Understand manage dr ashlea smith
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Understand & Manage Dr. Ashlea Smith. Self Mutilation. 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

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Self Mutilation

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Understand manage dr ashlea smith

Understand & Manage

Dr. Ashlea Smith

Self Mutilation


Case study

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


Definition

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


Stats

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


Stats cont

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


Categories

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


Superficial moderate self mutilation

Superficial/Moderate Self-Mutilation

  • Compulsive

  • Episodic

  • Repetitive


Episodic repetitive

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


Compulsive self mutilation

Compulsive Self Mutilation

  • Habitual, closely related to OCD may be part of a ritual from obsessive thoughts

  • Severe nail biting. Skin picking, trichotillomania


Measuring scales

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


Psychotherapeutic approaches

Psychotherapeutic Approaches

  • Cognitive restructuring

  • Behavior modification

  • Assertive training

  • Alternative coping skills

  • Dialectical Behavior Therapy (DBT)

  • Psychodynamic long term partial hospitalization program


Experience of self mutilation

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


Psychology of self mutilation

Psychology of Self Mutilation

  • Inability to think

  • Rage that cannot be repressed

  • An attempted solution to emotional pain, despair, anger, aggression, anxiety


Epidemiology risk

Epidemiology & Risk

  • Onset adolescence

  • 1.5-2% adolescents

  • May be increasing


Risk factors

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


Psychodynamic factors

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


Poor tolerance of anxiety and anger

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***


Neurobiological factors

Neurobiological Factors

  • Serotonin system

  • Time frame 50% of adolescents think of the act less than a hour before


Opiate system

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


Dopamine system

Dopamine System

  • Self mutilation see often in certain disorders which involve dysregulation of dopamine activity


Pharmacotherapy

Pharmacotherapy

  • Antidepressants

  • Antipsychotics

  • Mood stabilizers

  • Limitations: need adolescents studies, minorities, & co-morbidity

  • Combination therapy


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