SELF-HARM

Mandakini Sadhir, MD, FAAP

Stephanie Stockburger, MD FAAP
Division of Adolescent Medicine
Department of Pediatrics
UKHealthcare
• No financial disclosures
Objectives
• Describe the common types of self-harm
• Explain how to approach someone you think is self-
harming
• Identify the relationship between self-harm and suicide
• Summarize prevention and treatment of self-harming
behaviors
Self-harm
Cold glass, how you insert yourself

Between myself and myself.

I scratch like a cat.

The blood that runs is dark fruit---

An effect, a cosmetic.

You smile.
No, it is not fatal.
Sylvia Plath

(Ray, 2014)
“My body looks how I feel.”--Adolescent self-injurer
History of self-injury
• Karl Menninger, MD (1938) was the first to propose self-
injury as a way to soothe oneself, an act of “self
destruction—a partial suicide to avert total suicide”

• Contributed to the field of psychiatry

• (Ray, 2014) (Shafer)

What is self-harm?
• Also called Non-Suicidal Self-Injury (NSSI), self-
mutilation, and cutting.

• Deliberate, direct, and self-inflicted destruction of body

tissue resulting in immediate tissue damage

• For purposes not socially sanctioned

• Without suicidal intent

Common Types of self-injury

• The most common methods are:

Skin cutting (70-90%),

Head banging or hitting (21%-44%)
Burning (15%-35%).
How common is self-injury?

• Rates are higher among adolescents, who seem to be at

an increased risk for self-injury, with approximately 15% of
teens reporting some form of self-injury.

• Studies show an even higher risk for self-injury among

college students, with rates ranging from 17%-35%.

• 70% of teens engaging in self-injury behavior have made

at least one suicide attempt

• 5% had made multiple suicide attempts

Why do people Self Injury?
• By engaging in self-injury, a person intends to:

 Obtain relief from a negative feeling or mental state

 Resolve an interpersonal difficulty, like a

disagreement with a friend or loved one

 Deal with an intrapersonal problem, like boredom

 Induce a positive feeling state

Self-injury and suicide
• Common to assume the self-injury is a suicide attempt
• Intention of self-injurer is typically the opposite:
Individuals who self-injure are generally
aiming to feel better, not end life.
• Intention of self-harm is typically to self-integrate and
preserve life.
• Individuals who self-injure are at higher risk for suicidal
thoughts, gestures and attempts
• Always assess for suicide risk
Red flags for self-harm
• Unexplained or clustered scars or marks
• Fresh cuts, bruises, burns, or other signs of bodily damage
• Bandages worn frequently
• Inappropriate dress for the season (long pants in summer)
• Unwillingness to participate in events that require less body
coverage (i.e. swimming)
• Constant use of wrist bands
• Physical or emotional absence, preoccupation, distance
• Social withdrawal, sensitivity to rejection, difficulty handling
anger, compulsiveness
• Expressions of self-loathing, shame, and/or worthlessness
Working with individuals who self-injure
• Understand signs, symptoms, respectful response
strategies, and local resources
• Encountering self-injury may be uncomfortable.
• If you don’t know how to react, don’t react at all (better
than a negative reaction).
• Talk about your reactions with someone you trust.
• Be aware of your own reactions and feelings.
Is self-injury contagious?
• Increase in report of NSSI among youth over past decade

• Awareness of self-injury has increased

• Media stories and popular culture have had increased

references to NSSI since 1980s

• Prevalence is higher in youth with increased exposure to

images, stories, or messages

• Internet: help or hurt?

Self-Inflicted Injury Hospitalizations

United States Number

5-12 Years 1,463
13-15 Years 10,370
16-20 Years 26,571
Total for Ages 5-20 38,404
Responding to a disclosure
• Use the individual’s own language.
• Show respect and willingness to listen in a non-
judgmental fashion.
• Do not tell the individual to “just stop” or make them
promise they won’t do it anymore.
• Do not pretend to “know” how they feel.
• Reassure individual that there is nothing to be ashamed
of and they are not in trouble.
• Emphasize hope.
• Supervise until risk has been assessed.
• Create a safe and caring place for individual to talk.
• Do not show too much interest in the behavior itself.
What to do if you suspect self-injury
• Be direct and honest about what you are observing and
your concerns

• If they are, assess whether they have and use resources

“Are you talking with someone about your self-injury?”

• Respect privacy, unless you are worried that their life may
be in danger

• Stay connected with the person you are concerned about.

Assess for Immediate Risk
• Individuals should be assessed for immediate risk of
suicide and other mental health issues.

• High risk:
• Adolescent is at risk for suicide.
• Comorbid mental health problem.
• There is abuse or trauma, substance use, and/or an eating
disorder.
• There is severe tissue damage or indication of infection
Responding to Assessment
*response to self-harm depends on an organization’s
ethical and legal guidelines

High risk adolescents

-Confidentiality must be broken and parents contacted
immediately if individual is suicidal or homicidal.
-If severe tissue damage or infection, medical attention
must be sought immediately
Responding to Assessment
• Low risk adolescents
-provide interventions or referrals
-periodically check-in with adolescent
-contact parents as per organization’s protocol
Referring
• Referrals should be conducted in a sensitive manner to
increase likelihood that adolescent will utilize services and
so the adolescent continues to feel supported by adult
they confided in.

• Referrals should be based on severity of risk. If suicidal,

needs in-patient assessment. If multiple risk factors but
not currently suicidal with adolescent not seeing much
hope consider in-patient assessment or intensive
outpatient therapy.
Interventions
• Communication skill building
• Encourage individual to use communication to express emotions
• Use journals to express emotions through writing
• Trigger log-- individual tracks each time they engage in self-harm
and the events leading up to it

• Behavioral Interventions
• Stress management and tension release
• Diaphragmatic and controlled breathing
• Meditation and visualization
• Exercise, especially aerobic
Disclosing to parents
• When necessary, advise adolescent that parents must be
notified for their own safety

• Notify parents when adolescent is present

• Facilitate positive communication between adolescent

and parent

• Be supportive
Interventions
• Counseling groups
• Groups should focus on developing problem-solving techniques,
adaptive coping strategies, self-esteem building, communication
and social skills. Groups should NOT focus on self-harm behavior
due to contagion effect.

• Solution Focused Therapy

• Selekman’s Stress Busters’ Leadership Program – designed to
work with self harming adolescents in a group setting

• Family Therapy
• Provides student with family support
• Family learns about self-injury and helps the family cope
Interventions
• Cognitive Behavior Therapy (CBT)
• Based on the premise that cognitions influence mood and behavior
and targets both the faulty cognitions of the adolescent and the
maladaptive behaviors that result

• Dialectical Behavior Therapy (DBT)

• Goal is to reduce self-destructive behavior, learn adaptive coping
and problem-solving skills, and to accept self while changing

• Manual Assisted Cognitive Behavior Therapy (MCAT)

• Short-term problem-solving intervention that teaches how to
manage negative thoughts and emotions
Interventions
• Medication
• Antidepressants (SSRIs) including sertraline, fluoxetine, citalopram

• Hospitalization
• Not recommended for self-harm treatment. May be necessary for
adolescent at high risk for suicide.
Resources
• *1-800-DON'T-CUT – More info on self-injury
• *http://www.selfinjury.com – Referrals for therapists and tips
for how to stop.
• *1-800-273-TALK – A 24-hour crisis hotline if you're about to
self-harm or are in an emergency situation.
• *To Write Love On Her Arms (http://www.TWLOHA.com) - A
non-profit movement dedicated to presenting hope and finding
help for people struggling with depression, addiction, self-injury,
and suicide.
• *1-800-SUICIDE – Hotline for people contemplating suicide.
• *1-800-334-HELP – Self Injury Foundation's 24-hour national
crisis line.
• *1-800-799-SAFE – Domestic violence hotline.
• *1-877-332-7333 – Real Help For Teens' help line.
Coping Skills www.yourlifeyourvoice.org
• 1. Exercise (running, walking, etc.).
• 2. Put on fake tattoos.
• 3. Write (poetry, stories, journal).
• 4. Scribble/doodle on paper.
• 5. Be with other people.
• 6. Watch a favorite TV show.
• 7. Post on web boards, and answer others' posts.
• 8. Go see a movie.
• 9. Do a wordsearch or crossword .
• 10. Do schoolwork.
• 11. Play a musical instrument.
• 12. Paint your nails, do your make-up or hair.
• 13. Sing.
• 14. Study the sky.
• 15. Punch a punching bag.
• 16. Cover yourself with Band-Aids where you want to cut.
• 17. Let yourself cry.
• 18. Take a nap (only if you are tired).
• 19. Take a hot shower or relaxing bath.
Build youth strengths!!
• Self-injury is a response to stress.

• Help youth manage their stress and develop positive

coping skills.

• Most importantly, help youth identify and build on

their strengths to help them flourish!!
Thank you for listening!

Questions????

Stephanie Stockburger, MD
University of KY Adolescent Medicine 859-323-5643
[email protected]
Jennifer Perry, LCSW
University of KY Adolescent Medicine 859-323-6228
[email protected]
Resources
• Self-Injury Interventions for School Psychologists. PowerPoint presentation. Misty Bonta,
Sherry Jankans, Liana Lopes,
Deija Villasenor.
• Cornell Research Program on Self-Injurious Behaviors (CRPSIB): www.crpsib.com
• Fact sheets: top 15 misconceptions about self injury, coping, distraction techniques, information for
parents, how can I help a friend who self-injures?
• Safe Alternatives: http://www.selfinjury.com/index.html
• The National Self-Harm Network (UK): http://www.selfharm.org.uk/default.aspa
• The Self-Injury Foundation: http://www.selfinjuryfoundation.org/
• The American Self-Harm Information Clearinghouse (ASHIC):
http://www.selfinjury.org/intexnet.html
• Selby, E. A., Kranzler, A., Fehling, K. B., & Panza, E. (2015). Nonsuicidal self-injury disorder:
The path to diagnostic validity and final obstacles. Clinical Psychology Review, 3879-91.
doi:10.1016/j.cpr.2015.03.003
• Kerr, P. L., Muehlenkamp, J. J., & Turner, J. M. (2010). Nonsuicidal self-injury: A review of
current research for family medicine and primary care physicians. Journal of the American
Board of Family Medicine 23(2), 240-259. http://www.jabfm.org/content/23/2/240.full
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, D.C: American Psychiatric Publishing. ISBN 978-
0890425558
References
• Whitlock, Janis. The Cutting Edge: Non-suicidal self-injury in
adolescence. Research Facts and findings. ACT for youth
center of Excellence. Dec. 2009. www.actforyouth.net
• Hawton, Keith and Anthony James. Suicide and deliberate self
harm in young people. BMJ. Volume 330. April 2005.
• Alison Wood. Self-harm in adolescents. Advances in
psychiatric treatment. 2009:15:434-41.
• Meg Ray, MD. Non-suicidal self injury in adolescents. March
2014.
• Kathryn Shafer. Understanding the cutting edge: self-
mutilation. www.funtherapist.com
• Huff, Marlene. Crisis: understanding self-injury in adolescents.
Pediatrics Grand Rounds.
• Lucile Packard Foundation for Children's Health. Kidsdata.org