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Self Injurious Behaviors: Trends and Treatments. Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children’s Hospital and Regional Medical Center. Revisiting Definitions Recent Statistics: Prevalence Methods Trends Adolescent vulnerability Controversies

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self injurious behaviors trends and treatments

Self Injurious Behaviors: Trends and Treatments

Elizabeth McCauley, PHD, ABPP


University of Washington/Seattle Children’s Hospital and Regional Medical Center

Revisiting Definitions

Recent Statistics:




Adolescent vulnerability


Talking about suicide/self-harm

Medications as a trigger

Influence of the internet

Causal Models

Vulnerabilities to Self-Harm



Biosocial Theory of Emotional Dysregulation

Intervention Approaches


Prevention Strategies

Treatment Strategies

self harm definition
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 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!
Suicide and Suicide Attempts

3rd leading cause of death among adolescents 15-25

5th leading cause of death among youth 5-14

Multiple attempts for every completed suicide

Self-harm Behaviors

Community samples: 14% to 39%

Psychiatric inpatient samples: 40% to 61%

25,000 ED visits yrly for self-harm related events


Adolescence is period of increased risk for self-harm behaviors as well as suicidal thoughts and behaviors

recent trends
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
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
Changing Trends in Methods

10-14 year olds

FR: MMWR, CDC, 2004, 53:22

changing trends in methods1
Changing Trends in Methods

15-19 year olds

FR: MMWR, CDC, 2004, 53:22

changing trends
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
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:

Exposure to self-harm in friends, family

Smoking (fewer than 5 cigarettes/wk)

Boyfriend/girlfriend problems

Amphetamine use

Self-prescribing medications

Coping by blaming self

**Living with one parent was associated with lower rates of DSH (as opposed to step parent or other family members)

4000 teens; mean age 15.4

8.4% (6.2%) DSH w/i yr

11.1% females 1.6% males


59.2% cutting

29.6% overdose of meds

3% illicit drugs

2.2% self-battery

1.7 sniffing/inhalation

DSH--Recent community based studies: Australia
dsh recent community based studies england
Associated Factors:

Exposure to self-harm in friends, family

Drug use


Low self esteem

Sexual orientation worries

Trouble with police (girls)

Hx of being bullied

Hx of sexual abuse

6020 teens; 15-16 yrs

13.2% lifetime hx of DSH

8.6% (6.9%) w/i yr

11.2% females 3.2% males


64.6% cutting

30.7% overdose of meds

54.8% reported multiple acts

12.6% presented to EDs

15.0% suicidal ideation w/o DSH

DSH--Recent community based studies: England
why are adolescents so vulnerable1
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 vulnerable2
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 vulnerable3
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 vulnerable4
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 vulnerable5
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
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
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
Duration of Antidepressant Use

Richardson, et al, 2004

medications considerations
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
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 trigger1
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 depressionor 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 trigger2
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 trigger3
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
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 internet1
Controversies: Influence of the Internet


  • 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?”


  • 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
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 harm1
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
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 biological
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
Models:Brent et al. 2006

Familial Pathways to Early-Onset Suicidal Behavior.

causal models biological1
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

(Yates, 2003, Clinical Psychology Review, 24)

causal models behavioral
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
Causal Models: Biosocial Theory
  • Emotional Vulnerability


  • Invalidating Environment


  • Pervasive emotional, behavior, interpersonal, cognitive, and self dysregulation

Linehan, 1999 DBT

emotion vulnerability
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
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

Affective lability

Problems with anger

Interpersonal Dysregulation

Chaotic relationships

Fears of abandonment

Self Dysregulation

Identity disturbance/difficulties with sense of self

Sense of emptiness

Behavior Dysregulation

Parasuicidal behavior

Impulsive behavior

Cognitive Dysregulation

Dissociative responses/paranoid ideation

“Hot” cognitions

Domains of Dysregulation
summary of self harm functions
Respondent Behavior

Self-harm as “response to” past negative event/emotion

Goal is emotion regulation

Function is maladaptive coping mechanism

Intervention targets improved emotion regulation and distress tolerance skills

More common function

Operant Behavior

Self-harm as attempt to “operate on” (influence) future events/emotions

Goal is attention or avoidance/escape

Function is maladaptive attempt to influence behavior of others

Intervention targets interpersonal effectiveness skills

Less common function

Summary of Self-Harm Functions
intervention prevention
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 prevention1


  • Skill-building support groups Family support training
  • Screening programs with special populations Gatekeeper training
  • Crisis intervention services

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 of prevention interventions in each component

Surveillance of suicide and suicidal behaviors among youth 15-24 years

Intervention: Prevention
  • Current approaches and outcomes:
    • Signs of Suicide
    • TeenScreen
    • Prevention Models:
assessment and intervention
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

peer or media inspired

Occasional: coping strategy for major events

Persistent: standard coping/communication strategy (bad habit)

Intractable: frequent and severe (life disrupting addiction)

Associated with impulsive aggression/complex envir.

Cognitive Behavioral Therapy (CBT)

Case conceptualization Tx Choice
  • Dialectical Behavioral Therapy (DBT)
  • Multisystemic Therapy (MST)
interventions other concerns
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
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
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
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…

…To support use of CBT skills in clinical practice

treatments for adolescents with depression study tads
Treatments for Adolescents with Depression Study (TADS)
  • Fluoxetine combined with CBT had a response rate of 71%
  • Fluoxetine alone-63%
  • CBT alone 43%
  • Placebo 31%
  • Combination most effective in reducing SI

(TADS Team, 2004)

key elements of ba
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
BA Model

Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.

Sad, tired, worthless, indifferent..

Less Rewarding Life

Life events

Loss of friendships, conflicts w parents, teachers, bad grades, stress, poor health, etc.

interventions dialectical behavior therapy
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
Interventions:Other DBT Concepts
  • Wisemind
  • Pros/Cons—Long term

vs Short Term

  • Pain versus suffering
  • Distraction techniques
pain vs suffering
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
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 journal/write poetry

Play on the computer

Do your favorite hobby

Bake cookies

Imagine your favorite place and go there in your mind

Listen to music

Watch a funny movie

Do muscle relaxation exercises/squeeze a stress ball

Do Mindfulness exercises (deep breathing)

Put on clothes straight out of the dryer

Appreciate nature (look at the stars, listen to the rain, smell the flowers)

Other Distraction Techniques
multisystemic therapy
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)