance abuse • Triggers?

  23. Psychiatric disorders, teens, NSSI Source: Nock, Joiner, Gordon, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relationship to suicide attempts. Psychiatry Res 2006; 144(1):68.

  24. Substance disorders, teens, NSSI Source: Nock, Joiner, Gordon, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relationship to suicide attempts. Psychiatry Res 2006; 144(1):68.

  25. There is no profile. So, here’s a profile. • Emotional and somewhat self-oriented. • Emotional environment discourages expression of anger, sadness. • Highly sensitive about interpersonal status. Sensitive to rejection. • Lack of healthy outlet (perhaps combined with romanticizing of personal pain)

  26. Hx of child abuse? “Overwhelming evidence points to robust relationships between child maltreatment and NSSI.” (Yates, 2009) • Some studies are before late ‘80s. • Largely self-reported. • Is abuse a unique risk factor for NSSI or a more general predictor of psychopathology?

  27. Media Issues • Websites, including some defending behavior. • Movies, TV, Songs

  28. Movies/Songs with NSSI by year Whitlock, et al. in Nock’s text.

  29. Contagion effects • Widely recognized in inpatient settings. • Not documented in community studies. Anecdotes abound. • Internet/media effects?

  30. What does self-injurydo? • It relieves, at least partly and temporarily, overwhelming emotional pain. • It ends numbness, depersonalization, derealization. • NOT attention seeking, typically. • NOT manipulative, typically.

  31. What’s going on? Favazza (1996). Self-induced body modifications occur in multiple world cultures correct or prevent “a destabilizing condition that threatens the community.” (Angry gods, haunting, conflicts of all sorts, onset of adulthood, immoral or sinful behavior, ecological disasters, etc.)

  32. Cultural / adaptive “I do contend that at the deepest, irreducible level, the behaviors are prophylactic and salubrious for groups of and individuals threatened by death, disorganization, disease, and discomfort – Armando Favazza

  33. The self-mutilator can incorporate into his actions patterns which, to a greater or lesser degree, remain unarticulated in most of us.” – E. Podvoll, 1969

  34. What’s going on? Feminist analyses: Self-injury linked to increasingly unachievable standards of feminine beauty.

  35. What’s going on? • Environmental influences: Stress, multitasking, divorce rates, etc.) • Media influences: Exposure to self-injury, confessional interviews (Angelina Jolie, Princess Diana), websites, chat rooms. • Short answer: We don’t know.

  36. Body piercing, tattooing, etc. Is this a variant of the same phenomenon? • Seems to have increased during about the same recent time period. • Similar themes: Still mostly unacceptable to polite society. Role of skin. But PAIN not usually the goal, nor is interruption of distress.

  37. NSSI and suicidality

  38. “ a form of partial suicide, to avert suicide.” Karl Menninger, 1938

  39. NSSI and suicide • This behavior is not suicidal in intent. • Self-injury can be a way of coping with suicidal feelings, even preventing, suicide. • But, recent evidence accumulates that people who self-injure are at higher risk for later suicide.

  40. Self-injurious thoughts and behaviors Adapted and modified from Nock & Favazza (2009)

  41. Self-injurious thoughts and behaviors Non-Suicidal(No Intent to Die) Suicidal (Intent to Die) Adapted and modified from Nock & Favazza (2009)

  42. Self-injurious thoughts and behaviors Non-Suicidal(No Intent to Die) Suicidal (Intent to Die) ?Threats Ideation Plan Preparation Attempts Adapted and modified from Nock & Favazza (2009)

  43. Self-injurious thoughts and behaviors Non-Suicidal(No Intent to Die) Suicidal (Intent to Die) ?Threats Ideation Suicide “Gestures” Plan Preparation Attempts N S S I Adapted and modified from Nock & Favazza (2009)

  44. Self-injurious thoughts and behaviors Non-Suicidal(No Intent to Die) Suicidal (Intent to Die) ?Threats Ideation Suicide “Gestures” Plan Preparation Attempts N S S I High Frequency, Low Intensity High Intensity, Low Frequency Adapted and modified from Nock & Favazza (2009)

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