Cutting and Self Harm A Disturbing Trend

Cutting and Self Harm A Disturbing Trend Lori O’Dell McCollum, Ph.D. Comprehensive Psychological Services, LLP Licensed Psychologist, Iowa and Illinois 1302 7th Street, Moline, IL 309-762-3931 lori_mccollum@sbcglobal.net www.compsychserv.net

Learning Objectives 1) Be able to differentiate between types of self-harm behavior, and know how it differs from suicidal behavior. 2) Be able to recognize the incidence and risk factors associated with this behavior. 3) Be able to conduct a screening interview of high risk patients to identify this behavior and gain information necessary to direct treatment. 4) Describe specific causes and functions of self-harm, including affect regulation, stress reduction, suicide prevention, and problem solving deficits

Learning Objectives 5) Discuss the relationship between self-harm and co-morbid conditions, such as mood disorders, PTSD, Eating Disorders, BPD and OCD. 6) Outline specific treatment and prevention strategies useful for this population. 7) Be able to assess medical and mental health needs of these patients and make appropriate referrals.

History of Self Harm Seen in biblical references of self-flagellation. Early references in psychiatric research were predominantly within the population of Borderline Personality Disordered patients. In the 1970’s research expanded into patients with trauma experiences. Since the 1990’s we’ve seen an explosion of clients with this symptomatology from a wide range of diagnoses and backgrounds.

Well Known PersonalitiesWho’ve Engaged in Self-Harm Princess Diana- British Royalty Angelina Jolie- Actress Johnny Depp- Actor Alfred Kinsey- Sexuality Researcher Marilyn Manson & Sid Vicious- Musicians Kelly Holmes- Olympic Athlete Courtney Love- Musician Amy Winehouse- Musician

What is Self Mutilation? Non-life threatening, self inflicted bodily harm or disfigurement of a socially unacceptable nature May be deliberate or unconscious Generally of low lethality Commonly employ multiple methods

Examples of Self Harm • Cutting • Burning • Compulsive skin picking • Hair-pulling • Bone breaking • Hitting • Interference with wound healing

Types of Self Mutilation • Non-dissociative – • Feeling pain is the goal. Intolerable rage with which she is only capable of attacking herself. • Dissociative – • Numbing is the goal, distracts self from mental disintegration and pain. • Secondary gain – • Attention seeking

Differences between self injury and suicidal behavior • A suicidal client believes there is no way out and seeks a final solution. • A self injurious client responds strongly to short-term frustrations and seeks short term alleviation of tension

Incidence of Self Harm • Previously thought to be 1 in 250 – Same as anorexia • Current estimates are 1 in 100 for self mutilation and 1 in 10 for self harm • More girls than boys (2 to 1) • Highest incidence: • Girls ages 15-24 • Boys ages 12-34

Co-morbidity One of the criteria for BPD 40% overlap with Eating Disorders 24% with Anti-social Behavior/Prisoners 3X more likely for clients with PTSD 46% of runaways 73% of violent clients

Risk Factors • Family history of depression and anxiety • Family history of poor communication and/or domestic violence • Early abuse or trauma history • Girls often have a history of sexual abuse • Boys often have a history of physical abuse • Low self-esteem, social isolation and alienation from peer group

Associated Causal Factors • Inability to deal with emotional intensity • Feelings of mental disintegration • Attachment Issues • Identity Issues • Poor Interpersonal Skills • Family Dynamics • Physiological/Behavioral Explanations

Emotional Intensity • Lives life at survival level emotionally • May describe feelings of emptiness • Feelings of rage that can’t be expressed • Emotionally inarticulate • Those easily influenced by contagion effects • Inflicting harm is a way of controlling emotional pain

Mental Disintegration Sense that they are unable to think. Poor problem solving skills, which lead to fear of confronting problems or people with whom they are struggling. Loss of perspective in terms of the size of the problem, and losing sight of the impracticality of pain and danger

Attachment Issues • Poor family relationships in general • Poor bonding with parent figures • History of chronic illness or surgery • Has been in foster care or group homes • Runaway • Sexual promiscuity • No one they can trust to help them.

Identity Issues • Experiences self as powerless • Feels isolated • Alienation from peer group • Low self-esteem • Distress over sexual identity • Borderline Personality Disorder

Poor Interpersonal Skills • May have superficial communication skills, but not intimate connections • May express desire to communicate distress, or to shock and manipulate • Poor emotional perceptiveness of others • Peer isolation and conflict • May have been violent toward others

Family Dynamics • Boundary violations, including abuse • Violent behavior, Domestic Violence • Substance Abuse • Parent mental health problems • Parents who have difficulty with nurturing and authoritative behavior • Enmeshment vs. Disengagement

Physiological and Behavioral Explanations Self mutilation releases beta endorphins which give a feeling of well being and can mask emotional pain. Negative reinforcement contingency – tension reduction may lead to sense of calm. Self harm can be addictive. Cyclical – tension/release

Interventions • Identification is key - Assessment • Therapy - Build structures from without • Therapy - Build structures from within • Therapy – Building relationships • Medical Interventions

Identification • Family • Friends • School • Medical Professionals • Self Report - ASK • Assessing high risk groups

TherapyStructures from Without • Individual Therapist • Family Therapy • School Resources • Community Involvement • National policies for mental health treatment • Build relationships/support systems • Teach healthy dependencies

TherapyStructures from Within • Build insight • Helping them understand the function of the behavior • If related to family discord, help the patient recognize their losses, and deal with past and current issues. • If related to trauma, do the work to heal past pain and recognize their goal of avoidance. • If related to attention seeking behavior, help the patient understand how manipulative behavior patterns work against their goals for intimacy. • Help the patient recognize the limitations of control over others in their lives, and ways to improve self-control.

Therapy Structure from Within • Build skills • Distress tolerance • Emotional Regulation • Cognitive restructuring • Core mindfulness • Interpersonal Relationship Skills • Communication • Crisis Survival Skills • Self Acceptance

Therapy – Building Relationships Nurturing – authoritative therapy consists of therapist’s behaviors that are caring, supportive, guiding, and instructive. We build the therapeutic relationship in a safe setting with appropriate boundaries We model communication skills, and show the patient new ways to gain support. We build attachments, but teach how to expand those into their real world by giving homework assignments.

Treatment of Original Issues After the self-harm behavior is confronted, and the patient acquires skills and insight, we often have to back up and address pre-existing mental health issues. Patients may need ongoing treatment for these underlying concerns or co-morbid conditions, even after the self-harm behavior is extinguished. Relapse prevention is essential to plan for future stressful events or co-morbid episodes.

Medical Interventions • Review need for medical treatment of wounds or injuries • Review need for anti-depressant or anti-anxiety medication • Review need for referral to dermatologist for treatment of scars • Complications for ongoing treatment, particularly OB/GYN

References • Alderman, T. (1997). The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland: New Harbinger. • American Psychiatric Association. (1994). The diagnostic and statistical manual of mental disorders, 4th edition. Washington, D.C.: American Psychiatric Association. • Bohus, M.; Haaf, B.; Simms, T.; Limberger, M.F., et al. (2004). Effectiveness of inpatient dialectical behavior therapy for borderline personality disorder: A controlled trial. Behavioral Reseerch and Therapy, 42, (5), 487-499. • Favazza, A. (1996). Bodies Under Siege: Self Mutilation and Body Modification in Culture and Psychiatry. Baltimore: Johns Hopkins University Press.

References Favazza, A.R. and Conterio, K. (1988_. The plight of chronic self-mutilators. Community Mental Health Journal, 24, 22-30. Herman, J. (1992). Trauma and Recovery. NY: Basic Books. Levenkron, S. (1998). Cutting: Understanding and Overcoming Slef-Mutilation. New York: W.W. Norton and Company. McMain, S, et al. (2003). Implications of childhood sexual abuse for adult borderline personality disorder and complex post-traumatic stress disorder. American Journal of Psychiatry, 160, (2), 369-371. Miller, D. (1994). Women Who Hurt Themselves: A Book of Hope and Understanding. New York: Basic Books. Pipher, M. Reviving Ophelia: Saving the Selves of Adolescent Girls. NY: Ballantine Books, 1994.

References Rodham, K.; Hawton, K., and Evanas, E. (2004). Reasons for deliberate self-harm: Comparison of self-poisoners and self-cutters in a community sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43, (1), 80-87. S-A-F-E Alternatives Program (Self Abuse Finally Ends) 1-800-DONT-CUT Strong, M. (1998). A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Penguin Books. Walsh, B. & Rosen, P. (1988). Self-Mutilation: Theory, Research, & Treatment. New York: Guilford Press. Yen, S.; Shea, M.J.; Samislow, C.N.; Grilo, C. et al. (2004) Borderline personality disorder criteria associated with prospectively observed suicidal behavior. American Journal of Psychiatry, 161, (7), 1296-1298.

Cutting and Self Harm A Disturbing Trend