Self Injurious Behaviors:
Trends and Treatments
Elizabeth McCauley, PHD, ABPP
Professor
University of Washington/Seattle Children’s
Hospital and Regional Medical Center
Roadmap
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Revisiting Definitions
Recent Statistics:
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Talking about suicide/selfharm
Medications as a trigger
Influence of the internet
Causal Models
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Prevalence
Methods
Trends
Adolescent vulnerability
Controversies
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Vulnerabilities to Self-Harm
Biological
Behavioral
Biosocial Theory of
Emotional Dysregulation
Intervention Approaches
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Assessment
Prevention Strategies
Treatment Strategies
Definitions:
Suicidal and Self-injurious Behaviors
Suicidal Ideation
Thoughts of death or dying
Wishing to be dead
Thoughts of hurting self
Suicidal plan
Suicide Attempt
ED-1/3 report wish to die
Suicide
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:
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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
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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
Attempts
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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
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Community samples: 14%
to 39%
Psychiatric inpatient
samples: 40% to 61%
25,000 ED visits yrly for
self-harm related events
Recent Trends
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Suicide
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Declining rates 1992-2000
Changing methods
Changing patterns w/i ethnic groups
DSH
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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
Poisoning
All Others
0.6
0.4
10-14 year
olds
0.2
0
92
93
94
95
96
FR: MMWR, CDC, 2004, 53:22
97
98
99
2000 2001
Changing Trends in Methods
9
8
7
6
Firearms
Suffocation
Poisoning
All Others
5
4
3
2
15-19 year
olds
1
0
92
93
94
95
96
97
FR: MMWR, CDC, 2004, 53:22
98
99
2000 2001
Changing Trends
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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
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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
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4000 teens; mean age 15.4
8.4% (6.2%) DSH w/i yr
11.1% females 1.6% males
Methods:
 59.2% cutting
 29.6% overdose of meds
 3% illicit drugs
 2.2% self-battery
 1.7 sniffing/inhalation
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)
DSH--Recent community based studies:
England
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6020 teens; 15-16 yrs
13.2% lifetime hx of DSH
8.6% (6.9%) w/i yr
11.2% females 3.2% males
Methods:
 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
Associated Factors:
 Exposure to self-harm in
friends, family
 Drug use
 Depression/anxiety/impulsiv
ity
 Low self esteem
 Sexual orientation worries
 Trouble with police (girls)
 Hx of being bullied
 Hx of sexual abuse
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

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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
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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)
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Efficacy:
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Fluoxetine (Prozac) – efficacious
Up to 40% are “non-responders”
Resistance/Adherence: Adolescent Attitudes (Gray, 2003)
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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
SSI
100%
Tricyclic
80%
Other
60%
40%
20%
0%
Start
1
2
3
4
Months after initial prescription fill
Richardson, et al, 2004
5
6
Medications Considerations:
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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
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Hammad, 2004 meta-analysis:
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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
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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
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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)
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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
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Management: (Simon, 2006, NEJM)
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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:
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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
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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:
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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?”
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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
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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
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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
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Categories: interpersonal (personality disorders) versus
intrapersonal (trauma)
Motivational Factors:
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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:
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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.
Relief--terrible state of mind
Self-cutters
Self-Poisoners
73.3%
72.6%
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%
Punish self
*
*
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
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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
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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:
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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:
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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
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Social learning hypothesis
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Learned behavior—modeling
Behaviors maintained by reinforcement
contingencies:
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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
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
Linehan, 1999 DBT
Emotion Vulnerability

High sensitivity
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High reactivity
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Immediate reactions
Low threshold for emotional reaction
Extreme reaction
High arousal dysregulates cognitive processing
Slow return to baseline
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Long lasting reactions
Contributes to high sensitivity to next emotional stimulus
Invalidating Environment

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“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
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Emotion Dysregulation
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Affective lability
Problems with anger
Interpersonal
Dysregulation

Chaotic relationships
Fears of abandonment
Self Dysregulation

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
Identity
disturbance/difficulties
with sense of self
Sense of emptiness
Behavior Dysregulation

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Parasuicidal behavior
Impulsive behavior
Cognitive Dysregulation
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Dissociative
responses/paranoid
ideation
“Hot” cognitions
Summary of Self-Harm Functions
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Respondent Behavior
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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
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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
Intervention: Prevention

Population based suicide prevention
approaches greater effect than those focused
on youth at high risk

Public education:

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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:



Signs of Suicide
TeenScreen
Prevention Models:
INDICATED PREVENTION
Skill-building support groups
Family support training
SELECTIVE PREVENTION
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

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

Transient/experimental:
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.
Tx Choice
Cognitive
Behavioral
Therapy (CBT)



Dialectical
Behavioral
Therapy (DBT)
Multisystemic
Therapy (MST)
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/attentionseeking 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
you have at the
time?
What did you do?
Any other way to
look at it?
List all the emotions
you had at the time.
Did you feel some
more than others?
What does it mean
to you that….?
So what? 
What if?
Did you want to do
something you didn’t
do? Do something
you wish you hadn’t?
Do you feel
differently if you
think about it this
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
CBT had a response rate
of 71%
Fluoxetine alone-63%
CBT alone 43%
Placebo 31%
Combination most
effective in reducing SI
(TADS Team, 2004)
80
70
60
50
40
30
20
10
0
Comb
Prozac
CBT
Placebo
1st
Qtr
Key elements of BA




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
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
Life
events
Less
Rewarding
Life
Sad, tired,
worthless,
indifferent..
Stay home,
stay in bed,
watch TV,
withdraw
from social
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?
Depression is a vicious cycle
BUT Behavioral Activation can
break this cycle by:
1st by identifying what makes
you feel down
2nd by learning how to tackle
problems
Depression
Your life is more stressful. You
begin to feel tired, bored….life
gets harder, you do less, pull away
and may blame yourself for not
doing more….it gets harder to do
things. This can create more
problems with school, parents,
friends…….
3rd by working together with
your therapist to take small
steps, get active, accomplish
your goals, and
BUILD THE
LIFE YOU
WANT!
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
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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
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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
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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
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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)
Multisystemic Therapy
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Characteristics:
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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:
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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
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www.clinicalchildpsychology.org
www.dbtseattle.com
www.aacap.org