Self-Harm in Adolescents

Question 1

Define self-harm

Answer 1

The act of self-poisoning or self-injury, irrespective of the actual purpose of the act

Question 2

Define non-suicidal self-injury (Nock, 2009)

Answer 2

Deliberate damage to the body in the absence of conscious intent to die

Question 3

Which mental illness has traditionally been associated with non-suicidal self injury?

Answer 3

Borderline personality disorder

Question 4

What percentage of 16-24 year olds report having self-harmed? (2014 UK Adult Psychiatric Morbidity Survey)

Answer 4

Women: 25.7%
Men: 9.7%

Question 5

Why might there be a gender difference in self-harm reporting?

Answer 5

Society tends to associate self-harm with women so it may be easier for them to talk about, and men are more likely to use violent methods (e.g. punching a wall) which they may not recognise as self-harming

Question 6

How many individuals continue to self harm? (Moran et al, 2012)

Answer 6

1 in 4 are still self-harming after 4 years, with severity typically increasing

Question 7

State some predictors of non-suicidal self-injury (Wilkinson et al, 2011)

Answer 7

History of NSSI, hopelessness, anxiety disorder, younger age, female gender

Question 8

State some predictors of suicide after psychological therapy (Wilkinson et al, 2011)

Answer 8

Suicidal ideation before therapy, NSSI, poor family function

Question 9

State some risk factors for self-harm (Fox et al, 2015)

Answer 9

Disadvantaged socio-economic background, social isolation, negative life events, prior history, cluster B personality disorder, hopelessness

Question 10

Is self-harm always associated with a mental illness?

Answer 10

No - but it is more prevalent in those with mental illness, especially depression, anxiety, personality disorder, and substance abuse

Question 11

State some psychological factors associated with self-harm (O-Connor et al, 2012)

Answer 11

Sense of entrapment, lack of belonging, seeing oneself as a burden, low self-esteem, impulsivity, hopelessness, lack of emotion regulation, difficulties in problem-solving

Question 12

What is the biggest risk factor for suicide? (Whitlock et al, 2013)

Answer 12

Self-harm

Question 13

State some reasons for self-harm

Answer 13

Suicidal ideation, wanting to punish oneself, to stop feeling emotional pain, to feel in control, to feel anything, expressing distress, habit

Question 14

What proportion of individuals who self-harm present to hospital? (Hawton et al, 2002)

Answer 14

1 in 8

Question 15

Describe how reasons for self-harm can change over time (Towsend et al, 2016)

Answer 15

The most common reason to initiate self-harm is wanting to feel better, but the reason tends to shift to helplessness and wanting to die, or just out of habit. It initially tends to make the person feel better, but later becomes associated with guilt

Question 16

Name some emotion regulation models for self-harm

Answer 16

Gross emotion regulation model, difficulties in emotion regulation model, experimental avoidance model, emotional cascade model

Question 17

Describe the gross emotion regulation model of self-harm

Answer 17

Emotion regualtion involves antecedent-focused regulation strategies and response-focused strategies - the latter are aberrant in self-harm, with increased levels of emotion suppression and less cognitive reappraisal.

Question 18

Give a piece of evidence supporting the gross emotion regulation model of self-harm

Answer 18

Voon et al: Encouraging congnitive reappraisal reduces the frequency and medical severity of self-harm

Question 19

Describe the difficulties in emotion regulation model proposed by Gratz & Roemer in 2004

Answer 19

Self-harm features 4 main difficulties: alxeithymia (awareness & understanding of emotions), accepting emotion, controlling impulses and behaviour, and being flexible in situational strategies

Question 20

Give a piece of evidence against the difficulties in emotion regulation model proposed by Gratz & Roemer in 2004

Answer 20

Most studies have found no evidence of increased impulsivity in individuals who self-harm (Hamza et al, 2015)

Question 21

Describe Chapman’s experimental avoidance model of self-harm

Answer 21

It suggests that self-harm is the result of emotional suppression - a mixture of high emotion intensity, difficulty in regulation, and poor distress tolerance leads to emotion avoidance through deliberate self-harm. This produces temporary relief, trapping individuals in a negative cycle

Question 22

Give a piece of evidence supporting Chapman’s experimental avoidance model of self-harm

Answer 22

Self-harm commonly co-occurs with other avoidant emotion regulation behaviours such as binge-eating and substance abuse (Buckholdt et al, 2015)

Question 23

Describe Selby & Joiner’s 2013 emotional cascade model of self-harm

Answer 23

Minimal negative emotional stimuli are amplified by rumination, leading to self-harm

Question 24

Give a piece of evidence supporting Selby & Joiner’s 2013 emotional cascade model of self-harm

Answer 24

Self-harm is associated with increased levels of rumination and negative emotion, and increased reflection with no solution (Hoff & Muehlenkamp, 2009)

Question 25

Describe the differences in attention allocation seen in individuals who self-harm (Allen & Hooley, 2015)

Answer 25

Those who self-harm exhibit preferential automatic attention allocation to negative stimuli

Question 26

Describe the effect of imagery on self-harm (Wesslau et al, 2015; Hasking et al, 2017)

Answer 26

Distressing images of self-harm or its impact on others are not associated with self-harm, but images with a positive appraisal (e.g. escape) are associated with increased self-harm

Question 27

State some interpersonal hypotheses for self-harm

Answer 27

Social learning hypothesis, self-punishment hypothesis, social signalling hypothesis

Question 28

Describe the social learning hypothesis of self-harm (Whitlock et al, 2009)

Answer 28

Self-harm is increasing due to greater recognition of it and its prevalence in the media

Question 29

Describe the self-punishment hypothesis of self-harm (Glassman et al, 2017)

Answer 29

Self-harm is self-directed abuse learned via repeated abuse or criticism by others

Question 30

Describe the social signalling hypothesis of self-harm (Wedig & Nock, 2007)

Answer 30

When other communication strategies have failed, self-harm is the only method individuals have left

Question 31

Describe the association between self-harm and self-efficacy (Nock & Mendes, 2008)

Answer 31

Individuals who self-harm have lower self-efficacy than average, with low confidence in their ability to cope with stressful events

Question 32

Why might self-harm be an addiction?

Answer 32

Addictions are associated with high impulsivity, risky decision making, incentive sensitisation to substances, and attentional biases to cues. Individuals who self-harm self-report impulsivity, exhibit risky decision making, have some findings suggestive of incentive salience, and have reduced aversion to self-harm stimuli (Allen & Hooley, 2015)

Question 33

Describe the association between self-harm and pain tolerance

Answer 33

Individuals who self-harm have an increased pain tolerance - this appears to be mediated by emotional dysregulation rather than habituation or dissociation

Question 34

Describe the opioid dysfunction theory of self-harm

Answer 34

Acute self-harm could temporarily increase exogenous opioids

Question 35

Give a piece of evidence supporting the opioid dysfunction theory of self-harm

Answer 35

In a sample of individuals with borderline personality disorder, those who self-harmed had lower CSF B-endorphin and metenkephalin than those who did not

Question 36

Describe the neurofunctional abnormalities in individuals who self-harm

Answer 36

Those who self-harm have aberrant amygdala activity and connectivity in response to emotional stimuli. After self-harming they have activity in areas involved in pain, but also in reward in addiction (thalamus, dorsal striatum, anterior precuneus)

Question 37

What interventions are available to treat self-harm?

Answer 37

CBT, social support, interpersonal psychotherapy

Question 38

What are the challenges in treating self-harm?

Answer 38

No immediate intervention available after A&E presentation, not always associated with a diagnosis, if not deemed ‘severe enough’ individual is not eligible for psychological therapy, if ‘too severe’ individuak excluded from short psychological therapy, transition from child to adult services

Question 39

Name some apps developed to treat self-harm

Answer 39

BlueIce, Self-Health, Imaginator

Question 40

How does Imaginator treat self-harm

Answer 40

Using imagery-based training in emotion regulation, motivation, and planning