1. Driven to The Edge: Self- Injury in Adolescents Jeanette E. Cueva, M.D. Associate Clinical Professor of Psychiatry Columbia University College of Physicians and Surgeons

2. OVERVIEW History History Definition Definition Demographics Demographics Prevalence Prevalence Motivation Motivation Etiology Co-morbid Diagnoses Detection Intervention Treatment

3. HISTORY 496-406 BCE: Sophocles, Ancient Greece 496-406 BCE: Sophocles, Ancient Greece 460-370 BCE: Hippocrates 460-370 BCE: Hippocrates 11th Century: Christian Faith expressed by Self Mutilation 11th Century: Christian Faith expressed by Self Mutilation 1846: First report written on self mutilation: a guilt ridden widow enucleates both eyes 1846: First report written on self mutilation: a guilt ridden widow enucleates both eyes 1888: Van Gough cut his earlobe 1888: Van Gough cut his earlobe 1938: Menninger suggested self mutilation may be a way to heal oneself 1938: Menninger suggested self mutilation may be a way to heal oneself

4. DEFINITION C OMPLEX G ROUP OF B EHAVIORS C OMPLEX G ROUP OF B EHAVIORS Results in Tissue Damage Results in Tissue Damage INCLUDES: INCLUDES: Scratching, burning or cutting, pulling out hair, breaking bones, amputation, and eye enucleation Scratching, burning or cutting, pulling out hair, breaking bones, amputation, and eye enucleation Classification (Favazza and Rosenthal) : Classification (Favazza and Rosenthal) : MAJOR MAJOR STEREOTYPIC STEREOTYPIC SUPERFICIAL SUPERFICIAL

5. MAJOR SELF MUTILATION SIGNIFICANT AMOUNT OF DAMAGE TO BODY TISSUE SIGNIFICANT AMOUNT OF DAMAGE TO BODY TISSUE USUALLY INJURIES THAT CAN ONLY BE INFLICTED ONCE USUALLY INJURIES THAT CAN ONLY BE INFLICTED ONCE WHILE IN A HALLUCINATORY OR ZOMBIE-LIKE STATE WHILE IN A HALLUCINATORY OR ZOMBIE-LIKE STATE

6. STEREOTYPIC SELF- MUTITALTION REPETATIVE AND SOMETIMES RHYTHMIC REPETATIVE AND SOMETIMES RHYTHMIC MOST COMMON IS HEAD BANGING MOST COMMON IS HEAD BANGING MOST FREQUENTLY ASSOCIATED WITH MR MOST FREQUENTLY ASSOCIATED WITH MR MOST ARE UNAWARE OF THER ACTIONS MOST ARE UNAWARE OF THER ACTIONS

7. SUPERFICIAL/MODERATE SELF- MUTILATION Most common category observed Most common category observed Believed to exist in 1.4 percent of the population Believed to exist in 1.4 percent of the population TYPES: compulsive, episodic and repetitive TYPES: compulsive, episodic and repetitive

8. THE POWER OF SKIN When the embryo is < 6 weeks, it responds to delicate touch When the embryo is < 6 weeks, it responds to delicate touch Skin and Brain grow from the same embryonic cell layer- the ectoderm Skin and Brain grow from the same embryonic cell layer- the ectoderm Skin contact allows a newborn to experience itself and the world around it Skin contact allows a newborn to experience itself and the world around it In a way we are shaped by our earliest primitive memories and sensations through the skin In a way we are shaped by our earliest primitive memories and sensations through the skin

9. DEMOGRAPHICS/PREVALANCE 750 per 100,000 in the US (Conterio and Favazza) 750 per 100,000 in the US (Conterio and Favazza) Profile: female, mid 20s to 30s, Upper socioeconomic status, SI since teens, h/o abuse, eating disorders often reported Profile: female, mid 20s to 30s, Upper socioeconomic status, SI since teens, h/o abuse, eating disorders often reported Why so Many Women? Why so Many Women?

10. Women tend to internalize anger and men to externalize it Women tend to internalize anger and men to externalize it Women subjected to a focus on the body--encouraged to remain on the surface Women subjected to a focus on the body--encouraged to remain on the surface Females are more frequently victims of sexual abuse Females are more frequently victims of sexual abuse

11. MOTIVATION PSYCHOLOGICAL PSYCHOLOGICAL AFFECT REGULATION AFFECT REGULATION COMMUNICATION COMMUNICATION CONTROL/PUNISHMENT CONTROL/PUNISHMENT

12. ETIIOLGY ADDICTED TO TRAUMA ADDICTED TO TRAUMA FEEL NO PAIN FEEL NO PAIN PTSD PTSD SOUL MURDER SOUL MURDER

13. ETIOLOGY (2) NEUROTRANSMITTERS NEUROTRANSMITTERS STRESS HORMONES STRESS HORMONES STRESS RESPONSE STRESS RESPONSE

14. Social Explanations Eye injury in soldiers to avoid duty Eye injury in soldiers to avoid duty Prison Settings Prison Settings Gangs Gangs Peer Influence Peer Influence

15. Co-Morbid Diagnoses Borderline Personality Disorder Borderline Personality Disorder Mood Disorders Mood Disorders OCD OCD PTSD PTSD Dissociative Disorders Dissociative Disorders Anxiety or Panic Disorder Anxiety or Panic Disorder

16. DETECTION Change in behavior (eg. Withdrawal) Change in behavior (eg. Withdrawal) Wearing long sleeves despite warm weather to cover up cuts Wearing long sleeves despite warm weather to cover up cuts Exposed scratches, cuts or burns on the body Exposed scratches, cuts or burns on the body

17. INTERVENTION Multi-dimentional Multi-dimentional Includes: social workers, medical professional, psychologists and teachers Includes: social workers, medical professional, psychologists and teachers Psychotherapy Psychotherapy Medication (sometimes) Medication (sometimes)

18. PREVENTION ADVOCATE FOR BETTER SOCIAL ENVIRONMENT ADVOCATE FOR BETTER SOCIAL ENVIRONMENT FACILITATE BETTER PARENT-CHILD AND PEER COMMUNICATION FACILITATE BETTER PARENT-CHILD AND PEER COMMUNICATION NUTURING AND ENHANCING SELF INTEGRETY AND DIGNITY NUTURING AND ENHANCING SELF INTEGRETY AND DIGNITY