"Self Injurious Behaviors Trends and Treatments"
Self Injurious Behaviors: Trends and Treatments Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children’s Hospital and Regional Medical Center Roadmap Revisiting Definitions Causal Models Recent Statistics: Vulnerabilities to Self-Harm Prevalence Biological Methods Behavioral Trends Biosocial Theory of Emotional Dysregulation Adolescent vulnerability Intervention Approaches Controversies Assessment Talking about suicide/self- harm Prevention Strategies Medications as a trigger Treatment Strategies Influence of the internet Definitions: Suicidal and Self-injurious Behaviors Suicidal Ideation Thoughts of death or dying Suicide Attempt Wishing to be dead ED-1/3 report wish to die Thoughts of hurting self Suicide Suicidal plan Deliberate Self-Harm Purposeful self- harm self (cutting, jumping) behavior Ingestion of substance in excess of therapeutic dose Ingestion of recreation drug with intent to self-harm Ingestion of non-ingestible substance or object (Child and Adolescent Self-harm in Europe group) 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 Adolescence is period of increased risk for self-harm behaviors as well as suicidal thoughts and behaviors Suicide and Suicide Self-harm Behaviors Attempts Community samples: 14% 3rd leading cause of death to 39% among adolescents 15-25 Psychiatric inpatient 5th leading cause of death samples: 40% to 61% among youth 5-14 25,000 ED visits yrly for Multiple attempts for every self-harm related events completed suicide 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 1.2 1 0.8 Firearms Suffocation 0.6 Poisoning All Others 0.4 0.2 10-14 year 0 olds 92 93 94 95 96 97 98 99 2000 2001 FR: MMWR, CDC, 2004, 53:22 Changing Trends in Methods 9 8 7 6 Firearms 5 Suffocation 4 Poisoning All Others 3 2 1 15-19 year 0 olds 92 93 94 95 96 97 98 99 2000 2001 FR: MMWR, CDC, 2004, 53:22 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: 4000 teens; mean age 15.4 Exposure to self-harm in 8.4% (6.2%) DSH w/i yr friends, family 11.1% females 1.6% males Smoking (fewer than 5 Methods: cigarettes/wk) 59.2% cutting Boyfriend/girlfriend problems Amphetamine use 29.6% overdose of meds Self-prescribing medications 3% illicit drugs Coping by blaming self 2.2% self-battery **Living with one parent was 1.7 sniffing/inhalation associated with lower rates of DSH (as opposed to step parent or other family members) DSH--Recent community based studies: England 6020 teens; 15-16 yrs Associated Factors: 13.2% lifetime hx of DSH Exposure to self-harm in friends, family 8.6% (6.9%) w/i yr Drug use 11.2% females 3.2% males Depression/anxiety/impulsiv Methods: ity 64.6% cutting Low self esteem 30.7% overdose of meds Sexual orientation worries 54.8% reported multiple Trouble with police (girls) acts Hx of being bullied 12.6% presented to EDs Hx of sexual abuse 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, 2005 MECHANISM: 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 100% SSI Tricyclic 80% Other 60% 40% 20% 0% Start 1 2 3 4 5 6 Months after initial prescription fill 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 rates but 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 Self-Poisoners (220) (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 dysregulation Linehan, 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 Behavior Dysregulation Affective lability Parasuicidal behavior Problems with anger Impulsive behavior Interpersonal Cognitive Dysregulation Dysregulation Dissociative Chaotic relationships responses/paranoid Fears of abandonment ideation Self Dysregulation ―Hot‖ cognitions Identity disturbance/difficulties with sense of self Sense of emptiness Summary of Self-Harm Functions Respondent Behavior Operant Behavior Self-harm as ―response Self-harm as attempt to to‖ past negative ―operate on‖ (influence) event/emotion future events/emotions Goal is emotion Goal is attention or regulation avoidance/escape Function is maladaptive Function is maladaptive coping mechanism attempt to influence Intervention targets behavior of others improved emotion Intervention targets regulation and distress interpersonal tolerance skills effectiveness skills More common function 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: INDICATED PREVENTION Signs of Suicide Skill-building support groups Family support training TeenScreen SELECTIVE PREVENTION Prevention Models: Screening programs with special populations Gatekeeper training Crisis intervention services UNIVERSAL PREVENTION State-wide public educational campaign on suicide prevention School-based educational campaigns for youth and parents Public educational campaign to restrict access to lethal means Education on media guidelines EVALUATION AND SURVEILLANCE Evaluation of prevention interventions in each component Surveillance 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 Cognitive Behavioral Occasional: coping Therapy (CBT) strategy for major events Persistent: standard coping/communication strategy (bad habit) Dialectical Behavioral Intractable: frequent and Therapy (DBT) severe (life disrupting addiction) Multisystemic Associated with Therapy (MST) impulsive aggression/complex envir. 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 Supplementary Materials… Thought Record What happened? How did you feel? What thoughts did What did you do? Any other way to you have at the look at it? time? List all the emotions What does it mean Did you want to do Do you feel you had at the time. to you that….? something you didn’t differently if you Did you feel some So what? do? Do something think about it this more than others? What if? you wish you hadn’t? way? Would you do anything differently …To support use of CBT skills in clinical practice Treatments for Adolescents with Depression Study (TADS) Fluoxetine combined with 80 CBT had a response rate 70 of 71% 60 Fluoxetine alone-63% 50 Comb CBT alone 43% 40 Prozac Placebo 31% 30 CBT Combination most 20 Placebo effective in reducing SI 10 0 1st (TADS Team, 2004) Qtr 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 Stay home, stay in bed, Sad, tired, watch TV, Less worthless, withdraw Life Rewarding from social indifferent.. events Life contacts, ruminate, etc. Loss of friendships, conflicts w parents, teachers, bad grades, stress, poor health, etc. Adolescents Taking Action Sessions 1 & 2: Getting Started What Does Behavioral Activation Mean? BUT Behavioral Activation can Depression is a vicious cycle break this cycle by: 1st by identifying what makes you feel down 2nd by learning how to tackle problems 3rd by working together with Depression your therapist to take small steps, get active, accomplish your goals, and Your life is more stressful. You begin to feel tired, bored….life BUILD THE gets harder, you do less, pull away LIFE YOU and may blame yourself for not WANT! doing more….it gets harder to do things. This can create more problems with school, parents, friends……. TG 1-2, 2-2 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 Do muscle relaxation journal/write poetry exercises/squeeze a Play on the computer stress ball Do your favorite hobby Do Mindfulness exercises Bake cookies (deep breathing) Imagine your favorite Put on clothes straight place and go there in out of the dryer your mind Appreciate nature (look at Listen to music the stars, listen to the rain, smell the flowers) Watch a funny movie 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