3Non Suicidal Self Injury (NSSI) Defined as intentional, direct injury to one’s body tissue without suicidal ideation in a non socially sanctioned manner.Examples are cutting, burning, scratching, or interfering with wound-healing.Does not include overdosing, substance use, eating disorders, body piercing or tattooing
5NSSI 20% of adolescents engage in self-harm behaviors Estimated 6% of youth are actively engaged in chronic NSSITypically begins between ages of 12-1580% stop within 5 years, but may persist into adulthood
6NSSIFemales self-harm more often, but less than previously assumed. Best estimates are 60% female; 40% male.No known ethnicity or race differencesNo known socioeconomic differencesRisk is much higher among bisexual or questioning youth
7Cultural influences NSSI becoming more frequent Movies and songs increasingly depict self-harmFacebook and YouTube postings make it appear nearly normal and increase contagion effect.Tattooing and piercing may normalize it
9NSSIOver time, repetitive cutting can lead to scarring, shame, low self-esteem, substance abuse, family and school problems, depression and suicide attemptsDepression, Anxiety, PTSD, Conduct Disorder, or Borderline Personality Disorder (BPD) may co-exist, but not alwaysAlthough common, few adolescents receive treatment for NSSI
11NSSI in the DSM 5NSSI is now recognized as a distinct condition in DSM 5 (released May 2013).Placed in Section 3- so insurance does not reimburse for its treatmentCriteria-5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent within the past year.And at least 1 of the following expectations: to relieve negative feelings or thoughts, or to resolve a relationship problem, or to induce a positive mood.And the behavior must meet 1 of these criteria: triggered by a relationship problem or negative feelings; includes premeditation, and rumination about the self-injury.
12NeuroscienceThese youth exhibit more stress (in the brain’s limbic system as seen on brain scans) from negative images and even misinterpret neutral images compared to a control groupIn the face of a negative situation, distraction with another task decreases the emotional spike.
13Deficits in social interpretation These youth have deficits in interpreting and attributing the emotions, thoughts and intentions of others.They are less trustful of others, and they interpret negative intentions from others.They also express mixed and hard-to-read emotional signals to others, so they receive more negative responses from others.In fact, this negative relational style may be the most specific feature of these youth.
14Deficits in social interpretation “The world and the people in it are dangerous and malevolent.”Interpreted projective testing and social stories, interpretation of video clips.
15NSSI can be addictiveCommonly report little or no pain with cutting or burning- instead it releases endorphinsActivates the same dopamine brain circuits (reward centers) as drugs of addictionCan become addictive and hard to stop, because it is a powerful emotional regulator (very rewarding)Usually not done together with alcohol or drugs (both serve the same function-to change mood and relieve stress)Dopamine blocking meds (naltrexone) have been tried with little success
17Why do they do it? 1) Emotional regulation-”to calm myself down” 2) Self-punishment- “express anger toward myself”3) Anti-suicide- “put a stop to suicidal thoughts”4) Anti-dissociation- “stop feeling numb”5) Interpersonal influence- “let others know the extent of my pain”6) Excitement seeking- “generate excitement”Not mutually exclusive
18Why do they do it? 7) Peer Bonding- “fitting in with others” 8) Self care- “creating an injury easier to fix than my distress”9) Marking distress- “creating a physical sign that I feel awful”10) Interpersonal Boundaries- “creating a boundary between myself and others”11) Toughness- “seeing if I can stand the pain”12) Revenge- “getting back at someone”13) Autonomy- “demonstrating I do not need to rely on others for help”
19NSSI works to change emotions Before: “Overwhelmed”, “Sad”, “Hurt Emotionally”During: “Angry at Self”, “Hurt Emotionally, “Isolated”After: “Relieved”, “Angry at Self”, “Calm”Thus, negative, high arousal goes down (overwhelmed and sad), and positive, low arousal goes up (relief and calm)In summary, NSSI moves people from overwhelmed and sad; to relief and calm. It relieves emotional pressure
20Why do they do it?Frequent emotional distress and limited coping strategies (never normal)Because they are emotionally reactive and have difficulty recovering or communicatingCutting is rarely attention-seeking (normally done in private, and is hidden)Sometimes a contagion effect among real and virtual peersThey are uncomfortable with emotions
21Why do they do it?Greater emotional sensitivity, (low threshold for upset, and longer time to recover)Likely due to a biological predispositionAnd emotionally invalidating environmentTherefore, these youth have intense, negative emotions, but they are confused, overwhelmed and flooded by emotionsHave to rely on impulsive strategies to keep emotions at bay.
22Why do they do it?Limited ability to express emotions, or trust others enough to communicate about feelingsThey may lack good role models for coping with stressNot necessarily related to abuse, but often insecure attachment relationshipsAfter they do it, they describe relief, but also shame, disgust, and guiltCutting on face and genitals may reflect more psychopathology
24Why is it worse in adolescence? Transition from childhood to adulthoodMany new stressors and peer pressuresMore separation from parents- reactivates attachment insecuritiesRapid brain changesChanges in dopamine regulationHormonal changes affect mood and behavior
26Suicidality and NSSINSSI is distinct from suicidal behavior due to difference in intention, severity, and frequencyWith NSSI- there is no intention to die, it is less severe than a suicide attempt, and it may be much more frequentBut 70% of kids with NSSI had also made at least one suicide attemptMost kids with NSSI also have SI
27Suicidality and NSSIImportant to clarify SI from NSSI to avoid unnecessary hospitalization, misuse of resources, and misunderstanding.Ask, “Is your goal to die?”NSSI is distinct from SI, but it is a strong risk factor for a suicide attempt
28Suicidality and NSSIIn order to attempt suicide, need desire +capability. Suicide is scary, even if you have SIThose with NSSI often have the desire for suicide, triggered by hopelessness, and high self-criticismAnd they have the capability because of desensitization to pain and self injury.So those with NSSI are at high risk for suicideHowever, suicide is a rare event, and NSSI is common, so suicide is hard to predict
30What makes it worse? Family stressors and conflict Invalidation in the family environmentExcessive affective responses from parents or adultsBreak-ups and “drama” with friends
31How can mental health professionals help? Insure safetyAssess for co-existing psychiatric disordersAnxiety, depression, PTSD, eating disorders, or personality disorders can often be present.No specific medication to treat NSSI, but should treat the co-existing disordersInitiate psychotherapy
32What can other concerned adults do to help? Be direct and express concernKeep the door open for later disclosureStay connectedEducate about emotions and positive copingAsk for help or advice about how to handle thisRespond calmly- avoid shock and emotionality, but don’t minimize. Assess severityRefer for more helpInsist that kids cover wounds and scars and educate about contagion
33Developing emotional regulation Become self-reflective about emotions (poor insight is typical)Understand origins of one’s emotional experienceUnderstand the process of emotional regulation (starts with thumb sucking, social referencing)Understand the consequences of emotional expression in different circumstancesHelp draw connections between “emotional snapshots”, and make their narrative into a continuous video
34What about therapy?Therapy may include individual, family and group formsIndividual therapy focuses on support, skill-building, emotional expression, validationFamily therapy helps with communication, validation, conflict resolutionGroup and individual therapy should be Dialectical Behavioral Therapy (DBT) focused
35Therapy options- What is DBT? Dialectical Behavioral Therapy is an intervention shown to reduce self-harm behavior4 Modules- Mindfulness, Interpersonal Effectiveness, Distress Tolerance, Emotional RegulationDBT may be delivered through group or individual therapyParents may be involved. It is a skills-based group.
40Interpersonal Effectiveness How to regulate interpersonal relationshipsHow to establish appropriate boundariesHow to get one’s needs metHow to apologizeProblem-solvingAppropriate assertivenessMutual respectRelational Positivity
49Unhealthy Coping Self-harm Using alcohol or drugs Sexual acting out Reckless actsIsolationSuicidalityAggression or violence
50What about “replacement” behavioral techniques? Snapping a rubber band, rubbing ice on wrists, marking wrists with a marker have all been suggestedDo they help?May “take the edge off”, but likely are taking a complex problem and offering a simple solutionOkay to collaborate with kids about whether they would like to try such techniquesBetter to replace with a soothing ritual rub good smelling lotion on hands and wrists
51What should parents do? Seek professional help Also, be present and offer reassurance to your child
53What about taking doors off hinges, etc? 79% of adolescents with NSSI state that they want helpTry to avoid power struggles, but parents should supervise closely. Always know where kids are, and who they are with- and verify!Take all reasonable measures to remove access to harmful objectsGuns in the home increase risk of suicide and violenceParents should quietly increase positive presence and availability at home
54Parent education- “Don’t freak out” Validate- Communicate understanding and value the other person’s perspectiveThis is the most important skill, and the most difficultListen, accept, don’t judge, be caring and nurturingExpress love and concernRecognize the distressDon’t offer opinion or fix the problemGive positive attention
55More on validation- “Emotion Coaching” Dr. John Gottman described this, and found it to decrease physiological arousal.1) Notice emotions2) Listen without judgment- see emotions as an opportunity to connect3) Help label feelings4) Communicate empathy and understanding5) Support problem-solving processThe opposite of tickling while a child is mad or upset
58ReferencesNiedtfeld I, Schulze L, Kirsch P, Herpertz SC, Bohus M, & Schmahl C (2010). Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury. Biological psychiatry, 68 (4), PMID:SAMSHA- Suicide Prevention Resource Center (SPRC) Sept 12, E. David KlonskyKlonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology ReviewKlonsky, E. D. & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In session.
59ReferencesKlonsky, E.D. (2009). The functions of self-injury in young adults who cut themselves; Clarifying the evidence for affect-regulation. Psychiatry Research.Adler P, Adler P. 2007. The demedicalization of self-injury. Journal of Contemporary Ethnography, 36,Cheng H-L, Mallenckrodt B, Soet J, Sevig T. 2010. Developing a screening instrument and at-risk profile for nonsuicidal self-injurious behavior in college women and men. Journal of Counseling Psychology, 57,Hilt LM, Cha CB, Nolen-Hoeksema S. 2008. Nonsuicidal self-injury in young adolescent girls: moderators of the distress-function relationship. Journal of Consulting and Clinical Psychology, 76,
60ReferencesNixon MK, Cloutier P, Jansson SM. 2008. Nonsuicidal self- harm in youth: a population-based survey. CMAJ, 178,Rodham K, Hawton K, Evans 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 & Adolescent Psychiatry, 43,Whitlock J, Muehlenkamp J, Eckenrode J. 2008. Variation in nonsuicidal self-injury: identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child and Adolescent Psychology, 37,
61ReferencesProposed Diagnostic Criteria for the DSM-5 of Nonsuicidal Self-Injury in Female Adolescents: Diagnostic and Clinical Correlates Tina In-Albon, Claudia Ruf and Marc Schmid; Psychiatry JournalVolume 2013 (2013),Frontiers in Neuroscience, 14 January 2013| Social cognition in borderline personality disorder; Stefan Roepke, Aline Vater, Sandra Preißler, Hauke R. Heekeren and Isabel Dziobektrend-apparent-on-youtube