ࡱ> 4e( / 0LDArialȄA(0(z[ 0 @ .  @n?" dd@  @@`` 8&t#      !"$% 0AA@f33)))@8##ʚ;ʚ;g4NdNd@z[ 0ppp@ <4ddddl 0A (0___PPT10 pp___PPT9, (  ((?  %O  =5]1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS223Dr Edgard A Snchez Bernal Consultant Psychiatrist/Psychoanalyst Student Services KINGS COLLEGE LONDON / SOUTH LONDON AND MAUDSLEY NHS TRUST Edgard.Sanchez-Bernal@kcl.ac.uk,gF1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22WHY LOOK AT DSH?  Deliberate Self Harm is the strongest risk factor for suicide (Hawton et al; BJPsych 182:537-542, 2003)  30 to 47 percent of suicide completers had a prior history of parasuicide (Gunnel D, Frankel S; BMJ 308: 1227-1233, 1994) BUT& &  Attempted suicide and deliberate self harm that is not suicidal in nature are very different behaviours, however, in research literature, they are often blurred together&  (Shaw Welch S, Psychiatric Services Journal 52: 368-375, 2001) PPPP@PP3D+M03@1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22DESCRIPTIVE DEFINITIONS Self Harm: Deliberate and often repetitive destruction or alteration of one s own body tissue, without suicidal intent. (adapted from Favazza 1987-89 & Walsh+Rosen 1989) DSH: An act with a non-fatal outcome in which an individual deliberately did one or more of the following: - initiated a behaviour (e.g. self-cutting, jumping from a height) which they intended to cause harm to the self; - ingested a substance in excess of the prescribed or generally recognized therapeutic dose; - ingested a recreational or illicit drug (which they intended to cause harm to the self); ZtZ3 }2k<1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22X DESCRIPTIVE DEFINITIONS(2) ingested a non-ingestible substance or object (e.g. batteries, razor blades). (Hawton et al, 2002) OTHER NAMES: Self injurious Behaviour (the politically correct name for self mutilation) Favazza A, 1987. Parasuicide: Describes all non-fatal self-injurious behaviour with clear intent to cause bodily harm, reserving  attempted suicide for situations in which intent is known. TYPES Major: (e.g. eye enucleation and amputations) Stereotypic: (e.g. head banging and self biting) Compulsive: (e.g. severe excoriation of the skin and nail biting) Impulsive: (e.g. skin cutting, burning and carving) Favazza A, Paediatrics, 117: 2283-84, 2006Ph-P-P-P-P-P/-P3i H 31DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22< COMPLEMENTARY DEFINITIONS OF DSH  For many self-harm is not so much about the inflicting of physical pain as the cessation of emotional pain (Swales M, The Wellcome Trust.  Pain and Deliberate Self Harm )  Self injurious behaviour itself is a morbid form of self-help and is usually effective in decreasing severe anxiety, depersonalisation, and other symptoms (Favazza A, Paediatrics, 117: 2283-84, 2006) #!3; A- 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22] EPIDEMIOLOGICAL PERSPECTIVE OF DSH -Registration studies v. Population surveys -findings in Registration studies: (WHO data 1989 -1992) Overall Rates from 2.6 per 100.000 to 542 per 100.000 (Lowest rates in Africa and Asia) (would imply at KCL 0.5 to 108 cases per year) Rates of parasuicide varied substantially across sites. Consistent higher rates of parasuicide for females Higher rates found among younger people (in seven sites, females 15 to 24 years old had the highest rates, whilst in males highest rates in 25 to 34 years old) Parasuicide rates in the WHO study seemed to decrease over time. %ZZL" ZZ$39L> ?  7 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22EPIDEMIOLOGICAL PERSPECTIVE OF DSH Population surveys: Overall rates of 300 to 1,100 per 100,000. (60 to 225 per year at KCL) Women had higher rates than men 6.9% of a school population of 15 and 16 year olds had engaged in an act of DSH in the previous year. Only 12.6% of these episodes had led to a hospital visit. (USA, 1990, Centres for Disease Control. Attempted suicide among High School Students) 4% of representative sample of general population reported engaging in at least occasional instances of self-mutilation over the previous 6 months and 0.3% reported often engaging in such behaviour. (Briere J, Gil E. American Journal of Orthopsychiatry 68:609-620, 1998.)t#Z\Z:-Z#3\QiJ1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22RISK FACTORS(1) Marital Status:  Single and divorced : further studies suggest that it may have to do with interpersonal conflict. Change in living situation from a stable environment. Sexual abuse:  Sexual abuse as a child or adult is associated with later psychological problems. All forms of sexual molestation were predictive of DSH behaviour in men . (King M, Coxell A, Mezey G.  Sexual molestation of males: associations with psychological disturbance . BJPsych 81: 153-157, 2002) Mental disorders Mood Disorders: especially depression - Personality Disorders Substance Abuse: Alcohol Previous Attempts: highly predictive of future DSH $Z-Z&-ZZM-ZZ3d & ">mP1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22RISK FACTORS(2) Childhood experiences Neglect Emotional abuse Physical abuse Loss or separation Sexual abuse Parental mental health problems Parental substance abuseZZ-Z-Z3  Current experiences Domestic violence Rape/sexual abuse Psychiatric diagnoses Substance misuse (both alcohol and drugs) ? Medication, ?SSRIs. (Donovan S, Madeley R,  Deliberate self-harm and antidepressant drugs BJPsych 177: 551-556,2000)Z-Zd-ZxZdb>4 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22AIM OF TREATMENT  Motivation to stop harming fluctuates, and it is easy to vow abstinence in the midst of a hangover but less so during the excitement of a party (Bateman A,  Self-help books on DSH BJPsych 185: 441-442 2004) - Psychosocial Interventions: Latest meta-analysis: ( Psychosocial interventions following self-harm Crawford M, Thomas O, Nusrat K, Kulinskaya E, BJPsych, 190:11-17,2007)  The results of this meta-analysis provide little evidence to support the view that enhanced treatment following an episode of DSH substantially reduces the likelihood of subsequent suicide I3AP  1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS220TREATMENT Patients are referred to us or seek treatment due to Have been seen at A&E and referred after an episode of DSH In routine examination by GPs or nurses various scars are found Some patients are not only aware of their need to get help but also know some of the reasons by which they self-harm Feel frightened that the urge to cut is more powerful than their will Re-start DSH behaviour that they thought had gone Refer themselves for unrelated reasons, and only after a while the theme appears Are made to come by friends, flatmates, partners, tutorsV 5-- 35 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22TREATMENT Findings: Not uncommon to find them speaking of themselves as one would of a stranger. They do frequently describe not feeling that much pain when they cut, and a sense of relief at the slightest sight of blood. There is a powerful sense of shame and guilt that needs to be contained rather than re-enacted: at times they are told they are attention seeking, that they need to go on antidepressants, or simply by telling them off. The most common re-enactment is that the health professional dismisses the incident as not worth follow-up. It is also quite frequent to observe in these patients an enormous difficulty to express outwardly negative emotions, especially anger, except if it is against themselves. h Z Z-Z-Z 3  1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22MGolden Rules Patients will tell you as much as you can listen. It is not about rushing them to inform you of why they keep on doing it. They may well not know. DSH is a symptom, a coping mechanism, a defensive strategy, and still patients may not know why they do it. The more we treat patients who DSH, the more we become aware that it is not a short-term process. If the patient starts putting his life at risk, they will paradoxically be grateful to you if you delineate firm boundaries to the treatment. (You as the treating professional become the representative of reality in them)6 A- 3A1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22Golden Rules With some frequency they may attempt to use you as you have heard them say others behave towards them, e.g. as if you become the one who should be protecting them from DSH. Not to fall on role responsiveness, this is behaving as how their immediate relatives or friends are described. They may be so used to being treated in a defined style, that before you know it they may be grudging of you being like all the others. At this point is always worth to reflect how much their perceptions are being contaminated by powerful experiences of the past. ( When one s head is like a hammer, we tend to see everything like a nail ) At some points they will try to tell their story, either willingly or in a cathartic episode, make sure you are willing to listen.l -G- 3xL1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22Deliberate Self Harm in King s College London March 2005-2007 Total Population: 192 Referrals to Psychiatrist Deliberate Self Harm: 37 Cases Sexual Abuse: 11 students= 29.7% Psychotic parent: 5 students= 13.5% Loss of parent (death, divorce) 2 students= 5.4% Psychosis in patient: 1 student = 2.7% Chaotic family situation: 7 students= 18.9% Undisclosed as yet: 8 students= 21.6% Anger management, bullying & others 3 students= 8.1% 8>ZZ>3!1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22Treatment: Psychoanalytically orientated psychotherapy provided in a context of Dynamic Psychiatric orientation. We cannot assume that people who self harm will never be suicidal. Therapy can expand in patients to tolerate greater intensities of emotions without resorting to self harm Medication: Antidepressants on their own may foster further dissociation from the painful  forgotten memories. Paradoxically in a psychotherapeutic setting may allow painful feelings to be aired. Hospitalization: - We have found more benefit in liaising with Home Treatment Teams, that accompany patients during times of critical need.q- --- 3 33{"1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22pTreatment  What good will I get of thinking about those things in the past that I just hate thinking about? I d rather remember painful things, than have to keep on living them again and again in my present everyday life. These kind of patients are suffering from reminiscences At the age when this students arrive to College, the normal splits of childhood and adolescence are demanding to be integrated into one whole person. This makes the professionals who see them, people who can make a huge difference for the course life will take in these young students. l d-- 3d1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22$Outcomes:  I tried to cut myself yesterday, but couldn t as it really hurts&   I ve noticed that even if I cut myself, I still have the problem in front of me  It s not fun any more  I just have not felt the urge for a while  I can t believe that I haven t done it again 6  - 3 1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS22vTREATMENT Anger Management:  For those who are not angry at the things they should be angry at are thought to be fools, and so are those who are not angry in the right way, at the right time, or with the right persons; for such a man is thought not to feel things nor to be pained by them, and, since he does not get angry, he is thought unlikely to defend itself; and to endure being insulted and put up with insult to one s friends is slavish .  The man who is angry at the right things and with the right people, and, further, as he ought, when he ought, and as long as he ought, is praised. This will be the good-tempered man,& . ( Ethica Nicomachea, Aristotle 1125b15 -1126a26. 322 B.C. )B ZZ 3u=, */P     $   ` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@)))|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> w(    6A  `} A e1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS2 2  0 A  ` A RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  0A ^ ` A >*  0A ^  A @*  0A ^ ` A @*6  S  ? 33D<___PPT10..û`x Default Design*  @0(    6EA > A e1DELIBERATE SELF HARM IN HIGHER EDUCATION STUDENTS2 2  04+A  `   A W#Click to edit Master subtitle style$ $  0A ^ ` A >*  0A ^  A @*  0A ^ ` A @*6  S  ? 33D<___PPT10..[ 0 `*(    0| P   A X*   02    A Z* d  c $ ?    0ج  0  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  6T _P   X*   6t _   Z* H  0޽h ? 3380___PPT10.ʻ03h}   $(  r  S `;Ac A r  S 4 ` A H  0޽h ? 33___PPT10i.Ļ 3+D=' = @B +}  @$(  r  S 4> `}  > r  S 5>% > H  0޽h ? 33___PPT10i.ƻi+D=' = @B +  P:(  r  S x== `}  =   S = ` = "p`PpH  0޽h ? 33___PPT10i.ɻP F+D=' = @B +}   $(   r  S  = `}  = r  S = ` = H  0޽h ? 33___PPT10i.λ`RZ+D=' = @B +  (:(  (r ( S ~= `}  =  ( S <= ` = "p`PpH ( 0޽h ? 33___PPT10i.ѻ}+D=' = @B +}  0$(  0r 0 S = `}  = r 0 S D= ` = H 0 0޽h ? 33___PPT10i.ֻ+D=' = @B +}  8$(  8r 8 S \= `}  = r 8 S d]=  = H 8 0޽h ? 33___PPT10i.ڻp,+D=' = @B +   @(  @r @ S l= `}  = x @ c $,=   = r @ S =p `Y = H @ 0޽h ? 33___PPT10i.ݻa?+D=' = @B +  0L(  Lr L S = `}  =  L c $}@ = d~Psychiatric and Personality disorders in Deliberate Self-harm patients (Haw, C BJPsych 178: 48-54, 2001) A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12 to 16 months later. Results: ICD-10 psychiatric disorders were diagnosed in 138 patients (92%) - Most common diagnosis was affective disorder (72%) - Personality disorder was identified in 45.9% of patients interviewed at FU. - Comorbidity of psychiatric and personality disorder was present in 44.1%G&G3&;0*f,S >H L 0޽h ? 33___PPT10i.@V +D=' = @B +}  @P$(  Pr P S g= `}  = r P S g= ` = H P 0޽h ? 33___PPT10i.0 +D=' = @B +}  `X$(  Xr X S m= `}  = r X S \n= ` = H X 0޽h ? 33___PPT10i.d+D=' `Tw= @B +}  p\$(  \r \ S t `}   r \ S 4 `  H \ 0޽h ? 33___PPT10i.0))+D=' = @B +}  `$(  `r ` S X `}   r ` S  `  H ` 0޽h ? 33___PPT10i. x!+D=' = @B +}   h$(  hr h S  `}   r h S  `  H h 0޽h ? 33___PPT10i.Pa"]+D=' = @B +}  l$(  lr l S  `}   r l S  `  H l 0޽h ? 33___PPT10i.@3+D=' = @B +}  $(  r  S < `}   r  S  `  H  0޽h ? 33___PPT10i.z&+D=' = @B +}   $(  r  S $1 `}   r  S 1 `  H  0޽h ? 33___PPT10i.0U +D=' = @B +}  $(  r  S > `}  > r  S > ` > H  0޽h ? 33___PPT10i.L_+D=' = @B +}   x$(  xr x S Z> `}  > r x S x> ` > H x 0޽h ? 33___PPT10i.(+D=' = @B + 0 p.(  X  C    A  S > 0T  A<4___PPT9 Which is rare and is associated with psychosis, transexualism and intoxications which is not uncommon in mental retardation and Tourette s syndrome 4. Which is common and associated with a variety of mental disorders such as depression, anxiety, PTSD, and personality disorders, especially borderline, histrionic, and antisocial(" " JH  0޽h ? 3380___PPT10.ʻp6h! 0 $1(  $X $ C    A $ S > 0  A 3My experience with students who self harm tends to conceptualise DSH as a displacement of conflictualised feelings that urge the individual to attack their body as a let-out of such feelings. The actual self harming translates a wish to get rid of emotional pain as well as symbolically re-experiencing or recreating through the self-harm some aspects of the original episode. Although it produces immediate relief, it also becomes the start of a new cycle of accruing feelings of guilt and shame that will frequently lead to the next episode.H $ 0޽h ? 3380___PPT10.ϻ0 0 YQ,(  ,X , C    AQ , S I 0  A There are some methodological problems that researchers have encountered when looking at DSH, most commonly studies are based on hospital admissions for suicide attempts,(Registration studies v. Population surveys) Registration Studies: Based on medical records. May miss a substantial number of people who never seek treatment Population Surveys: typically collect lifetime prevalence rates, making them difficult to compare with the annual incidence rates reported in registration studies, and they are usually based on only one question about suicidal behaviour. outcome variables and assessment procedures are not standardised Another aspect is the lack of control groups in the research literature, which makes the meaning of findings uncertain. We may know for example, that a high proportion of people who attempt suicide are depressed. If the same proportion in the general population were depressed and did not attempt suicide, would imply depression not being a risk factor. Added to this we need to take into account how a horizontal measure of a MSE at point of entry, normally in A&E may not be as objective a measure of the mental state of the individual seen on a longitudinal perspective.H , 0޽h ? 3380___PPT10.ѻ``^ 0 4n(  4X 4 C    A 4 S > 0  A pusually one question on suicide   Have you ever attempted suicide? - is incorporated into larger population surveys not focused on parasuicide. H 4 0޽h ? 3380___PPT10.׻ K H H 0޽h ? 3380___PPT10.޻߾C  0 PTS(  TX T C    A T S p 0  > UAHaving seen the description and some of the reasons by which we think DSH occurs it is blind to assume that a psychopharmacological approach alone will be enough treatment. Having read this paper it epitomises how at times the quest for a statistical truth collides with our everyday perception in our clinic workplaces. H T 0޽h ? 3380___PPT10.`  0  d(  dX d C    = d S I 0  = fI think that listening is one of the most difficult things we have to do as doctors, and I don t remember ever having been taught how to do it. In the particular line of work that I do, Psychanalytically orientated psychotherapy, the greatest asset that we find is having spent not a small amount of time learning to listen to our own complicated language. Once we se start realising the many layers that conform our mental apparatus, by default we start allowing others to be at least as complicated as we are, which automatically widens our containing capacity.iH d 0޽h ? 3380___PPT10.ş 0 p"(  pX p C    = p S U= 0  = $Maybe here wouldH p 0޽h ? 3380___PPT10.^ 0 {st (  tX t C    =s t S  0  = Maybe here would be worthwhile to speak of how the type of listening we are talking about is not as if we were trying to follow some guidelines, it is much more to allow oneself to have empathetic understanding. To have it, not to pretend having it.H t 0޽h ? 3380___PPT10.p ( 0 |8(  |X | C     | S I 0   :&I find myself a good amount of times facing patients that have had such  wonderful upbringing that they never had a chance to show or witness negative emotions. I often describe to them having been brought up in a  dictatorship of fairness I have seen how some children have never seen their parents furious, and what an unpleasant experience this is, or never having been told off. It is often the case that they start developing some kind of unrivalled fantasy, where their parents outburst of emotion is paralleled to the worst catastrophe imagined. They have not learnt the relief that occurs after the storm has gone. It is always brewing and menacing.H | 0޽h ? 3380___PPT10.0: 0 P (  X  C      S  v 0   " H  0޽h ? 3380___PPT10.Ar@%t?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrsuvwxyz{}~Root EntrydO)Current UserSummaryInformation(tPowerPoint Document(DocumentSummaryInformation8|