Audience Poll Question #1 SELF-INJURY IN ADOLESCENTS AND ADULTS. Slide 1. Slide. 2 Self-Injury. Slide 3. Edward A. Selby, Ph.D.

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1 1 SELF-INJURY IN ADOLESCENTS AND ADULTS Edward A. Selby, Ph.D. Assistant Professor Department of Psychology Rutgers, The State University of New Jersey Rutgers Institute for Health, Healthcare Policy, and Aging Research Families for Borderline Personality Disorder Research Investigator Brain and Behavior Research Foundation Licensed Psychologist, New York, NY# Self-Injury 3 Audience Poll Question #1 1. Why do people engage in self-injury (without suicidal intent)? a) To get out of doing something unpleasant. b) To feel a rush of excitement. c) To get attention from someone they love. d) To escape feelings of emotional distress. Answer: d is the most typical reason reported, though b is very common too. a & c happen, but are less common.

2 4 Nonsuicidal Self-Injury Direct and deliberate destruction of one s own body tissue in the absence of lethal intent (Nock, 2010) Often given different names in the literature: Deliberate self harm Self mutilation Parasuicidal behavior The term nonsuicidal self injury is preferred because it makes the distinction between self injury and suicidal behavior Often abbreviated to: NSSI 5 Nonsuicidal Self-Injury Most Common Methods: Skin cutting (70%) Head banging or self hitting (20-40%) Burning self (15-35%) Also: scratching to the point of drawing blood, pinching, hair pulling Most people employ multiple methods Prevalence: 13%-40% adolescents, adults 4%-28% Mixed literature on gender differences, but appears more common in women Only official place in DSM-5 is as a symptom of borderline personality disorder 6 Health Consequences Treatment from emergency medical services Nerve damage Progressively more severe self injury Poor academic functioning Peer rejection Accidental death Suicidal ideation or behavior

3 7 Video The Silent Epidemic Video documentary Part One on YouTube: 8 Self-Injury and Suicide Primary distinction is presence of suicidal thoughts and/or desires (suicidal ideation) If suicidal ideation is present when injury occurs, may be better thought of as suicide attempt or gesture 70% of adolescents who engage in self-injury reported a lifetime history of suicide attempts (Nock et al., 2006) Presence of self injury increases suicide risk 7 fold (Guan et al., 2012) Self injury may erode fear of suicidal behavior by habituation to pain (Van Orden et al., 2010) 9 Risk Factors Alcohol or other substance use disorder Disordered body image Low global sense of self-worth Poor coping skills Rumination Thought suppression High conflict family environments Minority sexual orientation Peer rejection Bullying

4 10 Important Risk Factors, Continued Genetics Female sex Maternal depression History of physical or sexual abuse Maternal borderline personality disorder Major depressive disorder Anxiety disorder Eating disorder (Anorexia Nervosa, Bulimia Nervosa) 11 Borderline Personality Disorder TURBULENT EMOTIONS DYSREGULATED BEHAVIORS SUICIDAL BEHAVIOR/SELF- INJURY STORMY RELATIONSHIPS 12 Self Injury can be Confused with other Diagnoses or Conditions Suicidal behavior Psychotic disorders or substance use Developmental disorders Trichotillomania Excoriation

5 13 Developmental Disorders and Self Injury Self-Injury often occurs in developmental disorders Stereotypic Movement Disorder Developmental Delays Autism Spectrum However, most NSSI occurs in developmentally normal adolescents and adults In developmental disorders, it is difficult to tell if behavior is deliberate, and it is often repetitive and invariable 14 Trichotillomania Recurrent pulling out hair, often resulting in hair loss Repeated attempts to decrease or stop hair pulling Behavior causes distress or impairment Can lead to bald spots, social stigma NSSI can include hair pulling, but: Hair pulling in trichotillomania is often a result of boredom, anxiety, or stress, and does not necessarily seem to regulate emotion Trichotillomania is often more compulsive than impulsive and often involves playing with the hair 15 Excoriation Recurrent skin picking resulting in lesions Repeated attempts to decrease or stop picking Causes distress or impairment Not due to a substance or other condition NSSI can include skin picking, but: Excoriation is often focused on skin imperfections Picking can take place in short bursts or extended sessions Excoriation is often compulsive, rather than impulsive Self injury skin picking should involve a common self-injury motivaiton

6 16 Self-Injury In Adolescence Turbulent time for human development Family and peer problems are prevalent Unique and often challenging social context Bullying often serves as a trigger for suicidal ideation Social Media Worsens many social problems Problematic online communities Online communities promoting self-injurious behavior Pro-anorexia websites 17 Online Promotion of Self Injury 18 Self-Injury In Adolescence Turbulent time for human development Family and peer problems are prevalent Unique and often challenging social context Bullying often serves as a trigger for suicidal ideation Social Media Worsens many social problems Problematic online communities Online communities promoting self-injurious behavior Pro-anorexia websites However, important to remember that self-injury is most common in adolescence, but the majority cease selfinjurious behavior once adults!

7 19 Self Injury Assessment Self Report Inventory of Statements About Self-Injury (ISAS; Klonsky & Glenn, 2009) 12 different methods of self-injury Rate functions of self-injury from 0 (never) to 2 (frequent) releasing emotional pressure that has built up inside of me calming myself down causing pain so I will stop feeling numb doing something to generate excitement or exhilaration trying to feel something (as opposed to nothing) even if it is physical pain Clinical Interview Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock et al., 2007) 20 Nonsuicidal Self-Injury Disorder NSSI Disorder New DSM-5 Disorder for Further Consideration Not technically considered an actual disorder yet But finally giving self-injurious behavior the recognition of importance necessary! 21

8 22 NSSI Disorder Research Already much evidence to support this disorder (Selby et al., 2015; Clinical Psychology Review) Fewer than 50% of self-injuring individuals have BPD NSSI causes significant clinical impairment (Selby et al., 2012) Important to distinguish from related behaviors (e.g., trichotillomania, excoriation) People with NSSI disorder appear to have much more severe self injury, may be more reluctant to seek treatment, but seem responsive to treatment (i.e., good prognosis; Ward, Selby et al., 2013) However, there are still concerns about if NSSI disorder would be clinically useful 23 Major Functions of Self Injury Social motivations Biological functions Anti-suicide function Self-punishment function Anti-dissociation function Feeling generation function Affect regulation function 24 Biological Contributions to NSSI Genetic factors account for 37% of the cause for self-injury in men, and 59% in women, which means that familial and genetic factors likely contribute much to the development of self-injury, especially for women (Maciejewski et al., 2014) Opioid Hypothesis Self injury causes release of natural endorphins, which lead to feelings of euphoria and can give self injury addiction like properties Role of opioids still unclear, as naloxone (opiate blocker) doesn t prevent self injury Increasing evidence that genes involved in serotonergic neurotransmission may be linked to self-injurious behavior (Groschwitz & Plener, 2012)

9 25 Vulnerability Genetic Biological Social/Familial? Psychopathology Borderline Personality Disorder Self-Injury/Suicide Eating Disordered Behavior Emotional Mechanisms! 26 Emotional Cascades Selby, Anestis, & Joiner, 2008, Beh Res Ther 27 Emotion Rumination Physical Sensations Increased Emotional Intensity EMOTIONAL CASCADE Behavioral Dysregulation

10 Negative Emotion Negative Emotion 28 Emotion RELIEF Rumination Physical Sensations Increased Emotional Intensity EMOTIONAL CASCADE Behavioral Dysregulation Rumination Induction Baseline Post-Induction BPD Control Group Selby et al. (2009) J ABNORMAL PSY Rumination Induction p<.05 Baseline Post-Induction BPD Control Group Selby et al. (2009) J ABNORMAL PSY

11 31 Do Emotional Cascades Predict Future Dysregulated Behaviors? 32 Experience Sampling 33 Number Reported % Sample Reporting Behavior Alcohol Use % Reckless Driving % Self-Injury % Impulsive Shopping % Marijuana Use % Binge Episode % Physical Fight % Threw Object %

12 34 Signal 1 Predictive Validity Signal 2 High Lag- Rumination X High Lag- Negative Emotion Immediate Future Dysregulated Behavior Selby & Joiner, 2013, PDTRT 35 Track It! Smartphone App 36 Kranzler, Selby, In Preparation

13 37 Audience Poll Question #2 2. True or False Question. Even though people who self-injure get very upset, they should be able to control their emotions just as well as anyone else if they put their mind to it. a) True b) False Answer: b because of biological and psychological vulnerabilities, people with who self-injure are likely to have very strong emotional responses, much stronger than the average person. However, by learning skills and practicing, they can learn to manage these emotions in a healthy way. 38 Treatment Implications 39 Primary Treatments Research still very much lacking! Education about dangers and consequences of self injury Dialectical Behavior Therapy (Linehan, 1993) Emotion Regulation Group Therapy (Gratz et al., 2014) Cognitive Behavior Therapy (Stanley et al., 2014) Family Involvement in treatment is helpful for adolescents (Stepp et al., 2012) Unfortunately no recommended or medication for self injury as of yet! No conclusive study finding medication helpful for self injury Medication for co-occurring depression or anxiety can be helpful though

14 40 Mindfulness 41 Selby, Fehling, Panza, & Kranzler, in press, Mindfulness Activities 42 Puzzles Games

15 43 What Can Family Members Do? 1. Understand the emotion process of self-injury 2. Help your loved one distract when upset Knowing what is going on reduces negative reactivity and improves empathy, even in challenging situations Even being able to give a process a name, such as emotional cascade can help Work with them to come up with activities that they enjoy and are willing to do when distressed Develop a coping card of distracting activities, it is easy to forget strategies when you are distressed 3. Try not to get frustrated When we get frustrated, which can be easy at times, that can feed into the emotion dysregulation process Building emotion regulation skills takes time! 44 Reactions from Families and Friends Families, friends, educators often react with criticism, discomfort, or horror when the behavior is discovered by (Walsh, 2014) Important to respond to the disclosure of self-injury with an understanding and supportive response However, do not minimize or trivialize the behavior Validates the individual s emotional distress while at the same time avoiding inadvertently appearing to approve of the self-injurious behavior A low-key, dispassionate demeanor is recommended when discussing self-injury (Walsh, 2014) 45 Toolbox for Parents and Educators #1: Stay calm! Primary (and understandable) reaction is to become upset upon discovery of Self injury. #2: Investigate Don t avoid Learn motives, triggers, interpersonal factors (home situation, bullying) #3: Ask about suicidal thoughts Self injury is major risk factor for suicidal behavior Best thing to do is gently ask (again stay calm). Asking WILL NOT cause one to become suicidal, and most people are relieve they have someone to talk to about it

16 46 47 Toolbox for Parents and Educators #4: Refer One self-injury picture is understood, adolescent should typically be referred to onsite or outside mental health provider Team treatment approach is best, involving relevant teachers, school nurse, mental health clinician/psychologist, and parents #5: Watch out for contagion phenomenon Sometimes adolescents encourage each other to self-injure, or some students will hear about another student self-injuring and then self-injure to get special treatment Social self-injury contagion more common in adolescent delinquent settings #6: Remember that though self-injury is very serious, majority of adolescents will mature out of this behavior, so prognosis is good! Websites Adolescent Self Injury Foundation Self-Injury Outreach & Support The Cornell Research Program on Self-Injury and Recovery American Foundation for Suicide Prevention (AFSP) Because self-injury is so highly associated with suicide, it can be important for clinicians, families, and patients to look into foundations supporting suicide prevention and improving the understanding of suicide Funding Acknowledgements and Thanks to: Brain and Behavior Research Foundation (NARSAD) Young Investigator Grant Families for Borderline Personality Disorder Research National Institute of Mental Health Neil S. Jacobson Award for Outstanding and Innovative Clinical Research Contact: Website: