Cutting and Self Harm Cutting and Self Harm A Disturbing Trend A Disturbing Trend

Lori O’Dell McCollum, Ph.D.Lori O’Dell McCollum, Ph.D.Comprehensive Psychological Services, LLPComprehensive Psychological Services, LLP

Licensed Psychologist, Iowa and IllinoisLicensed Psychologist, Iowa and Illinois

1302 71302 7thth Street, Moline, IL Street, Moline, IL

309-762-3931309-762-3931

lori_mccollum@sbcglobal.netlori_mccollum@sbcglobal.net

www.compsychserv.net

Learning ObjectivesLearning Objectives

1) Be able to differentiate between types of self-harm 1) Be able to differentiate between types of self-harm behavior, and know how it differs from suicidal behavior.behavior, and know how it differs from suicidal behavior.

2) Be able to recognize the incidence and risk factors 2) Be able to recognize the incidence and risk factors associated with this behavior.associated with this behavior.

3) Be able to conduct a screening interview of high risk 3) Be able to conduct a screening interview of high risk patients to identify this behavior and gain information patients to identify this behavior and gain information necessary to direct treatment.necessary to direct treatment.

4) Describe specific causes and functions of self-harm, 4) Describe specific causes and functions of self-harm, including affect regulation, stress reduction, suicide including affect regulation, stress reduction, suicide prevention, and problem solving deficitsprevention, and problem solving deficits

Learning ObjectivesLearning Objectives

5) Discuss the relationship between self-harm and co-5) Discuss the relationship between self-harm and co-morbid conditions, such as mood disorders, PTSD, morbid conditions, such as mood disorders, PTSD, Eating Disorders, BPD and OCD.Eating Disorders, BPD and OCD.

6) Outline specific treatment and prevention strategies 6) Outline specific treatment and prevention strategies useful for this population.useful for this population.

7) Be able to assess medical and mental health needs of 7) Be able to assess medical and mental health needs of these patients and make appropriate referrals.these patients and make appropriate referrals.

History of Self HarmHistory of Self Harm

Seen in biblical references of self-flagellation.Seen in biblical references of self-flagellation. Early references in psychiatric research were Early references in psychiatric research were

predominantly within the population of predominantly within the population of Borderline Personality Disordered patients.Borderline Personality Disordered patients.

In the 1970’s research expanded into patients In the 1970’s research expanded into patients with trauma experiences.with trauma experiences.

Since the 1990’s we’ve seen an explosion of Since the 1990’s we’ve seen an explosion of clients with this symptomatology from a wide clients with this symptomatology from a wide range of diagnoses and backgrounds.range of diagnoses and backgrounds.

Well Known PersonalitiesWell Known PersonalitiesWho’ve Engaged in Self-HarmWho’ve Engaged in Self-Harm

Princess Diana- British RoyaltyPrincess Diana- British Royalty Angelina Jolie- ActressAngelina Jolie- Actress Johnny Depp- ActorJohnny Depp- Actor Alfred Kinsey- Sexuality ResearcherAlfred Kinsey- Sexuality Researcher Marilyn Manson & Sid Vicious- MusiciansMarilyn Manson & Sid Vicious- Musicians Kelly Holmes- Olympic AthleteKelly Holmes- Olympic Athlete Courtney Love- MusicianCourtney Love- Musician Amy Winehouse- MusicianAmy Winehouse- Musician

What is Self Mutilation?What is Self Mutilation?Non-life threatening, self inflicted bodily Non-life threatening, self inflicted bodily

harm or disfigurement of a socially harm or disfigurement of a socially

unacceptable natureunacceptable nature

May be deliberate or unconsciousMay be deliberate or unconscious

Generally of low lethalityGenerally of low lethality

Commonly employ multiple methodsCommonly employ multiple methods

Examples of Self HarmExamples of Self Harm

CuttingCutting BurningBurning Compulsive skin pickingCompulsive skin picking Hair-pullingHair-pulling Bone breakingBone breaking HittingHitting Interference with wound healingInterference with wound healing

Types of Self MutilationTypes of Self Mutilation

Non-dissociative – Non-dissociative – Feeling pain is the goal. Intolerable rage with Feeling pain is the goal. Intolerable rage with

which she is only capable of attacking herself.which she is only capable of attacking herself.

Dissociative – Dissociative – Numbing is the goal, distracts self from Numbing is the goal, distracts self from

mental disintegration and pain.mental disintegration and pain.

Secondary gain – Secondary gain – Attention seekingAttention seeking

Differences between self injury and Differences between self injury and suicidal behaviorsuicidal behavior

A suicidal client believes there is no way A suicidal client believes there is no way out and seeks a final solution.out and seeks a final solution.

A self injurious client responds strongly to A self injurious client responds strongly to short-term frustrations and seeks short short-term frustrations and seeks short term alleviation of tensionterm alleviation of tension

Incidence of Self HarmIncidence of Self Harm

Previously thought to be 1 in 250 – Same Previously thought to be 1 in 250 – Same as anorexiaas anorexia

Current estimates are 1 in 100 for self Current estimates are 1 in 100 for self mutilation and 1 in 10 for self harmmutilation and 1 in 10 for self harm

More girls than boys (2 to 1)More girls than boys (2 to 1) Highest incidence: Highest incidence:

Girls ages 15-24 Girls ages 15-24 Boys ages 12-34Boys ages 12-34

Co-morbidityCo-morbidity

One of the criteria for BPDOne of the criteria for BPD 40% overlap with Eating Disorders40% overlap with Eating Disorders 24% with Anti-social Behavior/Prisoners24% with Anti-social Behavior/Prisoners 3X more likely for clients with PTSD3X more likely for clients with PTSD 46% of runaways46% of runaways 73% of violent clients73% of violent clients

Risk FactorsRisk Factors

Family history of depression and anxietyFamily history of depression and anxiety Family history of poor communication and/or domestic Family history of poor communication and/or domestic

violenceviolence Early abuse or trauma historyEarly abuse or trauma history

Girls often have a history of sexual abuseGirls often have a history of sexual abuse Boys often have a history of physical abuseBoys often have a history of physical abuse

Low self-esteem, social isolation and alienation from Low self-esteem, social isolation and alienation from peer grouppeer group

Associated Causal FactorsAssociated Causal Factors

1.1. Inability to deal with emotional intensityInability to deal with emotional intensity

2.2. Feelings of mental disintegrationFeelings of mental disintegration

3.3. Attachment IssuesAttachment Issues

4.4. Identity IssuesIdentity Issues

5.5. Poor Interpersonal SkillsPoor Interpersonal Skills

6.6. Family DynamicsFamily Dynamics

7.7. Physiological/Behavioral Explanations Physiological/Behavioral Explanations

Emotional IntensityEmotional Intensity

Lives life at survival level emotionallyLives life at survival level emotionally May describe feelings of emptinessMay describe feelings of emptiness Feelings of rage that can’t be expressedFeelings of rage that can’t be expressed Emotionally inarticulateEmotionally inarticulate Those easily influenced by contagion Those easily influenced by contagion

effectseffects Inflicting harm is a way of controlling Inflicting harm is a way of controlling

emotional painemotional pain

Mental DisintegrationMental Disintegration

Sense that they are unable to think.Sense that they are unable to think. Poor problem solving skills, which lead to Poor problem solving skills, which lead to

fear of confronting problems or people with fear of confronting problems or people with whom they are struggling.whom they are struggling.

Loss of perspective in terms of the size of Loss of perspective in terms of the size of the problem, and losing sight of the the problem, and losing sight of the impracticality of pain and dangerimpracticality of pain and danger

Attachment IssuesAttachment Issues

Poor family relationships in generalPoor family relationships in general Poor bonding with parent figuresPoor bonding with parent figures History of chronic illness or surgeryHistory of chronic illness or surgery Has been in foster care or group homesHas been in foster care or group homes RunawayRunaway Sexual promiscuity Sexual promiscuity No one they can trust to help them.No one they can trust to help them.

Identity IssuesIdentity Issues

Experiences self as powerlessExperiences self as powerless Feels isolatedFeels isolated Alienation from peer groupAlienation from peer group Low self-esteemLow self-esteem Distress over sexual identityDistress over sexual identity Borderline Personality DisorderBorderline Personality Disorder

Poor Interpersonal SkillsPoor Interpersonal Skills

May have superficial communication May have superficial communication skills, but not intimate connectionsskills, but not intimate connections

May express desire to communicate May express desire to communicate distress, or to shock and manipulatedistress, or to shock and manipulate

Poor emotional perceptiveness of othersPoor emotional perceptiveness of others Peer isolation and conflictPeer isolation and conflict May have been violent toward othersMay have been violent toward others

Family DynamicsFamily Dynamics

Boundary violations, including abuseBoundary violations, including abuse Violent behavior, Domestic ViolenceViolent behavior, Domestic Violence Substance AbuseSubstance Abuse Parent mental health problemsParent mental health problems Parents who have difficulty with nurturing Parents who have difficulty with nurturing

and authoritative behaviorand authoritative behavior Enmeshment vs. DisengagementEnmeshment vs. Disengagement

Physiological and Behavioral Physiological and Behavioral ExplanationsExplanations

Self mutilation releases beta endorphins Self mutilation releases beta endorphins which give a feeling of well being and can which give a feeling of well being and can mask emotional pain.mask emotional pain.

Negative reinforcement contingency – Negative reinforcement contingency – tension reduction may lead to sense of calm.tension reduction may lead to sense of calm.

Self harm can be addictive.Self harm can be addictive. Cyclical – tension/releaseCyclical – tension/release

InterventionsInterventions

1.1. Identification is key - AssessmentIdentification is key - Assessment

2.2. Therapy - Build structures from withoutTherapy - Build structures from without

3.3. Therapy - Build structures from withinTherapy - Build structures from within

4.4. Therapy – Building relationshipsTherapy – Building relationships

5.5. Medical InterventionsMedical Interventions

IdentificationIdentification

FamilyFamily FriendsFriends SchoolSchool Medical ProfessionalsMedical Professionals Self Report - ASKSelf Report - ASK Assessing high risk groupsAssessing high risk groups

TherapyTherapyStructures from WithoutStructures from Without

Individual TherapistIndividual Therapist Family TherapyFamily Therapy School ResourcesSchool Resources Community InvolvementCommunity Involvement National policies for mental health National policies for mental health

treatmenttreatment Build relationships/support systemsBuild relationships/support systems Teach healthy dependenciesTeach healthy dependencies

TherapyTherapyStructures from WithinStructures from Within

Build insightBuild insight Helping them understand the function of the behaviorHelping them understand the function of the behavior If related to family discord, help the patient recognize If related to family discord, help the patient recognize

their losses, and deal with past and current issues.their losses, and deal with past and current issues. If related to trauma, do the work to heal past pain and If related to trauma, do the work to heal past pain and

recognize their goal of avoidance.recognize their goal of avoidance. If related to attention seeking behavior, help the If related to attention seeking behavior, help the

patient understand how manipulative behavior patient understand how manipulative behavior patterns work against their goals for intimacy.patterns work against their goals for intimacy.

Help the patient recognize the limitations of control Help the patient recognize the limitations of control over others in their lives, and ways to improve self-over others in their lives, and ways to improve self-control.control.

Therapy Therapy Structure from WithinStructure from Within

Build skillsBuild skills Distress toleranceDistress tolerance Emotional RegulationEmotional Regulation Cognitive restructuringCognitive restructuring Core mindfulnessCore mindfulness Interpersonal Relationship SkillsInterpersonal Relationship Skills CommunicationCommunication Crisis Survival SkillsCrisis Survival Skills Self AcceptanceSelf Acceptance

Therapy – Building Therapy – Building RelationshipsRelationships

Nurturing – authoritative therapy consists of Nurturing – authoritative therapy consists of therapist’s behaviors that are caring, supportive, therapist’s behaviors that are caring, supportive, guiding, and instructive.guiding, and instructive.

We build the therapeutic relationship in a safe We build the therapeutic relationship in a safe setting with appropriate boundariessetting with appropriate boundaries

We model communication skills, and show the We model communication skills, and show the patient new ways to gain support.patient new ways to gain support.

We build attachments, but teach how to expand We build attachments, but teach how to expand those into their real world by giving homework those into their real world by giving homework assignments.assignments.

Treatment of Original IssuesTreatment of Original Issues

After the self-harm behavior is confronted, and After the self-harm behavior is confronted, and the patient acquires skills and insight, we often the patient acquires skills and insight, we often have to back up and address pre-existing mental have to back up and address pre-existing mental health issues.health issues.

Patients may need ongoing treatment for these Patients may need ongoing treatment for these underlying concerns or co-morbid conditions, underlying concerns or co-morbid conditions, even after the self-harm behavior is even after the self-harm behavior is extinguished.extinguished.

Relapse prevention is essential to plan for future Relapse prevention is essential to plan for future stressful events or co-morbid episodes.stressful events or co-morbid episodes.

Medical InterventionsMedical Interventions

Review need for medical treatment of Review need for medical treatment of wounds or injurieswounds or injuries

Review need for anti-depressant or anti-Review need for anti-depressant or anti-anxiety medicationanxiety medication

Review need for referral to dermatologist Review need for referral to dermatologist for treatment of scarsfor treatment of scars

Complications for ongoing treatment, Complications for ongoing treatment, particularly OB/GYNparticularly OB/GYN

ReferencesReferences Alderman, T. (1997). Alderman, T. (1997). The Scarred Soul: Understanding and Ending The Scarred Soul: Understanding and Ending

Self-Inflicted ViolenceSelf-Inflicted Violence. Oakland: New Harbinger. . Oakland: New Harbinger. American Psychiatric Association. (1994). The diagnostic and American Psychiatric Association. (1994). The diagnostic and

statistical manual of mental disorders, 4statistical manual of mental disorders, 4thth edition. Washington, D.C.: edition. Washington, D.C.: American Psychiatric Association.American Psychiatric Association.

Bohus, M.; Haaf, B.; Simms, T.; Limberger, M.F., et al. (2004). Bohus, M.; Haaf, B.; Simms, T.; Limberger, M.F., et al. (2004). Effectiveness of inpatient dialectical behavior therapy for borderline Effectiveness of inpatient dialectical behavior therapy for borderline personality disorder: A controlled trial. Behavioral Reseerch and personality disorder: A controlled trial. Behavioral Reseerch and Therapy, 42, (5), 487-499.Therapy, 42, (5), 487-499.

Favazza, A. (1996). Favazza, A. (1996). Bodies Under Siege: Self Mutilation and Body Bodies Under Siege: Self Mutilation and Body Modification in Culture and PsychiatryModification in Culture and Psychiatry. Baltimore: Johns Hopkins . Baltimore: Johns Hopkins University Press.University Press.

ReferencesReferences

Favazza, A.R. and Conterio, K. (1988_. The plight of chronic self-Favazza, A.R. and Conterio, K. (1988_. The plight of chronic self-mutilators. Community Mental Health Journal, 24, 22-30.mutilators. Community Mental Health Journal, 24, 22-30.

Herman, J. (1992). Herman, J. (1992). Trauma and RecoveryTrauma and Recovery. NY: Basic Books.. NY: Basic Books. Levenkron, S. (1998). Levenkron, S. (1998). Cutting: Understanding and Overcoming Slef-Cutting: Understanding and Overcoming Slef-

MutilationMutilation. New York: W.W. Norton and Company. . New York: W.W. Norton and Company. McMain, S, et al. (2003). Implications of childhood sexual abuse for McMain, S, et al. (2003). Implications of childhood sexual abuse for

adult borderline personality disorder and complex post-traumatic adult borderline personality disorder and complex post-traumatic stress disorder. American Journal of Psychiatry, 160, (2), 369-371.stress disorder. American Journal of Psychiatry, 160, (2), 369-371.

Miller, D. (1994). Miller, D. (1994). Women Who Hurt Themselves: A Book of Hope Women Who Hurt Themselves: A Book of Hope and Understandingand Understanding. New York: Basic Books.. New York: Basic Books.

Pipher, M. Pipher, M. Reviving Ophelia: Saving the Selves of Adolescent GirlsReviving Ophelia: Saving the Selves of Adolescent Girls. . NY: Ballantine Books, 1994.NY: Ballantine Books, 1994.

References References Rodham, K.; Hawton, K., and Evanas, E. (2004). Reasons for Rodham, K.; Hawton, K., and Evanas, E. (2004). Reasons for

deliberate self-harm: Comparison of self-poisoners and self-cutters deliberate self-harm: Comparison of self-poisoners and self-cutters in a community sample of adolescents. Journal of the American in a community sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43, (1), 80-87.Academy of Child and Adolescent Psychiatry, 43, (1), 80-87.

S-A-F-E Alternatives Program (Self Abuse Finally Ends) 1-800-S-A-F-E Alternatives Program (Self Abuse Finally Ends) 1-800-DONT-CUTDONT-CUT

Strong, M. (1998). Strong, M. (1998). A Bright Red Scream: Self-mutilation and the A Bright Red Scream: Self-mutilation and the Language of PainLanguage of Pain. New York: Penguin Books.. New York: Penguin Books.

Walsh, B. & Rosen, P. (1988). Walsh, B. & Rosen, P. (1988). Self-Mutilation: Theory, Research, & Self-Mutilation: Theory, Research, & TreatmentTreatment. New York: Guilford Press.. New York: Guilford Press.

Yen, S.; Shea, M.J.; Samislow, C.N.; Grilo, C. et al. (2004) Yen, S.; Shea, M.J.; Samislow, C.N.; Grilo, C. et al. (2004) Borderline personality disorder criteria associated with prospectively Borderline personality disorder criteria associated with prospectively observed suicidal behavior. observed suicidal behavior. American Journal of PsychiatryAmerican Journal of Psychiatry, 161, , 161, (7), 1296-1298.(7), 1296-1298.