Self Injurious Behaviors: Trends and Treatments

Elizabeth McCauley, PHD, ABPPProfessor

University of Washington/Seattle Children’s Hospital and Regional

Medical Center

Roadmap

Revisiting Definitions Recent Statistics:

Prevalence Methods Trends Adolescent vulnerability

Controversies Talking about suicide/self-

harm Medications as a trigger Influence of the internet

Causal Models Vulnerabilities to Self-Harm Biological Behavioral Biosocial Theory of

Emotional Dysregulation Intervention Approaches

Assessment Prevention Strategies Treatment Strategies

Definitions: Suicidal and Self-injurious Behaviors

Suicide AttemptED-1/3 report wish to die

Suicide

Deliberate Self-Harm Purposeful self- harm self (cutting, jumping) behaviorIngestion of substance in excess of therapeutic doseIngestion of recreation drug with intent to self-harm

Ingestion of non-ingestible substance or object(Child and Adolescent Self-harm in Europe group)

Suicidal IdeationThoughts of death or dying

Wishing to be deadThoughts of hurting self

Suicidal plan

Self-Harm: Definition

Non-fatal, intentional self-injurious behavior resulting in actual tissue damage, illness or risk of death; or any ingestion of drugs or other substances not prescribed or in excess of prescription with clear intent to cause bodily harm or death.*

Intent may vary. Self-harm: without intent to die with ambivalent intent with intent to die

* Some make distinction between DSH and SHB bec of behaviors that occur during dissociative states

Self-Harm vs. Suicide

Self-harm is major risk factor for completed suicide, either by accident or habituation

The higher the frequency of self-harm, the higher the risk for completed suicide

Self-harm is not a suicide prevention strategy!

Prevalence

Suicide and Suicide Attempts

3rd leading cause of death among adolescents 15-25

5th leading cause of death among youth 5-14

Multiple attempts for every completed suicide

Self-harm Behaviors Community samples:

14% to 39% Psychiatric inpatient

samples: 40% to 61% 25,000 ED visits yrly for

self-harm related events

Adolescence is period of increased risk for self-harm behaviors as well as suicidal thoughts and behaviors

Recent Trends

Suicide Declining rates 1992-2000 Changing methods Changing patterns w/i ethnic groups

DSH Prevalence Increases in frequency Associated factors

Prevalence: Adolescent Suicide

Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources:Anderson, 2002;CDC, 2002;National Center for Health Statistics, 1999. (prior to 1979, African-Americans not broken out. From:   GOULD: J Am Acad Child Adolesc Psychiatry, Volume 42(4).April 2003.386-405

Changing Trends in Methods

0

0.2

0.4

0.6

0.8

1

1.2

92 93 94 95 96 97 98 99 2000 2001

Firearms

Suffocation

Poisoning

All Others

10-14 year olds

FR: MMWR, CDC, 2004, 53:22

Changing Trends in Methods

0

1

2

3

4

5

6

7

8

9

92 93 94 95 96 97 98 99 2000 2001

Firearms

Suffocation

Poisoning

All Others

FR: MMWR, CDC, 2004, 53:22

15-19 year olds

Changing Trends

May reflect issues of access Rapid shifts in youth suicidal behavior can

occur Differential profiles of risk, motivation,

behavior, intent

Hispanics in US-1997-2001

2020 17% of populations Rates of suicide lower overall but still 3rd leading

cause of death among 10-24 yr olds Methods: firearms, suffocation, poisoning Growing risk: Hispanics in grades 9-12,

particularly females, report more sadness, hopelessness and suicidal ideation and attempts than while or black non Hispanics

Hyp risk factors: mental illness, substance use, acculturative stress, family issues, low SES

DSH--Recent community based studies: Australia

Associated Factors: Exposure to self-harm in

friends, family Smoking (fewer than 5

cigarettes/wk) Boyfriend/girlfriend problems Amphetamine use Self-prescribing medications Coping by blaming self **Living with one parent was

associated with lower rates of DSH (as opposed to step parent or other family members)

4000 teens; mean age 15.4 8.4% (6.2%) DSH w/i yr 11.1% females 1.6% males Methods:

59.2% cutting 29.6% overdose of meds 3% illicit drugs 2.2% self-battery 1.7 sniffing/inhalation

DSH--Recent community based studies: England

Associated Factors: Exposure to self-harm in

friends, family Drug use Depression/anxiety/

impulsivity Low self esteem Sexual orientation worries Trouble with police (girls) Hx of being bullied Hx of sexual abuse

6020 teens; 15-16 yrs 13.2% lifetime hx of DSH 8.6% (6.9%) w/i yr 11.2% females 3.2% males Methods:

64.6% cutting 30.7% overdose of meds

54.8% reported multiple acts 12.6% presented to EDs 15.0% suicidal ideation w/o

DSH

Why are Adolescents So Vulnerable??

Why are Adolescents so Vulnerable?

Adolescence represents one of the healthiest periods in life span with respect to physical illness BUT 200-300% increase in mortality and morbidity rates

between mid childhood to late adolescence Problems related to control of emotions and

behavior:• Accidents, homicides• Suicide, depression, anorexia, bulimia• Alcohol and substance use• STDs, unwanted pregnancies

Why are Adolescents so Vulnerable?

Adolescence period of rapid changing in CNS Structural changes occurring in this time

period:• Completion of brain cell genesis, nerve

myelination, dendrite pruning in the frontal cortex

• These developments in turn lay the foundation for more sophisticated “executive function” problem solving skills

Why are Adolescents so Vulnerable?

Pubertal development assoc with changes in brain: Changes in Brain assoc. with behavioral

changes• Animal models--sensation seeking• Adolescents—mood regulation, romantic

interests, changes in sleep/wake cycles, risk taking (DAHL, 2004)

Exploring mechanisms: Dahl, et al, 2005MECHANISM: Rise in estrogen availability during

puberty—may impact the functional integrity of the amygdala and prefrontal cortex

Why are Adolescents so Vulnerable?

Emotional changes associated with pubertal development (emotional intensity, romantic interests, risk taking)

Cognitive changes (inhibitory control, problem solving, long term planning) are more related to increasing age and experience

Why are Adolescents so Vulnerable?

Asynchrony between physical and emotional changes and cognitive maturation During this period of rapid change, adolescents are

not yet able to make rational decisions in the face of intense emotional and motivational states

Prone to biased interpretations of experiences, self-criticality, low inhibitory control, and emotion-focused coping.

“Starting the engines with an unskilled driver”

(Dahl, 2005)

Controversies: Asking about Suicide Gould et al (2005)--? does asking about suicidal ideation

or behavior create distress or increase SI among HS students generally or among high-risk students reporting depressive symptoms, substance use problems, or suicide attempts

2342 students in 6 high schools in New York State Classes were randomized to an E group (n = 1172),

which received the first survey with suicide questions, or C group (n = 1170), which did not receive suicide questions.

Exposure not assoc. w diff in distress, depression or suicidal ideation; not for hi or low risk students

Gould, et al: Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1635-43.

Controversies: Medications as a Trigger

3 to 8 fold increase in the use of antidepressants in children and adolescents from approx 1990-2000 (Zito, et al., 2002; Rushton, et al. 2001)

Efficacy: Fluoxetine (Prozac) – efficacious Up to 40% are “non-responders”

Resistance/Adherence: Adolescent Attitudes (Gray, 2003) 69% stopped taking meds by end of 4 weeks 58-61% report bias against meds “Medicine might…change my personality, control my

thoughts, not let me be myself” Issues around belief in efficacy of meds and stigma about

MI

Duration of Antidepressant Use

0%

20%

40%

60%

80%

100%

Start 1 2 3 4 5 6

Months after initial prescription fill

SSI

Tricyclic

Other

Richardson, et al, 2004

Medications Considerations:

BLACK BOX Warning Providers to monitor weekly for four weeks,

monthly for approx three months Monitor for anxiety, agitation, panic, insomnia,

irritability, hostility, impulsivity, severe restlessness, mania as well as suicidal ideation

Meta analyses of 23 studies with 9 agents: 2:1 increase risk of documented suicide

attempts active med vs. placebo NO suicides completed

Medication and Suicide

Hammad, 2004 meta-analysis: No completed suicides--monitoring No evidence for med association with emergence No evidence for med association with worsening Meds associated with activation in 10-20% of cases

TADS 6 of 7 attempts youth had clear suicide “flags” at

entry into the study Combined tx or CBT best for reduction of suicidal

ideation

Controversies: Medications as a Trigger

Large scale studies of youth and adults suggest that communities with higher rates of antidepressant use have lower suicide rates (Simon, 2006, NEJM)

Difficulty of completing studies to resolve issue—need for large samples (6000) (Simon, 2006, NEJM)

Fact that emergent suicidality is a factor in any treatment of depression or related adolescent problems (Bridge et al., 2005, Am J Psychiatry)

Psychotherapy only study—emergent suicidality in 11 of 88 (12.5%) pts who had not reported current suicidality at intake

Self-reported suicidal thoughts at intake were sign predictor

Controversies: Medications as a Trigger Management: (Simon, 2006, NEJM)

Efficacy only est for those with current MDD—careful dx evaluation

Fluoxetine only proved and approved med—therefore it should be first choice medication

Patients and families need to be clearly warned that suicidal ideation might increase and that aggression and agitation are also signs of possible increased risk

Regular follow-up with active outreach Factors that can increase compliance with tx:

Monitoring and targeting specific behaviors Trial period—CBT “experiment” approach

Controversies: Medications as a Trigger

Are we at risk for increases in suicidality? 2004 FDA advisory regarding increased risk of

suicidal thoughts and behaviors in patients treated with newer antidepressant meds

25% drop in antidepressant prescriptions No change in follow-up care as recommended

by FDA Now some concerns about increases in

suicide ratesbut NO DATA to support at this time

Controversies: Influence of the Internet

80% of 12-17 yrs. report use of internet; half log on daily Primarily for social reasons—may be advantageous for shy,

socially anxious, marginalized youth Depressed youth more likely than others to engage on line—

therefore concern that self injurers may be drawn to internet Could provide positive support BUT also could serve to

spread of deepen practice among adolescents Studied role of internet in spreading DSH info and influencing

help seeking: Prevalence and nature of self-injury message boards Coded 2,942 messages over a 2 mos period (10 boards)

Whitlock, Powers, Eckenrode, 2006. Developmental Psychology, 42:407-412 .

Controversies: Influence of the Internet

Findings: 28.3% informal support—”just relax and take a breath” but also

apologizing beh—”I’m so sorry to lay this on you”, “I hate myself for doing this”

19.2% triggers—conflict with others, depression, school/work stress, most common, loneliness, sexual abuse/rape

9.1%--anx re concealment, managing scars, dishonesty 8.9%--addictiveness of behavior 7.1%--help seeking—largely positive 6.2%--techniques—”how to cut w/o having it bleed so much?”

Conclusions: Internet is providing powerful vehicle to bring DSH youth

together + These youth engage in typical social discourse--exchanging

stories, voicing opinions, providing support - Exposure to subculture that normalizes and encourages self-

harming beh contributing to a social contagion effect

Causal Models: Vulnerabilities to Self-Harm

Depression (emotional lability, irritability, loneliness, isolation, hopelessness)

Anxiety (weak coping and/or social skills) Impulsivity Low self-esteem Perfectionism Confused sense of self (including sexual

orientation) Internal locus of control (self-blaming)

Causal Models: Vulnerabilities to Self-Harm

Awareness of self-harm by peers/family (contagion)

Impaired family communication Hypercritical parents Violent/dysfunctional family Use of cigarettes, alcohol, & drugs Criminal history

Causal Models: Functions of Self-Harm Behaviors

Categories: interpersonal (personality disorders) versus intrapersonal (trauma)

Motivational Factors: Affect modulation (dec anger, fear) Desolation (stop feeling empty) Punish self Influence others (express anger) Magical control (prevent one from hurting others) Self-stimulation (provide excitement)

Additional reasons: To feel relaxed Something to do when alone To get control of a situation To get attention/help To feel more a part of a group

Causal Models: Why do adolescents engage in DSH?

Res to Ques. Self-cutters Self-Poisoners

Relief--terrible state of mind 73.3% 72.6%

Punish self 45% 38.5%

To die 40.2% 66.7% *Show desperation 37.6% 43.9%

? if someone loves me 27.8% 41.2% *Get attention 21.7% 28.8%

Frighten someone 18.6% 24.6%

Get back at someone 12.5% 17.2%

Causal Models: Why do adolescents engage in DSH?

Spontaneous Remarks Self-cutters

(220)

Self-Poisoners(86)

Depression 18.2% 10.5%

Pressure 10.9% 17.4%

Escape 8.3% 22.1% *Angry at self 8.2% 0 * Want to die 0.9% 10.5% *Arguments 1.4% 10.5%

Seeking attention 2.3% 4.6%

Tension relief 2.7% 0

Causal Models: Biological

Heritability—Offspring of parents with mood disorders Those who have attempted suicide 6X more likely to have a child who attempts suicide Role of impulsive aggression –highly heritable Lower levels of the serotonin metabolite 5-

hydroxyindoleacetic acid (5-HIAA) in persons with suicidal behavior or impulsive aggression than dx controls

MRI studies—alterations in the number and function of serotonin receptors in prefrontal cortex—emotional regulation and behavioral inhibition

(Brent et al., 2002, Arch Gen Psychiatry, 59; 2006 NEJM, 355)

Models: Brent et al. 2006

Familial Pathways to Early-Onset Suicidal Behavior.

Causal Models: Biological

Serotonin and DSH Initial findings of some evidence that self-injury is associated

with lower levels of presynaptic serotonin release—MORE RESEARCH NEEDED

Endogenous opioid system (EOS) hypothesis: DSH associated with partial or complete analgesia during the

act Two hypothesis regarding involvement of the EOS in DSH:

Addiction hypothesis—EOS repetitively activated by DSH produces a elevation in mood

Pain hypothesis: Indiv with DSH have an altered EOS, congenitally or 2nd to

changes with repeated experience leading to neurochemical alternations

Mediates reduced pain sensitivity MORE RESEARCH NEEDED

(Yates, 2003, Clinical Psychology Review, 24)

Causal Models: Behavioral

Social learning hypothesis Learned behavior—modeling Behaviors maintained by reinforcement

contingencies: Negative reinforcement—avoid even more

aversive consequences Positive reinforcement—attention, inclusion,

sense of relief, tension reduction

(Yates, 2003, Clinical Psychology Review, 24)

Causal Models: Biosocial Theory

Emotional Vulnerability

+ Invalidating Environment

= Pervasive emotional, behavior, interpersonal,

cognitive, and self dysregulationLinehan, 1999 DBT

Emotion Vulnerability

High sensitivity Immediate reactions Low threshold for emotional reaction

High reactivity Extreme reaction High arousal dysregulates cognitive processing

Slow return to baseline Long lasting reactions Contributes to high sensitivity to next emotional

stimulus

Invalidating Environment

“Poorness of fit” Child’s expression of private experiences are not

validated, but dismissed (i.e., “You can’t be hungry, we just had dinner”)

Child searches social environment for cues on how to act, think, and feel and learns to distrust internal cues

Child “ups the volume” to convince invalidating environment that what they’re feeling is real

Domains of Dysregulation

Emotion Dysregulation Affective lability Problems with anger

Interpersonal Dysregulation Chaotic relationships Fears of abandonment

Self Dysregulation Identity

disturbance/difficulties with sense of self

Sense of emptiness

Behavior Dysregulation Parasuicidal behavior Impulsive behavior

Cognitive Dysregulation Dissociative

responses/paranoid ideation

“Hot” cognitions

Summary of Self-Harm Functions

Respondent Behavior Self-harm as “response

to” past negative event/emotion

Goal is emotion regulation

Function is maladaptive coping mechanism

Intervention targets improved emotion regulation and distress tolerance skills

More common function

Operant Behavior Self-harm as attempt to

“operate on” (influence) future events/emotions

Goal is attention or avoidance/escape

Function is maladaptive attempt to influence behavior of others

Intervention targets interpersonal effectiveness skills

Less common function

Intervention: Prevention

Population based suicide prevention approaches greater effect than those focused on youth at high risk Public education:

Signs and symptoms What to say and do How to get help

Restriction of access to means: Gun locks Monitoring

Intervention: Prevention

Current approaches and outcomes: Signs of Suicide TeenScreen Prevention Models:

INDICATED PREVENTIONSkill-building support groups Family support training

SELECTIVE PREVENTIONScreening programs with special populations Gatekeeper trainingCrisis intervention services

UNIVERSAL PREVENTIONState-wide public educational campaign on suicide preventionSchool-based educational campaigns for youth and parentsPublic educational campaign to restrict access to lethal means Education on media guidelinesEVALUATION AND SURVEILLANCE

Evaluation of prevention interventions in each componentSurveillance of suicide and suicidal behaviors among youth 15-24 years

Assessment and Intervention

Assessment before making treatment plan

Assessment of changes in key symptoms/ behaviors during tx

Assessment of how things are going from family/youth’s persepctive

Case conceptualization Tx Choice

Transient/experimental: peer or media inspired Occasional: coping

strategy for major events

Persistent: standard coping/communication strategy (bad habit)

Intractable: frequent and severe (life disrupting addiction)

Associated with impulsive aggression/complex envir.

Cognitive Behavioral Therapy (CBT)

Dialectical Behavioral Therapy (DBT)

Multisystemic Therapy (MST)

Interventions: Other Concerns

Contagion Curiosity, peer pressure, and risk-taking make teens more

likely to try on various roles and try out various behaviors Self-harm becoming more common, but do not normalize.

“Everybody’s doing it”—NOT! Clearly label self-harm as inappropriate coping/attention-

seeking behavior Respect privacy of those unable to cope effectively Ignore those seeking attention in negative ways

Inadvertent reinforcement Reinforce appropriate behaviors Extinguish (ignore) inappropriate behaviors

Interventions: Referrals

Refer for assessment and treatment Inform parent/guardian Harm to self trumps confidentiality

Questions to ask potential therapists How do you conceptualize self-harm? What is your model for treating self-harm? What is your experience level with these

behaviors?

Evidence Based Interventions

Common Features: Focus on suicidal/DSH

behaviors directly Structure contact and

monitoring Flexibility to include

outreach Issues—no thoroughly

proven intervention, all involve considerable training, DBT and MST designed for complex pts.

Interventions: CBT

CBT Incorporates Behavior, Cognition, Affect and Social factors• Utilizes Treatment Strategies: Enactive Performance-based procedures Structured sessions Cognitive and affective interventions to effect

change in: Thoughts Feelings Behaviors

Thought Record

What happened? How did you f eel?

What thoughts did you have at the time?

What did you do? Any other way to look at it?

List all the emotions you had at the time. Did you f eel some more than others?

What does it mean to you that….? So what? What if ?

Did you want to do something you didn’t do? Do something you wish you hadn’t?

Do you f eel diff erently if you think about it this way? Would you do anything diff erently

Supplementary Materials…

…To support use of CBT skills in clinical practice

Treatments for Adolescents with Depression Study (TADS) Fluoxetine combined

with CBT had a response rate of 71%

Fluoxetine alone-63% CBT alone 43% Placebo 31% Combination most

effective in reducing SI

(TADS Team, 2004)

0

1020304050607080

1stQtr

CombProzacCBTPlacebo

Key elements of BA Distinctly behavioral case conceptualization Functional analysis Activity monitoring and scheduling Emphasis on avoidance patterns Emphasis on routine regulation Behavioral strategies for targeting rumination

BA Model

Life events

Less Rewarding Life

Sad, tired, worthless, indifferent..

Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.

Loss of friendships, conflicts w parents, teachers, bad grades, stress, poor health, etc.

TG 1-2, 2-2

Adolescents Taking Action Sessions 1 & 2: Getting Started

1st by identif ying what makes you feel down 2nd by learning how to tackle problems 3rd by working together with your therapist to take small steps, get active, accomplish your goals, and

Depression

What Does Behavioral Activation Mean?

Depression is a vicious cycle

Your lif e is more stressful. You begin to feel tired, bored….lif e gets harder, you do less, pull away and may blame yourself f or not doing more….it gets harder to do things. This can create more problems with school, parents, f riends…….

BUT Behavioral Activation can break this cycle by:

BUI LD THE LI FE YOU

WANT!

Interventions:Dialectical Behavior Therapy

DBT therapy specifically targets self-harm behaviors Individual therapy Skills Training

Emotion regulation Distress Tolerance Interpersonal effectiveness Mindfulness/self-awareness

Diary cards Chain analyses

Interventions:Other DBT Concepts

Wisemind

Pros/Cons—Long term vs Short Term Pain versus suffering Distraction techniques

Pain vs. Suffering

Pain is part of nature Pain is natural signal that change is needed Pain only creates suffering when you refuse to

accept the pain Acceptance does not equal approval Acceptance transforms suffering into pain Use pain as motivation for effective change

(“make lemonade out of lemons”) Pain we can change…a whole lot easier than

suffering

High Intensity Distraction Techniques

Dance to loud rock/rap music (using a headphone if others are around!)

Take hot/cold shower Exercise/get active Go to the mall Talk to a trusted adult Page your DBT therapist!

Other Distraction Techniques

Write in a personal journal/write poetry

Play on the computer Do your favorite

hobby Bake cookies Imagine your favorite

place and go there in your mind

Listen to music Watch a funny movie

Do muscle relaxation exercises/squeeze a stress ball

Do Mindfulness exercises (deep breathing)

Put on clothes straight out of the dryer

Appreciate nature (look at the stars, listen to the rain, smell the flowers)

Multisystemic Therapy

Characteristics: Intensive family and community based treatment Intensive services—3-5 mos. High engagement and completion rates Effective with youth in juvenile justice system Home based model

Study of MST vs hospitalization as usual: 4 mos and 1 yr follow-up; youth in MST group sign

reduction in suicidal attempts and parental control but no diff in SI, depression, hopelessness

(Huey, et al., 2004, J Am Acad Child Adolesc Psychiatry, 43)

Resources

www.clinicalchildpsychology.org www.dbtseattle.com www.aacap.org