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Self Injurious Behaviors: Trends and Treatments
Elizabeth McCauley, PHD, ABPPProfessor
University of Washington/Seattle Children’s Hospital and Regional
Medical Center
Roadmap
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
Definitions: Suicidal and Self-injurious Behaviors
Suicide AttemptED-1/3 report wish to die
Suicide
Deliberate Self-Harm Purposeful self- harm self (cutting, jumping) behaviorIngestion of substance in excess of therapeutic doseIngestion of recreation drug with intent to self-harm
Ingestion of non-ingestible substance or object(Child and Adolescent Self-harm in Europe group)
Suicidal IdeationThoughts of death or dying
Wishing to be deadThoughts of hurting self
Suicidal plan
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
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!
Prevalence
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
Adolescence is period of increased risk for self-harm behaviors as well as suicidal thoughts and behaviors
Recent Trends
Suicide Declining rates 1992-2000 Changing methods Changing patterns w/i ethnic groups
DSH Prevalence Increases in frequency Associated factors
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
Changing Trends in Methods
0
0.2
0.4
0.6
0.8
1
1.2
92 93 94 95 96 97 98 99 2000 2001
Firearms
Suffocation
Poisoning
All Others
10-14 year olds
FR: MMWR, CDC, 2004, 53:22
Changing Trends in Methods
0
1
2
3
4
5
6
7
8
9
92 93 94 95 96 97 98 99 2000 2001
Firearms
Suffocation
Poisoning
All Others
FR: MMWR, CDC, 2004, 53:22
15-19 year olds
Changing Trends
May reflect issues of access Rapid shifts in youth suicidal behavior can
occur Differential profiles of risk, motivation,
behavior, intent
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
DSH--Recent community based studies: Australia
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: England
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
Why are Adolescents So Vulnerable??
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
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
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, 2005MECHANISM: Rise in estrogen availability during
puberty—may impact the functional integrity of the amygdala and prefrontal cortex
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
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)
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.
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
Duration of Antidepressant Use
0%
20%
40%
60%
80%
100%
Start 1 2 3 4 5 6
Months after initial prescription fill
SSI
Tricyclic
Other
Richardson, et al, 2004
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
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
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 depression or 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
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
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 ratesbut NO DATA to support at this time
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 .
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
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)
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
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
Causal Models: Why do adolescents engage in DSH?
Res to Ques. Self-cutters Self-Poisoners
Relief--terrible state of mind 73.3% 72.6%
Punish self 45% 38.5%
To die 40.2% 66.7% *Show desperation 37.6% 43.9%
? if someone loves me 27.8% 41.2% *Get attention 21.7% 28.8%
Frighten someone 18.6% 24.6%
Get back at someone 12.5% 17.2%
Causal Models: Why do adolescents engage in DSH?
Spontaneous Remarks Self-cutters
(220)
Self-Poisoners(86)
Depression 18.2% 10.5%
Pressure 10.9% 17.4%
Escape 8.3% 22.1% *Angry at self 8.2% 0 * Want to die 0.9% 10.5% *Arguments 1.4% 10.5%
Seeking attention 2.3% 4.6%
Tension relief 2.7% 0
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)
Models: Brent et al. 2006
Familial Pathways to Early-Onset Suicidal Behavior.
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)
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)
Causal Models: Biosocial Theory
Emotional Vulnerability
+ Invalidating Environment
= Pervasive emotional, behavior, interpersonal,
cognitive, and self dysregulationLinehan, 1999 DBT
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
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
Domains of Dysregulation
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
Summary of Self-Harm Functions
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
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
Intervention: Prevention
Current approaches and outcomes: Signs of Suicide TeenScreen Prevention Models:
INDICATED PREVENTIONSkill-building support groups Family support training
SELECTIVE PREVENTIONScreening programs with special populations Gatekeeper trainingCrisis intervention services
UNIVERSAL PREVENTIONState-wide public educational campaign on suicide preventionSchool-based educational campaigns for youth and parentsPublic educational campaign to restrict access to lethal means Education on media guidelinesEVALUATION AND SURVEILLANCE
Evaluation of prevention interventions in each componentSurveillance of suicide and suicidal behaviors among youth 15-24 years
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
Case conceptualization Tx Choice
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)
Dialectical Behavioral Therapy (DBT)
Multisystemic Therapy (MST)
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
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?
Evidence Based Interventions
Common Features: Focus on suicidal/DSH
behaviors directly Structure contact and
monitoring Flexibility to include
outreach Issues—no thoroughly
proven intervention, all involve considerable training, DBT and MST designed for complex pts.
Interventions: CBT
CBT Incorporates Behavior, Cognition, Affect and Social factors• Utilizes Treatment Strategies: Enactive Performance-based procedures Structured sessions Cognitive and affective interventions to effect
change in: Thoughts Feelings Behaviors
Thought Record
What happened? How did you f eel?
What thoughts did you have at the time?
What did you do? Any other way to look at it?
List all the emotions you had at the time. Did you f eel some more than others?
What does it mean to you that….? So what? What if ?
Did you want to do something you didn’t do? Do something you wish you hadn’t?
Do you f eel diff erently if you think about it this way? Would you do anything diff erently
Supplementary Materials…
…To support use of CBT skills in clinical practice
Treatments for Adolescents with Depression Study (TADS) Fluoxetine combined
with CBT had a response rate of 71%
Fluoxetine alone-63% CBT alone 43% Placebo 31% Combination most
effective in reducing SI
(TADS Team, 2004)
0
1020304050607080
1stQtr
CombProzacCBTPlacebo
Key elements of BA Distinctly behavioral case conceptualization Functional analysis Activity monitoring and scheduling Emphasis on avoidance patterns Emphasis on routine regulation Behavioral strategies for targeting rumination
BA Model
Life events
Less Rewarding Life
Sad, tired, worthless, indifferent..
Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.
Loss of friendships, conflicts w parents, teachers, bad grades, stress, poor health, etc.
TG 1-2, 2-2
Adolescents Taking Action Sessions 1 & 2: Getting Started
1st by identif ying what makes you feel down 2nd by learning how to tackle problems 3rd by working together with your therapist to take small steps, get active, accomplish your goals, and
Depression
What Does Behavioral Activation Mean?
Depression is a vicious cycle
Your lif e is more stressful. You begin to feel tired, bored….lif e gets harder, you do less, pull away and may blame yourself f or not doing more….it gets harder to do things. This can create more problems with school, parents, f riends…….
BUT Behavioral Activation can break this cycle by:
BUI LD THE LI FE YOU
WANT!
Interventions:Dialectical Behavior Therapy
DBT therapy specifically targets self-harm behaviors Individual therapy Skills Training
Emotion regulation Distress Tolerance Interpersonal effectiveness Mindfulness/self-awareness
Diary cards Chain analyses
Interventions:Other DBT Concepts
Wisemind
Pros/Cons—Long term vs Short Term Pain versus suffering Distraction techniques
Pain vs. Suffering
Pain is part of nature Pain is natural signal that change is needed Pain only creates suffering when you refuse to
accept the pain Acceptance does not equal approval Acceptance transforms suffering into pain Use pain as motivation for effective change
(“make lemonade out of lemons”) Pain we can change…a whole lot easier than
suffering
High Intensity Distraction Techniques
Dance to loud rock/rap music (using a headphone if others are around!)
Take hot/cold shower Exercise/get active Go to the mall Talk to a trusted adult Page your DBT therapist!
Other Distraction Techniques
Write in a personal journal/write poetry
Play on the computer Do your favorite
hobby Bake cookies Imagine your favorite
place and go there in your mind
Listen to music Watch a funny movie
Do muscle relaxation exercises/squeeze a stress ball
Do Mindfulness exercises (deep breathing)
Put on clothes straight out of the dryer
Appreciate nature (look at the stars, listen to the rain, smell the flowers)
Multisystemic Therapy
Characteristics: Intensive family and community based treatment Intensive services—3-5 mos. High engagement and completion rates Effective with youth in juvenile justice system Home based model
Study of MST vs hospitalization as usual: 4 mos and 1 yr follow-up; youth in MST group sign
reduction in suicidal attempts and parental control but no diff in SI, depression, hopelessness
(Huey, et al., 2004, J Am Acad Child Adolesc Psychiatry, 43)
Resources
www.clinicalchildpsychology.org www.dbtseattle.com www.aacap.org