Slide 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#020331
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2 Self-Injury
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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.
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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
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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
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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
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7 Video
• The Silent Epidemic
• Video documentary
• Part One on YouTube:
https://www.youtube.com/watch?v=IAcSeVCnJSA&feature=relmfu
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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)
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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
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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)
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11
Borderline Personality Disorder
TURBULENT EMOTIONS
DYSREGULATED BEHAVIORS
SUICIDAL BEHAVIOR/SELF-INJURY
STORMY RELATIONSHIPS
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12 Self Injury can be Confused with other
Diagnoses or Conditions• Suicidal behavior
• Psychotic disorders or substance use
• Developmental disorders
• Trichotillomania
• Excoriation
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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
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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
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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
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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
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17 Online Promotion of Self Injury
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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 self-
injurious behavior once adults!
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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)
• http://harvardmagazine.com/sites/default/files/SITBI_LongForm.pdf
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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!
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21
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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
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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
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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)
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25
Vulnerability Psychopathology
Genetic
Biological
Social/Familial
Borderline Personality
Disorder
Self-Injury/Suicide
Eating Disordered
Behavior
Emotional Mechanisms!
?
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26
Emotional Cascades
Selby, Anestis, & Joiner, 2008, Beh Res Ther
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27
Increased Emotional Intensity
EMOTIONAL CASCADE
Emotion
Rumination
Behavioral Dysregulation
Physical
Sensations
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28
Increased Emotional Intensity
EMOTIONAL CASCADE
Emotion
Rumination
Behavioral Dysregulation
Physical
Sensations
RELIEF
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29
Selby et al. (2009)
J ABNORMAL PSY
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BPD Control
Neg
ati
ve E
mo
tio
n
Group
Rumination Induction
Baseline
Post-Induction
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30
Selby et al. (2009)
J ABNORMAL PSY
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12
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BPD Control
Ne
ga
tiv
e E
mo
tio
n
Group
Rumination Induction
Baseline
Post-Induction
p<.05
0
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31
Do Emotional Cascades
Predict
Future Dysregulated
Behaviors?
2007
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32 Experience Sampling
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33
Number Reported % Sample Reporting Behavior
Alcohol Use 50 45.30%
Reckless Driving 14 20.30%
Self-Injury 25 13.80%
Impulsive Shopping 21 25.60%
Marijuana Use 116 34.20%
Binge Episode 62 36.80%
Physical Fight 9 4.40%
Threw Object 20 29.00%
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34
High Lag-
Rumination
X
High Lag- Negative
Emotion
Predictive Validity
Immediate Future
Dysregulated Behavior
Signal 1
Signal 2
Selby & Joiner, 2013, PDTRT
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35 Track It! Smartphone App
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36
Kranzler, Selby, In Preparation
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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.
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38
Treatment Implications
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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
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40
Mindfulness
Selby, Fehling, Panza, & Kranzler, in press, Mindfulness
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41 Activities
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42 Puzzles
Games
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43 What Can Family Members Do?
• 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
1. Understand the emotion process of self-injury
• 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
2. Help your loved one distract when upset
• When we get frustrated, which can be easy at times, that can feed into the emotion dysregulation process
• Building emotion regulation skills takes time!
3. Try not to get frustrated
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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)
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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
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46 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!
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47 Websites
• Adolescent Self Injury Foundation
• http://www.adolescentselfinjuryfoundation.com
• Self-Injury Outreach & Support
• http://www.sioutreach.org
• The Cornell Research Program on Self-Injury and
Recovery
• http://www.selfinjury.bctr.cornell.edu
• 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.
• http://www.afsp.org
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48 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: [email protected]
Website: www.edwardaselby.com
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