1. Understand & Manage Dr. Ashlea Smith Self Mutilation

6. Case Study • Early 30’s Anglo-American woman • 2 small children • Previously an accountant (occupation) • Divorced • Unemployed • No social supports (cut ties with in-laws, no contact with sister) • Lost children to EX • Mother just passed away • Clinically dx with Bipolar Disorder with psychotic features, Borderline Personality Disorder, hx of eating disorder (AN), 5 prior suicide attempts (drinking bleach, cutting wrists, hanging, drug overdose (2) • Left a suicide note for staff

7. Definition • Self directed, repetitive behavior causing self-physical injury • Deliberate alteration or destruction of body tissue without conscious suicidal intent • Cutting (90.5%), burning, pin pricking, Skin picking (83.8%) hair pulling (74.3%), scratching, hitting self to cause bruises, bone breaking

8. Stats • Increased by 150% in past 20 years • 4% of general population • 14% HS students • 12-35% of undergraduate students • 21% clinical populations • 75% of BPD • 13 years of age • Most common sites arm-19%, leg 10%, torso 5.5%, genitals 1% • Frequency 1 to 700 times a week mean 10.88

9. Stats cont. • Depression 28.4% • PTSD 23% • Anxiety Disorders 17.6% • Bipolar Disorder 14.9% • Substance Abuse 10.8% • Eating Disorders 9.5% • 75% BPD

10. Categories • Severe-extensive damage found in psychotic and/or drug-induced altered mental states • Stereotyped-repetitive rhythmic self-destructive behaviors usually found in mental retardation or developmental disorders • Socially accepted tattooing, ear piercing, other culturally based behaviors • Superficial or moderate self mutilation multiple forms of self injury, causing tissue damage without lethal intent

11. Superficial/Moderate Self-Mutilation • Compulsive • Episodic • Repetitive

12. Episodic & Repetitive • Impulsive in nature & involves skin burning and/or cutting • Episodic-reflex response to stress or life events can transition to more repetitive self mutilation involving ruminating on the act and/or self identification as a self-mutilator or little resistance gratifying

13. Compulsive Self Mutilation • Habitual, closely related to OCD may be part of a ritual from obsessive thoughts • Severe nail biting. Skin picking, trichotillomania

14. Measuring Scales • Self Harm Behavior Questionnaire (SHBQ) • Suicidality, self harm history, frequency, risk, disclosure, treatment • Functional Assessment of Self-Mutilation (FASM) methods, functions, frequency. • Self Harm Inventory (SHI) predictive of borderline personality

15. Psychotherapeutic Approaches • Cognitive restructuring • Behavior modification • Assertive training • Alternative coping skills • Dialectical Behavior Therapy (DBT) • Psychodynamic long term partial hospitalization program

16. Experience of Self Mutilation • Recurrent cutting or burning of one’s skin • Tension • Relaxation, gratification, pleasant feelings, and numbness • A sense of shame, fear, social stigma

17. Psychology of Self Mutilation • Inability to think • Rage that cannot be repressed • An attempted solution to emotional pain, despair, anger, aggression, anxiety

18. Epidemiology & Risk • Onset adolescence • 1.5-2% adolescents • May be increasing

19. Risk Factors • Adolescence to college age • Female gender • Substance abuse • Personality disorders • History of self mutilation • Conduct problems • Anxiety • Depression • Eating disorders • History of abuse

20. Psychodynamic Factors • Express or terminate emotional turmoil • Attempts at coping • Environmental model • Drive model • Affect regulation control over emotions • Boundary model • Combination of the above

21. Poor tolerance of Anxiety and Anger • Cutting temporary relieves dysphoria • Self punishment • Behaviors less manipulative than what clinicians think • Dissociative symptomology • Inflicting pain • Impulsive control issues • Similar to OCD • Increase in frequency and severity • Antisocial,BPD, AN, BN***

22. Neurobiological Factors • Serotonin system • Time frame 50% of adolescents think of the act less than a hour before

23. Opiate System • 2/3 of BPD suffer no pain associated with cutting/burning • Habitual high levels of opiods-endorphins body’s natural pain reliever • Need supranormal levels of endorphins to cope with stress • Meditative state

24. Dopamine System • Self mutilation see often in certain disorders which involve dysregulation of dopamine activity

25. Pharmacotherapy • Antidepressants • Antipsychotics • Mood stabilizers • Limitations: need adolescents studies, minorities, & co-morbidity • Combination therapy