Intentional Non-suicidal Self Injury

Transcription

1 Intentional Non-suicidal Self Injury Janice Selekman DNSc, RN, NCSN, FNASN Non-suicidal; Self-inflicted; Often repetitive Exclusions: Rite of passage Peer bonding Symbols of status, bravery, or courage Protection from evil or harm Atonement through suffering Healing of a diseased body or self/ acupuncture Those with intellectual disability and genetic conditions that result in self-injury (Lesch-Nyhan) Those who are truly psychotic and castrate self or amputate body parts or enucleate eye Those who self-harm when intoxicated or under the influence of drugs Those who are suicidal DSM-5 Nonsuicidal Self-Injury Definition Engaged in intentional self-inflicted damage to surface of body, likely to induce bleeding, bruising, or pain 5 or more days in past year With one of the following: interpersonal difficulties or negative feelings or thoughts (depression, anxiety, anger) occurring immediately prior to the self-injurious act; prior to engaging in the act, preoccupied with the intended behavior; or thinks about self-injury frequently How do they do it? Cutting (usually superficial) of lines, words, symbols Burn/ scald Bruise/ punch/hit with an object Pick (scabs, skin, interfere with wound healing) Stab Scratch/rub skin to the point of soreness/bleeding (erasers) Hair pulling (trichotillomania) Hair plucking Head banging Poke objects through body openings Excessive/questionable forms of Self Injury Disordered eating Inhaling dangerous substances Severing/ gouging body parts Drinking to excess Sexual acting out Masturbating with dangerous objects (knife, curling iron) The implements used Cigarettes, matches, candles, bic lighter, iron Razor blade/knives /scissors/shards of glass/ metal/paperclip Eraser/quarters Teeth, Fingernails/pop tops of cans/broken CDs

2 Self-injury Paradoxical and contradictory A calculated violent act upon one s body that is often intended to ward off feelings and to make oneself feel more normal Deficits in COMMUNICATION COPING DEVICE A WAY TO SELF-SOOTHE CONTROL Why do they do it As per DSM-5: 1. To obtain relief from a negative feeling or cognitive state; 2. To resolve an interpersonal difficulty, or 3. To induce a positive feeling state Communication Cutting is a specific language of pain The Bright Red Scream A way to communicate emotional pain, suffering EMOTIONALLY INARTICULATE I had no voice, so I created my own My body looks how I feel: hurt, damaged, angry A silent scream of agony The body says what they are unable to articulate blood flows easier than words A way of telling; a cry for help Speaks to the psychological distress (pain) of an individual Coping/ control It gives a sense of relief It lets out the hurt, anger, loneliness, feelings of not being loved Reduces anxiety, tension, depression, guilt, loneliness by releasing pent-up pressure Feel alive I feel therefore I am Regulates internal tension and affective states A quick fix to feel good A way to restore emotional equilibrium; an emotional regulator A way to reclaim control over one s body and one s identity The way they mentally survive To get attention (< 4%) Inability to sufficiently manage, soothe, or tolerate strong negative emotions Replaces warmth and intimacy a wounding embrace A form of self punishment For adolescents, it is the perfect storm They already experience emotions more intensely They have the fewest coping skills available to process them

3 Additional DSM-5 Criteria: the behavior is not socially sanctioned (like body decoration or biting one s nails) and the behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning Differentiate from suicide They do not want to die; they want to live They want to kill the emotional pain.not themselves The intent of suicide is to end emotional pain by ending life The intent of self-injurious behavior is to cope and manage life, not to end it Teens who cut versus teens who attempt suicide are often responding to different emotional motivations. Cutters are often seeking tension reduction, distraction from distressing emotions, self punishment, or a sense of control Suicidal feelings usually experienced as a global sense of depression, hopelessness, and despair Self injurers have less depressive symptoms, less suicidal ideation, and more positive attitudes towards life Up to 50% of those who commit suicide have a history of self-harm. In 2000, only 6 teens committed suicide by injury with a sharp object The incidence of cutting is 12 times greater than suicide among youth Doesn t it hurt? The physical pain is less than the emotional pain they feel Is described as numbing May release endorphins, natural opiate-like chemicals that result in feel of well-being Decreases pain and distress Addictive if it works well (Results in self-medication) Therefore, infliction of pain is followed by a sense of relief and calm Self-injury vs. body modification Self injurious behaviors have no legitimate social function Those who cut do NOT consider it aesthetically pretty Cutting is private It is a source of shame and they try to keep it hidden Body modification is usually for beauty or sentiment It is a way of being accepted; The pain is endured to reach the goal; It is usually performed by others Prevalence 7.7% of preadolescents (8% of 3 rd graders) 7%-24% of adolescents and young adults (at least once); 6%-8% are chronic 40%-61% in psychiatric in-patient units for teens 17% of US college students practiced cutting 8.6% in past year 21% injured selves more severely than expected (But only 6.5% sought medical attention) For 36%, no one was aware of their behavior 4% of adults engage in cutting 25% start between 10 and 14; 5% started < 10 years 77% white; 59% from 2-parent homes; Females 4:1 male

4 Famous personalities who cut Johnny Depp Marilyn Manson Angelina Jolie Drew Barrymore Courtney Love Princess Diana Who is at increased risk of self injury Exposure to trauma (perceived, acute, and chronic) Increased in those with eating disorders Increased in those who were sexually or physically abused Low self esteem Identify the cutter Often identified in school May avoid activities like swimming Wear long clothes even in hot weather Make poor excuses about how injuries happen How to respond Do NOT respond with shock or horror (Be nonjudgmental; Have a low key approach) Do NOT demand that the self-injurious behavior stop Do NOT push the teen into a defensive mode This really tells me how badly you are hurting I m glad you ve told me and I m committed to helping you get through it in your own way SAFETY FIRST Assessment Appraise severity of injury Are major blood vessels hit, large portions of skin removed, stitches needed Assess suicide risk on a continuum of lethality and risk for further self harm or suicide If there is a question that child is suicidal DO NOT PANIC OR OVER-REACT DO NOT LEAVE CHILD ALONE Access emergency care (psychologist/counselor, ER, emergency help line) Treatment goals Acquire knowledge and actionable skills to decrease the negative emotional state Help teen maintain highest level of freedom and choice as possible Help to communicate emotions Find alternatives (Only half of teens recognize that they need help) It is difficult to treat More Assessment What does the adolescent want? Is there more than meets the eye; get the bigger picture What was child s previous level of functioning? IDENTIFY STRENGTHS and weaknesses Assess family and their resources/ supports Who are child s significant others?

5 Assess for other risk-taking behaviors Assess for co-morbid conditions Cutters May not trust Believe others don t care about them Feel vulnerable Will resist discussing painful issues until they trust and are not feeling overwhelmed Are ambivalent to let go of the behavior Aims of therapy Help child identify antecedents and conditions that result in self injury Know your triggers Keep a log When did you experience the urge to cut What were your feelings at the time How did your body feel What events, feelings, or thoughts preceded the urge What was the goal of the self injury What would be the intended message communicated to others through the self injury What action did you finally take What was the result Identify and understand psychological dynamics of the behavior Verbalize feelings and dilemmas (Develop a language to articulate feelings) Learn to regulate emotional intensity Move from black and white. To color They are older now and may acknowledge that they can cope better Identify situations where they experienced positive feelings Identify alternatives to deal with stress Walk/exercise Journal Listen to music Leave the room Take a warm bath Drink tea Watch TV Call a friend Contact therapist Cook/bake Cuddle family pet Cry Use imagery/ Look at photos with Write letter to teacher/ visualization positive memories friend to confront them Medications SSRIs (antidepressants) (Increase serotonin and improve mood (Prozac, paxil, zoloft, celexa) Cognitive Behavioral Therapy Yes you are suffering; Yes, you are doing the best you can; Yes, you can grow and change and cope more effectively Use positive self talk Dialectical behavior therapy Targets problematic behavior directly What does this behavior DO for the teen Find the kernal of truth in what is being said and bring the kernals together Cognitive component: examine and challenge prior unhelpful, unrealistic beliefs about selves and world Behavior component: teach and reinforce new and effective behaviors

6 What about the parents? Composure, compassion, comprehension FIRST, DO NOT PANIC Do not demand, freak out, judge, or control This increases teen s anxiety Misinterpreted as anger causes teen to be defensive Parental panic gives the teen power Do NOT dismiss as trivial Do NOT express guilt; transfer responsibility to teen DO give unwavering love and support DO set limits; be the guardian of their safety You did not cause it; you cannot fix it Do unto yourself as your better self does unto others Provide hope Empower She is in charge and no one can make her stop Only she can take responsibility for her self Praise the positives Issues Do not over sensationalize; avoid specific details (51% learned it from a friend or the media) Groups can help or make it worse Chance of infection Confidentiality issues Scars Addiction Enduring the mental health stigma Self injury is ALWAYS a cause for concern; It should never be dismissed or trivialized The kids are hurting and they have come to you Be non-judgmental and non-alarmist Acknowledge their suffering Resources American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Washington DC: APA Cathledge, C., Scharer, K., & Fuller, S. (2012). Assessment and identification of deliberate self-harm in adolescents and young adults. Journal for Nurse Practitioners, 8(4), International Society for the Study of Self-Injury S.A.F.E. (self abuse finally ends) don t cut ( ) Walsh, B. (2012). Treating self-injury: A practical guide. New York: Guilford Press.