أ.د/ أماني هارون

1. Prof. Amany Haroun El Rasheed
M.N.P., D.P.P., M.D.
Master in Mental Hygiene (Johns Hopkins Univ.)
Fellowship in Substance Abuse Treatment & Prevention (Johns
Hopkins Univ.)
APA Membership
WPA Fellowship
ISAM Fellowship
FRC Psych

2. DSH is a behaviour and not an illness

3. Deliberate Self Harm
Terminology and definition
 Diversity of terms: “parasuicide”, “self-
poisoning”, “self injury”, “deliberate self harm”, “self
harm”
 Common definition:
‘An act with non-fatal outcome in which an
individual deliberately initiates a non-habitual
behaviour, that without intervention from others
will cause self harm, or deliberately ingests a
substance in excess of the prescribed or generally
recognised therapeutic dosage’ (Platt et al., 1992;
WHO).

4. Deliberate Self Harm
What is Self Harm?
Terminology and definition
 ‘self-poisoning or injury, irrespective of the
apparent purpose of the act’. (NICE, 2004)
 ‘Self-injury is a compulsion or impulse to
inflict physical wounds on one's own
body, motivated by a need to cope with
unbearable psychological distress or regain a
sense of emotional balance. The act is
usually carried out without
suicidal, sexual, or decorative intent.’
(Sutton 2005)

5. Key elements of an operational definition?
• Self-inflicted
• Deliberate
• Alters body tissue
• Purpose to cause harm – but not suicidal

6. Drugs used in self-poisoning: Trends in selected drug
1970-1992 Oxford, UK

8. DSH: the facts
 Such behaviors are found in about 75%
of borderline personality disorder.
 The frequency with which self-
destructive behaviors occur
(e.g., unprotected sex with
strangers, drinking while taking
antabuse) would increase this rate into
90% range.

9. Incidence and Onset
 4% in the general population
 = numbers of males and females (though
more females present for treatment)
 Typical onset: puberty
 though can be seen in young children and
adults
 Often lasts 5-10 years
 But can last longer without treatment

10. Background Factors in Teens who Self-
Injure: Generalized
 Found in = numbers in all ethnic groups
 Nearly 50% report physical/sexual abuse (At least
50% have NOT reporting abuse)
 Many report that they were discouraged from
expressing emotion, particularly anger and
sadness
 Feelings of emptiness, over/under stimulated
 Unable to express feelings
 Lonely, fearful of intimate relationships or adult
responsibility
 Feeling invalidated/disconnected from parents

11. Prevalence
Community Samples
• Adolescents: 13-16% (Ross & Heath, 2002; Muehlenkamp &
Gutierrez, 2004)
• College Students: 17-36% (Gratz, 2001; Whitlock et al. 2006; Brown
et al. 2007)
• Adults: ~4% (Klonsky, et al., 2003; Briere & Gil, 1998)
Clinical Samples
• Inpatient adolescent: 24-82% (Taimenin et al. 1998; Rosen &
Walsh, 1989; Nock & Prinstein, 2004)
• Inpatient adult: 21-35% (Briere & Gil, 1998; Paul et al. 2002)
• Inpatient BPD: 75-80% (Soloff, 1994; Shearer et al., 1988)

12. Deliberate Self Harm

13. Deliberate Self Harm

14. Self-Injury: Behaviors
•carving
•scratching
•branding
•marking
•picking, and pulling skin and hair
•burning/abrasions

15. Self-Injury: Behaviors
•Ingestion of sharps/toxins
•cutting
•biting
•head banging
•bruising
•hitting
•excessive body piercing

16. Deliberate Self Harm

17. Behavior Patterns
 Cutting arm/legs most common practice
 May attempt to conceal injuries (long
sleeves/pants)
 Often make excuses
 Significant number also struggle with eating
disorders/substance/alcohol abuse
 Big difference between self decorating
(tattoos/piercings) and self harm
 Teens who self harm are seeking relief from
emotional distress

18. Warning Signs
 Unexplained, frequent injuries including
cuts and bruises
 Wearing of long pants/sleeves in warm
weather
 Low self-esteem
 Overwhelmed by feelings
 Inability to function at home, school or
work
 Inability to maintain stable relationships

19. Methods
What is your primary method of self-injury? (choose one)
[38728 votes total]
Cutting (27436) 71%
Burning (1750) 5%
Hitting (Self/Object) (1619) 4%
Head banging (455) 1%
Skin picking/Scratching (4721) 12%
Wound Interference (740) 2%
Bone-breaking (196) 1%
Biting (553) 1%
Other (1199) 3%
Self Injury Poll (2004) What is your primary method of self-injury (online)
http:vote.pollit.com/webpoll2?ID=25897 (accessed: 25-02-08)

20. Methods
Cutting 80%
Bruising 24%
Burning 20%
Head banging 15%
Biting 7%
 These are the most common symptoms by which
people with borderline disorder come to the
clinical attention.
 Such self-injurious acts occur in people who have
histories of suicidal attempts (62%), with an
average frequency of about three attempts.

21. Females vs Males
 More females cut
 More males punch
 More females report
 Males likely underreport
 Males hurt hands

22. DSH: Why?
Emotion Relief (92%, at least one)
 To stop bad feelings (immediate relief)
 To stop feeling angry or frustrated or enraged
 To relieve anxiety or terror
 To relieve feelings of aloneness, emptiness or
isolation
 To stop feeling self-hatred, shame
 To obtain relief from a terrible state of mind
 To control feelings (to exert control)

23. DSH: Why?
 Physical pain distracts from emotional pain
 To disassociate from intolerable feelings
 To transfer emotional pain into physical pain
 Physical pain is easier to deal with than
emotional pain
 IT WORKS

24. DSH: Why?
 Not understood by others
 Means of communicating distress
 Make internal wounds external (visible)
 Event markers (memorial for traumatic events)
 Creates euphoria

25. DSH: Why?
 To punish yourself (63% of nonsuicidal self-injury)
 Replicates earlier abuse
 Only 13 % wanted to punish someone or make
someone feel guilty
 Social modeling – 82% of responders say at least
one friend self-injured in the last 12 months
Nock and Prinstein (2004) A functional approach to the assessment of self-mutilative
behavior. Journal of Consulting and Clinical Psychology 72: 885-890.

26. DSH: Why?
 Wanting to fit in
 Feeling emotionally dead inside
 Self harm feels alive and confirms existence
 Coping strategy

27. A patient struggling with her
impulse to cut wrote
 I want to cut. I want to see pain, for
it is the most physical thing to show.
You can not show pain inside. I want
to cut, cut, cut, show, show. Get it
out. What out? Just pain.

28. Immediate Consequences of SIB
 Feels alive, functioning, able to act
 Clears the mind, helps to focus
 Release of endorphins
 Tension reduction
 Relief from stress or feelings
 Calmness
 Relaxation
 Sleep

29. Later Consequences of SIB
 Guilt
 Shame
 Stigma
 Feelings of isolation and abandonment

30. Stigma
 Self-injury is not a behavior that “works” for
someone who is not in acute emotional distress
 Important for caregivers to recognize that there is
NO safe amount of self-injury
 Self-injury, like substance abuse and eating
disorders, is a coping strategy used by people who
are in emotional distress
 Those who self-injure feel great amounts of pain
and often, shame

31. Deliberate Self Harm

32. Feelings Associated with Cutting
Before During After
Tension Pleasure Guilt
Worthlessness Exhilaration Shame
Vulnerability Satisfaction Crushed
Loneliness Numbness Pathetic
Confusion Relief Disturbed
Detachment Control Out of Control

33. Some Quotes (Look Beyond The Scars, 2002)
 “It’s something that needs to be done to get me
living” (Vicky, over 25)
 “I didn’t want to kill myself. I just wanted some of
the hurt and all of the pain to just go away”
(Rachel, late teens)
 “Way of coping … when things get really bad.
People deal with things in different ways
and, unfortunately or not, this is my way”
(Kirsty, early 20s)

34. Etiology of S.I.B.
Biological Considerations and Neurochemistry
 Serotonin – Decreased levels correspond to
increased aggression and self injurious behavior.
 Irritability is expressed as screaming or throwing things
when serotonin levels are normal.
 Research correlates this by showing decreased platelet
imipramine binding sites in self-injurers (Simeon et al. 1992)
and linked to impulsivity and aggression (Birmaher et al. 1990)

35. Etiology of S.I.B.
Biological Considerations and Neurochemistry
 Endorphin Model – Pain resulting from SIB may elicit release
of endogenous opioids (endorphins) which acts as an analgesic
on opiate receptors like morphine or heroin. (Thompson et al. 1994).
Little or no pain seen in many self-injurers which is termed
“blunted nociception”.
Dopamine supersensitivity or hypersecretion of endorphins
seen. Repetitive self-injurious actions my come under control of
addictive reinforcers and these receptor effects.
Thompson, T., Hackerberg, T., Cerulti, D., Baker, D., Axtell, S. (1994), Opioid Antagonist Effects on Self-Injury in Adults
with Mental Retardation. American Journal on Mental Retardation, 49: 85-102.

36. S.I.B.
Culturally Sanctioned Pathological
Ritual Practices Suicidality Self-Mutilation
Major Stereotypic Superficial/Moderate
Compulsive Impulsive
(OCD spectrum) (Impulse Control D/O)
Favazza, A. R. (1996). Bodies Under Siege: Self-
Mutilation and Body Modification in Culture and Episodic Repetitive
Psychiatry, 2nd ed. Baltimore: The Johns Hopkins
University Press.

37. Favazza’s Typology of Self-Mutilation
(1988)
 Major Self-Mutilation
 Rare and typically seen in people with psychotic
disorders, mania or severe drug intoxication.
 Includes severe self-mutilating behaviors such as eye
enucleation or amputation of limbs, or self-castration.
 Explanations given are usually based in religious or
sexual delusions, or delusions of sinfulness.
 Identification with Christ
 Biblical or demonic influence
 Commands from God
 Desire to be female
 Control of sexuality
Favazza, 1988;
Favazza, 1989, Favazza, 1998

38. Favazza’s Typology of Self-Mutilation
(1988)
 Stereotypic Self-Mutilation
 Common among individuals with mental retardation and
developmental disabilities (autism, Lesch-Nyhan
disease, Tourette’s syndrom)
 Includes behaviors such as scratching, biting, head-
banging, oral injuries (biting/picking of lips, gums)
 Hypotheses for this type of behavior
 Social reinforcement (behavior decreases in the absence of
adults)
 Negative reinforcement (the behavior is used to end an aversive
situation, such as classroom time)
 Self-stimulation: in the absence of adequate neurosensory
stimulation, an individual will engage in self-harming behavior to
stimulate himself (also found in normal-intelligence infants and
animals).

39. Favazza’s Typology of Self-Mutilation
(1988)
 Moderate/Superficial Self-Mutilation
 Most commonly seen in women, with onset in
adolescence
 Most common form is skin cutting, though 75% use
multiple methods
 Numerous, wide-ranging explanations for the behavior
 Tension release
 Anti-dissociation
 Interpersonal control/influence
 Social functions (identity formation, group membership)

40. Emotion Regulation Model of DSH
(automatic-negative reinforcement)
 96% of self-harmers (with BPD) reported that
emotion release was the reason for the behavior.
(Brown et al. 2002)
 Emotional dysregulation develops through a
combination of individual risk factors
(emotional reactivity and intensity) and
environmental risk factors (invalidating
environments that fail to teach strategies for
emotion regulation).

41. Emotion Regulation Model of DSH
(automatic-negative reinforcement)
 DSH may develop as a way to manage intense or
out-of-control emotions. It may serve to:
 Reduce anxiety
 Release tension
 Release anger
 Provide a sense of control
 Relieve guilt, loneliness
 “Concretize” emotional pain
 Terminate dissociation
 Stop racing thoughts
Gratz, 2003; Briere & Gil, 1998; Connors, 1996; Linehan, 1993

42. Experiential Avoidance Model
Chapman, Gratz & Brown’s
 Experiential avoidance: any effort to avoid or
escape internal experiences or the situations
that produce them
 Experiences: thoughts, feelings or physical
sensations
 Avoidance strategies: thought
suppression, substance abuse, DSH.
 Avoidance is negatively reinforced since, when
you avoid, immediate discomfort is reduced.
This relationship becomes very strong after
repeated experiences.

43. Experiential Avoidance Model
Chapman, Gratz & Brown’s
 In the long term, thought suppression tends to
increase distress, increase the frequency of
distressing thoughts and increase the likelihood of
a rebound effect from the suppressed emotional
experience (ie temporary relief leads to greater
anxiety)
 Avoidance decreases the likelihood of extinction of
unwanted emotions and prevents the individual
from learning that aversive emotional states, while
unpleasant, are not threatening.

44. Methods of Experiential Avoidance
 Denial of problems (rather than problem-solving)
 Dissociation and emotional numbing
 Isolation
 Drug and alcohol abuse
 Suicide attempts (and suicide)
 Nonsuicidal self-injury
 Self-punishment, self-criticism
 Secondary emotions to avoid primary emotions
 Hospitalization to escape stressful circumstances

45. Self-Injury: Diagnosis
• Borderline Personality Disorder (as adult)
• Bipolar Disorder
• Depression
• PTSD
• Psychosis
• Mental Retardation
• Autism

46. Risk Factors
 Depression
 Trauma
 Substance use
 Eating Disorder
 Conduct disorder
 Personality Disorder

47. Risk Factors
 The most consistent risk factor for DSH is
childhood abuse--
physical, sexual, emotional abuse and
neglect.
 For men only, childhood separation from the
father is a risk-factor
 Familial alcohol abuse
 Dissociation

48. Social Risk Factors
 Social circumstances are important:
1. Isolation
2. Socioeconomic deprivation
3. Excess of life events (month before SH)
4. Younger people : relationship difficulties
5. Older people: health or bereavement
6. War

49. What Isn’t Self- Injury
 Taking drugs to get high
 Tattooing
 Piercing
 Suicide
 Attention Seeking

50. Measurement Approaches (cont.)
• Assess existing instruments – for example:
• Self-harm behavior survey (Favazza)
• Functional assessment of self-mutilation
(Lloyd)

51. Psychosocial assessment
 Principals : privacy, conduct interview safely and
with adequate time, let patient tell their story
 Question relatives and friends about what
patient has recently said
 Three main issues:
1. Are there current mental health difficulties?
2. What is the risk of further self harm/suicide?
3. Are there any current medical or social
problems?

52. Assessment
Short term risk assessment
 Careful history of events surrounding
self harm serious medical
attempt/perception of seriousness ie in
children/learning disability
 Precautions against being found
 Previous mental health problems
(DSH)

53. Assessment
Short term risk assessment
 Harmful use of alcohol or drugs
 Social circumstances and problems – loneliness
and lack of network
 Forensic history – impulsive or aggressive traits
 MSE – symptoms of depression, suicidal
thoughts , plans or intent to self harm

54. Circumstances and Comorbidity
 Interpersonal conflicts in 50 % who self harm
 Unemployment and physical illness
 Most common diagnosis – depression (50 – 90%)
 Substance use (25 – 50 %)
 Personality disorders common , particularly young
people BUT
 56 % will have 2 or more psych diagnosis
 Thus, what looks like another “borderline” might
also have an underlying bipolar disorder etc

55. Help seeking behaviour in adolescents before and
after the deliberate self harm act
Percentage of adolescents who engaged in DSH and who
sought help or talked to someone before and after the
event:
Help source Before DSH After DSH
(%) (%)
Friend 43.7 49.8
Family 7.8 20.5
Health Service 11.1 15.3
Teacher 5.8 6.5

56. The epidemiology of suicidal behaviour:
The iceberg phenomenon
Suicide
Deliberate self
harm
medically treated
“Hidden” cases of
deliberate self harm and
related mental health problems

57. The majority of deliberate self harm patients
are “hidden” from the services

58. Challenges
for Research and Prevention
- Research into specific risk
factors of suicide
- Explaining cross-cultural
differences in suicide rates
- Implemenation of evidence based
suicide prevention programmes in
all countries
Suicide
- Standardised assessment
and treatment referral
- Research into the
Deliberate self effectiveness of treatments
for DSH patients
harm
medically treated
“Hidden” cases of Evidence based
deliberate self harm and mental health
Promotion
related mental health problems

59. Differentiating SIB from Suicide Attempts
Assessment Suicide Attempt SIB (Walsh & Rosen,
(Schneidman, 1985) 1988)
1. What was the To escape pain; Relief from
expressed and terminate unpleasant affect
unexpressed intent? consciousness (e.g., anger, tension,
sadness, etc.)
2. What was the level Serious physical Little physical
of physical damage damage; lethal means damage and/or non-
and potential of self-harm lethal means used
lethality?
3. Is there a chronic, Rarely chronic Frequent, chronic
repetitive pattern and repetition; some high-rate pattern
potential lethality? overdose repeatedly

60. Differentiating SIB from Suicide Attempts
Assessment Suicide Attempt SIB (Walsh & Rosen,
(Schneidman, 1985) 1988)
4. Have multiple Usually one method Usually more than
methods of self- one method
injury been used over
time?
5. What is the level of Unendurable and Uncomfortable and
psychological pain? persistent intermittent
6. Is there Extreme constriction; Little or no
constriction of suicide is the only way constriction; choices
cognition? out; seeking a final available; seeking a
solution temporary solution

61. Differentiating SIB from Suicide Attempts
Assessment Suicide Attempt SIB (Walsh & Rosen,
(Schneidman, 1985) 1988)
7. Are there feelings of Hopelessness and Periods of optimism
hopelessness and helplessness are and some sense of
helplessness? central control
8. Was there a No immediate Rapid improvement;
decrease in improvement; rapid return to usual
discomfort following treatment required cognition and affect
the act? for improvement
9. What is the core Depression and/or Body alienation;
problem? rage about exceptionally poor
inescapable body image (in
unendurable pain clinical populations)

62. Similarities Between SI Addiction
and SA Addiction
 Unhealthy, unsafe way of “coping”
 Numbing or avoiding emotional pain
 Distraction from pain
 The “rush”
 The secretiveness/illicitness
 “Stress” reliever
 You cannot force someone to stop self-
injuring, just like you cannot force
someone to stop abusing substances

63. Clinical Tip – the Dos and Don’ts of Cutting
Do…
 Talk openly about it – If you are comfortable
talking about, clients will be too
 Take this very seriously and explore the issue of
suicidal ideation
 Ask about other forms of self-injury
 Be supportive
 Help clients identify the factors that lead to
cutting and the feelings behind it
 Help clients identify healthy alternatives to dealing
with their feelings

64. Clinical Tip – the Dos and Don’ts of Cutting
Don’t…
 React with anger, fear, or revulsion
 Assume this is a phase that they will outgrow
 Assume that they are not thinking about
suicide
 Tell them to stop – getting into a power
struggle does not stop the behavior, serves to
increase resistance, and impairs the
therapeutic relationship
 Assume self injury is manipulation

65. What To Look For
 Unexplained cuts, scratches, burns, or
bruises
 Excuses such as, “my cat scratched me”
 Clothing inappropriate for the weather
 Reluctance to dress out for physical
education class or swimming
 Dressing to fit in

66. Clinical Tip – Use Pop Culture
 Use pop culture like movies, music, scripted TV
shows, reality TV shows, You Tube, blogs, etc. in
therapy to facilitate discussion of difficult topics like
self injury
 Clients are not only very likely to connect to
movies, songs, etc., but they are also more likely to
address delicate issues and feel more comfortable
discussing “characters” than discussing themselves
directly

67. Prognosis
 Subsequent risk of suicide – at least 3% and
up to 10 % after 10 or more years
 DSH is an ominous sign for repeated acts
 40 % will repeat self harm
 13 % will do this within the first year

68. Dangers
 Can become desperate about lack of self-
control and addictive-like nature of acts
 May lead to true suicidal attempts
 Self-injury may cause more harm than
intended. Can result in medical
complications or death
 Eating disorders/AODA intensifies threat to
overall health and quality of life

69. Self-Injury: Interventions
• Accept reality and find ways to make the
present moment more tolerable.
• Identify feelings and talk them out rather
than acting on them.
• Distract themselves from feelings of self-
harm (for example, counting to ten, waiting
15 minutes, saying "NO!" or "STOP!”

70. Self-Injury: Interventions
• Stop, think, and evaluate the pros and cons
of self-injury.
• Soothe themselves in a positive, non-
injurious, way.
• Practice positive stress management.
• Develop better social skills.
• Hospitalization

71. Reducing Self-Mutilation
 Viewed as means of replacing emotional
pain with “fake pain”, or physical pain that
is under control of patient
 Non-adaptive approach to distraction
 To replace anger: Engage in physical task.
Punch doll, crush aluminum cans, make doll
cut or tear instead of self.

72. Reducing Self-Mutilation
 Feeling depersonalized: Replace self-
mutilation with something that hurts:
Squeeze ice-cube for 1 minute. Put ice on
spot you want to burn. Slap tabletop hard.
Snap wrist with rubber band. Take cold
bath
 Wanting focus: Do other task (cleaning
room, play computer game) that requires
focus. Find simple object (paper clip) and
try to name 30 uses for it

73. Reducing Self-Mutilation
 Wanting to see blood: Draw on self with
red felt pen. Use food coloring bottle
(red, naturally) and draw it across area you
want to cut as if it were a knife.
 Wanting to see scars, pick scabs: Use
henna tattoo kit. Put henna on as paste.
Picking it off when dry feels like scab, leaves
red mark like a scar

74. Case Scenario
 Called by A/E to see a 28 year old female
who has presented after ingesting 25
paracetamol and 20 fluoxetine after the
break up of a relationship. Used to be a
regular attender with self harm a few years
ago. You are requested to do a psychosocial
assessment.
 What are you going to do?

75. Assessment
 Collateral information
 Physical Assessment
 DSH/ Suicide Risk
 Mental Illness

76. Case Scenario
 Had the tablets at home
 Boyfriend left her that day
 Thinking about it for a few hours
 Drank half a bottle of vodka
 Took the tablets but vomited afterwards
 Didn’t expect mother to come round
 Wanted to die but now not sure
 No suicide note
 Similar episode 3 years ago

77. Assessment
Suicidal Intent
 Method
 Premeditated
 Suicide note
 Wanted to die at time of attempt
 Tried to avoid discovery
 Alcohol/ Drug use
 Precipitant of self harm
 Previous self harm

78. “I got the impression that [the
psychiatrist] wanted to get it over
and done with as quickly as he
could and get on with whatever it is
he had to do next. There was
nothing personal about it”

79. “O.K. The first interview was just „so tell us
what happened‟ and he wrote it up and said
„um hm, um, hm‟ and wrote notes and he didn‟t
look at me but he was nodding and looking at
the other guy. And they looked at each other
and exchanged nods. It was very factual like
„So what did you take?‟ and „What happened at
the house?‟ Um, you know I felt like saying „I
can understand English, doctor.‟ It was just
very factual. They filled out their little form and
that was it”

80. THANK YOU