1. Mary Nan S Mallory MD
Professor and Residency Program Director
Department of Emergency Medicine
University of Louisville

2. …in a group of students at two Ivy
League universities who were
willing to respond anonymously to
a survey, nearly 20 percent reported
self-injury, and more than a third of
them had never told anyone about
it.
Whitlock, J., Eckenrode, J, Silverman, D. 2006. “Self-Injurious Behaviors in a
College Population.” Journal of Pediatrics 117 (6): 1939–48.

3. Self-harm (DSH) Behaviors
Youth Prevalence Rate 15-20%
81% School Counselors impacted
Suicide
Completion
#3 Cause of
Death ages 14-25
Suicide
Attempt
1.2 %
ages 18-25

4. Of the adults who attempted suicide in the 2008:
62.3 % received medical attention for their
suicide attempts
46.0 % stayed overnight or longer in a hospital
for their suicide attempts
http://www.samhsa.gov/data/2k9/165/suicide.htm

5. Burns
Cuts
Self-hitting
Self-poisoning
Object
Ingestion/Inserting
Tobacco
Excessive alcohol
consumption
Excessive risk-taking
behavior
Insufficient exercise
Over/under eating, Stress

7. Posterior Left Shoulder view

8. Neurotic: nail-biters, pickers, extreme hair removal, cosmetic surgery
Religious – circumcision, self-flagellants and auto-sacrifice
Puberty rites – hymen removal, circumcision or clitoral alteration
Psychotic – eye/ear removal, genital self-mutilation, amputation
Organic brain diseases – repetitive head-banging, hand-biting, finger-
fracturing or eye removal
Conventional – nail-clipping, trimming of hair and shaving beards.
Menninger, K. (1935), "A psychoanalytic study of the significance
of self-mutilation", Psychoanalytic Quarterly: 408–466

9. Ear-piercing, nail-biting, small tattoos, cosmetic
surgery
(not considered self-harm by the majority)
Piercings, saber scars, ritualistic clan scarring,
sailor and gang Tattoos
Wrist/body-cutting,
Self-inflicted cigarette burns, Wound-excoriation
Auto-castration, Self-enucleation, Amputation
(psychotic decompensation)
Adapted from Walsh, B. W., & Rosen, P. M. (1988), Self Mutilation: Theory,
Research and Treatment, Guilford. of N..Y, NY., ISBN 0-89862-731-1

10. Issues for DSM-V: Suicidal Behavior as a
Separate Diagnosis on a Separate Axis
Am J Psychiatry 2008;165:1383-1384. doi:10.1176/appi.ajp.2008.08020281
“Personal history of self-harm” is a new diagnostic
category listed in what are called the V-codes. These diagnoses
are not considered mental illnesses in and of themselves, but
rather are “other conditions or problems that may be a focus of
clinical attention or that may otherwise affect the diagnosis,
course, prognosis, or treatment of a patient’s mental disorder.”
fifth edition of the Diagnostic and Statistical Manual of Mental
Health Disorders, June 2013

11.  Self-injury (SI)
 Self-mutilation
 Para-suicide
 Self Inflicted Violence (SIV)
 Non-Suicidal Self Injury (NSSI)
 Misapplied Malingering, Munchausen‟s Syn,
Borderline Personality Disorder
 Misinterpreted as Child (or Date) abuse

12. „a wide range of things that people do to
themselves in a deliberate and usually
hidden way, which are damaging’
Camelot Foundation/Mental Health Foundation, 2004

13.  Cutting
 (making cuts or severe scratches on different parts of the body
with a sharp object)
 Burning
 (with lit matches, cigarettes or hot sharp objects like knives)
 Carving words or symbols on the skin
 Breaking bones
 Hitting or punching
 Piercing the skin with sharp objects
 Head banging
 Biting
 Pulling out hair
 Persistently picking/interfering with wound healing

14. http://self-injury.net/

15. "A lot of people quit when they get out of the
situation that's triggering it, but not everybody
does."
”…there tends to be a natural turning point where
people drop off. As you get older, there are
fewer”
“Teenagers who started in their early teens still
constitute more than 50%...the next biggest group
is people in their 20s, and then there's a drop off."
“The people who self-harm to fit in with a social
group – this became another curious part of her
research – or see it as a passing fashionable
rebellion fall off earlier. I think it will peak as a
fad eventually, and then settle down.”
Adler & Adler, 2011- an ethnographical look

16. Trauma impacts one‟s sense of having power and
control, of being able to acknowledge and
guide internal and external experiences.
Control is a crucial issue for many
trauma survivors, and it is the
thread that runs through the
experience of self-harm

17.  Our tardiness in acknowledging the prevalence of
self-harm is tied to our tardiness in coming to
acknowledge the prevalence of violent trauma in our
culture and the tendency toward violence in
ourselves. . . .
 For many abused and traumatized people who have
plenty to scream and cry about, self-harm is what
happens when screams are not listened to.
 —S.K. Farber
Farber, S.K. 2000. When the Body Is the Target: Self-Harm, Pain, and Traumatic
Attachments, Northvale, NJ, Jason Aronson p 107.

18.  Coping Strategy  Prevents Suicide (attempt) ?
 At the milder end of the spectrum, these
behaviors include mild to moderate self-injury
as a response to emotional pain and, at the
more extreme end, attempted suicide
Skegg K. Self-harm. Lancet. 2005 Oct 22-28;366(9495): 1471-1483.

20.  History of self-harm and/or previous suicide attempt
 Mental or substance use disorders, especially
depression
 Physical illness: terminal, painful or debilitating illness
 FH: suicide, substance abuse, psychiatric disorders
 History of sexual, physical or emotional abuse
 Social isolation
 Bereavement in childhood
 Family disturbances
 Rejection by a significant person e.g.relationship
breakup
 Mental health or substance use disorder

21.  Obvious changes in mood, sleeping and eating
patterns
 Losing interest and pleasure in activities
 Decreased participation and poor communication
 Problems in social, work, intimate relationships
 Hiding or washing their own clothes
 Avoiding situations were exposure of arm and legs
is required (e.g. swimming)
 Strange excuses provided for injuries

22.  To feel real, get a sense of physical boundaries
 To diminish intense emotions: despair, terror, self-hate,
rage, shame
 To facilitate dissociation, to disconnect from oneself
 To make pain visible
 To communicate what cannot be said verbally
 To express anger at someone else by directing it at
one‟s own body
 To avoid violence toward another
 To feel part of a group of peers who self-injure
 To stop flashbacks of abuse
 To facilitate remembering
 To punish oneself
 To symbolize spiritual beliefs

23.  A release of emotions
 As a means of communication
 To appropriate a reaction from someone
 There being a physical cause
 Low self-worth/self-efficacy
 To obtain something tangible
 A lack of choice and control
 Being in disempowering circumstances
 Having a lack of control within their living
environment
 Having the opportunity to do so

24. Most Teens Who Self-Harm Are Not
Evaluated for Mental Health in ER
(2/14/2012)HealthDay News
Most children and teens who deliberately injure themselves are
discharged from emergency rooms without an evaluation of
their mental health, a new study shows. The findings are
worrisome since risk for suicide is greatest right after an
episode of deliberate self-harm.
The majority of these kids do not receive any follow-up care
with a mental health professional up to one month after
their ER visit.
http://consumer.healthday.com/Article.asp?AID=661301
Nationwide Children’s Hospital, Columbus, OH

25. Assessment for Ongoing Abuse
Professional Assessment of Suicide Risk
Treatment of Underlying Depression, Psychosis
Substance Abuse Rehabilitation/Treatment
Home Assessments/Family Therapy
PEER therapies

26.  SOS@ High School Program
 Suicide prevention
 Training Trusted Adults
 Professional development for school employees
 ACT@ (Acknowledge-Care-Tell)
 Peer-to-peer help-seeking model
http://www.mentalhealthscreening.org/

27.  Only school-based suicide prevention
programon SAMHSA‟sNational Registry of
Evidence-based Programs and Practices that
addresses suicide risk and depression, while
reducing suicide attempts.
 In a randomized control study, the SOS
program showed a reduction in self-reported
suicide attempts by 40% (BMC Public Health,
July 2007).
http://www.mentalhealthscreening.org/programs/youth-prevention

28. Go to a public place
Wait 5 minutes and reassess
Yell aloud, listen to calming music, write in a journal
Eat spicy food
Rub an ice cube onto wrist
Snap a rubber band that is around your wrist
Draw with a red marker/pen at the site instead
Call upon a peer
1-800-273-TALK (8255): National Suicide Prevention Hotline, a 24-
hour crisis line for if you're about to self-harm
1-800-334-HELP (4357): The Self-Injury Foundation's 24-hour
crisis line.

29. Excellent and effective
An excellent worker—
The day flows by smiling and productive
with co-workers—
The night falls And with it the façade—
Terror, lost time, flashbacks—
Burning off the filth—
Cutting away the painful memories—
Beating the offending parts—
Whatever it takes
To find a moment of Relief—
Until tomorrow comes—
And I begin again——Amy3
http://www.witnessjustice.org/health/siv_whitepaper.pdf