Non-Suicidal Self-Harm in Youth Peggy Scallon, M.D. Clinical Associate Professor Child and Adolescent Psychiatry UW School of Medicine and Public Health

Non 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

Cutting

NSSI 20% of adolescents engage in self-harm behaviors Estimated 6% of youth are actively engaged in chronic NSSI Typically begins between ages of 12-15 80% stop within 5 years, but may persist into adulthood

NSSI Females self-harm more often, but less than previously assumed. Best estimates are 60% female; 40% male. No known ethnicity or race differences No known socioeconomic differences Risk is much higher among bisexual or questioning youth

Cultural influences NSSI becoming more frequent Movies and songs increasingly depict self-harm Facebook and YouTube postings make it appear nearly normal and increase contagion effect. Tattooing and piercing may normalize it

Celebrities who cut (and talk about it)

NSSI Over time, repetitive cutting can lead to scarring, shame, low self-esteem, substance abuse, family and school problems, depression and suicide attempts Depression, Anxiety, PTSD, Conduct Disorder, or Borderline Personality Disorder (BPD) may co-exist, but not always Although common, few adolescents receive treatment for NSSI

DSM 5

NSSI in the DSM 5 NSSI is now recognized as a distinct condition in DSM 5 (released May 2013). Placed in Section 3- so insurance does not reimburse for its treatment Criteria- 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.

Neuroscience These 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 group In the face of a negative situation, distraction with another task decreases the emotional spike.

Deficits 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.

Deficits in social interpretation “The world and the people in it are dangerous and malevolent.” Interpreted projective testing and social stories, interpretation of video clips.

NSSI can be addictive Commonly report little or no pain with cutting or burning- instead it releases endorphins Activates the same dopamine brain circuits (reward centers) as drugs of addiction Can 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

Cutting becomes rewarding

Why 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

Why 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”

NSSI 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

Why do they do it? Frequent emotional distress and limited coping strategies (never normal) Because they are emotionally reactive and have difficulty recovering or communicating Cutting is rarely attention-seeking (normally done in private, and is hidden) Sometimes a contagion effect among real and virtual peers They are uncomfortable with emotions

Why do they do it? Greater emotional sensitivity, (low threshold for upset, and longer time to recover) Likely due to a biological predisposition And emotionally invalidating environment Therefore, these youth have intense, negative emotions, but they are confused, overwhelmed and flooded by emotions Have to rely on impulsive strategies to keep emotions at bay.

Why do they do it? Limited ability to express emotions, or trust others enough to communicate about feelings They may lack good role models for coping with stress Not necessarily related to abuse, but often insecure attachment relationships After they do it, they describe relief, but also shame, disgust, and guilt Cutting on face and genitals may reflect more psychopathology

Why do they do it?

Why is it worse in adolescence? Transition from childhood to adulthood Many new stressors and peer pressures More separation from parents- reactivates attachment insecurities Rapid brain changes Changes in dopamine regulation Hormonal changes affect mood and behavior

Suicidality and NSSI

Suicidality and NSSI NSSI is distinct from suicidal behavior due to difference in intention, severity, and frequency With NSSI- there is no intention to die, it is less severe than a suicide attempt, and it may be much more frequent But 70% of kids with NSSI had also made at least one suicide attempt Most kids with NSSI also have SI

Suicidality and NSSI Important 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

Suicidality and NSSI In order to attempt suicide, need desire +capability. Suicide is scary, even if you have SI Those with NSSI often have the desire for suicide, triggered by hopelessness, and high self-criticism And they have the capability because of desensitization to pain and self injury. So those with NSSI are at high risk for suicide However, suicide is a rare event, and NSSI is common, so suicide is hard to predict

What makes it worse?

What makes it worse? Family stressors and conflict Invalidation in the family environment Excessive affective responses from parents or adults Break-ups and “drama” with friends

How can mental health professionals help? Insure safety Assess for co-existing psychiatric disorders Anxiety, depression, PTSD, eating disorders, or personality disorders can often be present. No specific medication to treat NSSI, but should treat the co-existing disorders Initiate psychotherapy

What can other concerned adults do to help? Be direct and express concern Keep the door open for later disclosure Stay connected Educate about emotions and positive coping Ask for help or advice about how to handle this Respond calmly- avoid shock and emotionality, but don’t minimize. Assess severity Refer for more help Insist that kids cover wounds and scars and educate about contagion

Developing emotional regulation Become self-reflective about emotions (poor insight is typical) Understand origins of one’s emotional experience Understand the process of emotional regulation (starts with thumb sucking, social referencing) Understand the consequences of emotional expression in different circumstances Help draw connections between “emotional snapshots”, and make their narrative into a continuous video

What about therapy? Therapy may include individual, family and group forms Individual therapy focuses on support, skill-building, emotional expression, validation Family therapy helps with communication, validation, conflict resolution Group and individual therapy should be Dialectical Behavioral Therapy (DBT) focused

Therapy options- What is DBT? Dialectical Behavioral Therapy is an intervention shown to reduce self-harm behavior 4 Modules- Mindfulness, Interpersonal Effectiveness, Distress Tolerance, Emotional Regulation DBT may be delivered through group or individual therapy Parents may be involved. It is a skills-based group.

Dialectical Behavioral Therapy

Mindfulness “Acceptance of what is” Being fully present Non-judgement Impermanence Non-attachment Curiosity

Interpersonal Effectiveness

Interpersonal Effectiveness How to regulate interpersonal relationships How to establish appropriate boundaries How to get one’s needs met How to apologize Problem-solving Appropriate assertiveness Mutual respect Relational Positivity

Distress Tolerance

Distress Tolerance Tolerance of pain and discomfort Enduring in the face of difficulty Coping skills to persist or survive Recognizing increasing stress levels Teach emotion perception

Emotional Regulation

Emotional Regulation Coping strategies to try to change a situation or one’s emotional state Opposite action Half smile Coping strategies Important to have a big “tool box”

Healthy coping

Healthy Coping Exercise Playing or listening to music Talking with someone trusted Meditation or prayer Distraction Relaxation Humor

Healthy Coping Journaling or expression Getting outdoors Looking at photos or happy memories Cooking Enjoying pets Being productive Helping others More….

Unhealthy coping

Unhealthy Coping Self-harm Using alcohol or drugs Sexual acting out Reckless acts Isolation Suicidality Aggression or violence

What about “replacement” behavioral techniques? Snapping a rubber band, rubbing ice on wrists, marking wrists with a marker have all been suggested Do they help? May “take the edge off”, but likely are taking a complex problem and offering a simple solution Okay to collaborate with kids about whether they would like to try such techniques Better to replace with a soothing ritual- rub good smelling lotion on hands and wrists

What should parents do? Seek professional help Also, be present and offer reassurance to your child

Level of supervision

What about taking doors off hinges, etc? 79% of adolescents with NSSI state that they want help Try 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 objects Guns in the home increase risk of suicide and violence Parents should quietly increase positive presence and availability at home

Parent education- “Don’t freak out” Validate- Communicate understanding and value the other person’s perspective This is the most important skill, and the most difficult Listen, accept, don’t judge, be caring and nurturing Express love and concern Recognize the distress Don’t offer opinion or fix the problem Give positive attention

More on validation- “Emotion Coaching” Dr. John Gottman described this, and found it to decrease physiological arousal. 1) Notice emotions 2) Listen without judgment- see emotions as an opportunity to connect 3) Help label feelings 4) Communicate empathy and understanding 5) Support problem-solving process The opposite of tickling while a child is mad or upset

Communicate well- Listen!

Offer hope and help

References Niedtfeld 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), 383-91 PMID: SAMSHA- Suicide Prevention Resource Center (SPRC) Sept 12, 2014. E. David Klonsky Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review Klonsky, E. D. & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In session.

References Klonsky, 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, 537-370. 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, 128 - 139. 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, 63- 71. www.actforyouth.net/resources/rf/rf_nssi_1209.pdf

References Nixon MK, Cloutier P, Jansson SM.  2008.  Nonsuicidal self- harm in youth: a population-based survey.  CMAJ, 178, 306- 312. 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, 80-87. 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, 725-735.

References Proposed 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), http://dx.doi.org10.1155/2013/159208 Frontiers in Neuroscience, 14 January 2013|.2012.00195 Social cognition in borderline personality disorder; Stefan Roepke, Aline Vater, Sandra Preißler, Hauke R. Heekeren and Isabel Dziobek http://abcnews.go.com/GMA/Parenting/video/self-cutting- trend-apparent-on-youtube-12970972