Non-suicidal self-injury Dr Claire Kelly Mental Health First Aid Training and Research Program ORYGEN Research Centre

2 Overview What is NSSI? –Types of NSSI –Terminology Why do people engage in NSSI? –Motivations –Outcomes Controversies Stigma

3 Overview Associated mental disorders Treatment What do you do if someone has injured themselves? –Guidelines for first aid for NSSI –ALGEE …Questions?

4 What is NSSI? 3 main types of NSSI: 1.Major self-injury or major self-mutilation Usually a result of psychosis Single large injury (removing an eye, self- castration or cutting off a digit or limb) 2.Stereotypic self-injury Usually associated with intellectual disability or brain injury, occasionally Autism Repeated self-injury such as banging a head on the wall or self-punching over and over again

5 What is NSSI? 3.Compulsive self-injury Usually associated with personality disorders and depressive disorders Can be a pattern over weeks, months or years This is the type of injury we are talking about.

6 What is NSSI? Types of self-injury: –Cutting, scratching, ripping, tearing, burning, or pinching skin –Carving words or patterns into skin –Interfering with healing of wounds –Banging or punching objects or self –Self-poisoning when this is NOT intended to be a suicide attempt

7 Terminology Non-suicidal self-injury –Deliberately inflicting physical harm on oneself without conscious intent to die. Use a term which best reflects what you intend to say.

8 Who engages in NSSI? Estimates vary: –4% in general population (lifetime) –7 - 21% in clinical populations (review) –60% in psychiatric inpatients (review) –13% - 23% of children and adolescents (lifetime) based on reviews –3-47% in previous 12 months based on multiple cross- sectional studies Exact numbers hard to estimate Lets say “a lot”.

9 Motivations for self-injury  To escape from an intolerable state  Emotional pain, numbness  Suicidal feelings  Wanting to change others’ behaviours  Can be a morbid form of help-seeking  Can be a way to get noticed

10 Motivations Feeling unreal or non-human –Seeing blood or feeling pain can stop this Feeling dissociated –Can bring self back ‘into the body’ “It should show on the outside” –Scars, wounds and dressings can express emotional pain and suffering –Showing desperation to others To die* - not addressed here.

11 Outcomes Common theme: –Current state is intolerable –SI can change the state enough to make it tolerable Most people stop when they have what they need Some can lose control –Most injuries are superficial –Can accidentally cause more serious damage or die

12 Controversies A history of NSSI is associated with increased suicide risk Relationship is very strong – but poorly understood Some people argue that there is always suicidal ideation - even if person is not aware of it Others argue that the person’s intent should be accepted as spoken NSSI must be taken seriously, as a future suicide is possible.

13 Stigma Individuals presenting to emergency rooms may be treated badly Stigma towards people with borderline personality disorder can be directed toward people who have self-injured NSSI is frightening to people who see it, is usually ugly, can leave visible scars and can provoke disgust

14 Associated mental illnesses Most commonly associated with borderline personality disorder (BPD) Also associated with depressive disorders, anxiety disorders, eating disorders, and others

15 Treatment Treating any underlying mental illnesses can decrease number and severity of SI episodes Small trials and small numbers mean there is little strong evidence for any specific treatments for SI alone Some people describe a spontaneous remission in the urge to self-injure

16 First aid for NSSI Evidence base is very limited No evidence base for first aid strategies Guidelines developed by the team –Consensus method –Consumers and clinicians Guidelines document provided

17 The MHFA Action Plan: 1. Assess the risk of suicide or harm

18 The MHFA Action Plan: 1. Assess the risk of suicide or harm Risks associated with SI: –Accidental death Overdose or arterial bleeding –Permanent damage to muscles/tendons Resulting in limited mobility –Secondary harms from infection

19 The MHFA Action Plan: 1. Assess the risk of suicide or harm Attend to any serious injuries first. –Heavy bleeding, arterial bleeding –Burns (especially to face, hands and feet) –Possible broken bones If you are able to offer first aid, do so. Call for emergency assistance as needed. If the person has taken an overdose, regardless of their intention, call an ambulance.

20 The MHFA Action Plan: 1. Assess the risk of suicide or harm Offer to attend to less serious injuries. Ensure adequate first aid supplies are available. Be aware that tending to injuries may be part of what the person needs to do for themselves.

21 The MHFA Action Plan: 1. Assess the risk of suicide or harm ASK: “Are you having thoughts of suicide?” If YES: –Apply first aid for suicidal thoughts. If NO: –Move on to the next action.

22 The MHFA Action Plan: 2. Listen non-judgementally Always stay calm and do not express judgement Do not express disgust or horror Do not trivialise the feelings which have lead to the NSSI Do not punish the person –Especially by threatening to withdraw care

23 The MHFA Action Plan: 2. Listen non-judgementally If you suspect NSSI: –Don’t ignore signs - ask the person about what is happening. –Before talking to the person, consider your own state of mind: Can you stay calm? Can you help without saying something which may cause further hurt? Can you cope with the person’s answer? Ask the person if you can help them to feel better

24 The MHFA Action Plan: 2. Listen non-judgementally If NSSI is confirmed: –Discuss SI calmly with the person –Remember that “stopping self-injury” is not the main aim Main aim is to alleviate distress

25 The MHFA Action Plan: 3. Give reassurance and information NSSI is a response to an intolerable emotional state It is common By getting help for the underlying problems, you can cope without it.

26 The MHFA Action Plan: 4. Encourage professional help-seeking Self-injury is not an illness in itself May need treatment for psychological distress or a mental illness Make sure they know where they can get help, but don't force them to use it A GP, psychiatrist or psychologist can help

27 The MHFA Action Plan: 5. Encourage self-help strategies Talk to someone next time the urge hits Develop your own methods for staying safe Harm minimisation: –Ensure the person has adequate first aid supplies –This can reduce the risk of secondary harms from infections, etc.

28 Keeping safe Ensure that the person has access to first aid supplies Encourage them to speak to someone they trust next time they feel the need to injure themselves Encourage them to find other ways to relieve pain Encourage them to delay for as long as they can Encourage them to do something distracting

29 Questions?