Transcript Adolescent Deliberate Self-Harm: Issues of Development

Adolescent Deliberate Self-Harm:
Issues of Development, Culture,
Biology, and Treatment
Clinical perspectives15
แพทย์ หญิงรัชนี ฉลองเกือ้ กูล โรงพยาบาลศรีธัญญา
Deliberate Self-Harm
• Deliberate damage to one’s own body
tissue without suicidal intent
part of larger class of self-injurious behavior
• Methods:
Cutting/Carving skin
Picking at a wound
Hitting self
Scraping skin to draw blood
Biting self
Picking skin to draw blood
Inserting objects under skin
Tattooing self
Burning skin
Pulling out own hair
Erasing skin to draw blood
A Typology of Adolescent
Self-Cutting based on
Frequency
Larry K. Brown M.D.
Bradley/Hasbro Research
Center
Prevalence of self-cutters
 Adolescents:
in community 15 %
in psychiatric treatment 50 %
 ศึกษาในเด็ก:
50% กรีดแขนอย่ างน้ อย 1 ครั้ง
30 % กรีดแขนมากกว่ า 4 ครั้ง
F>M
Frequncy
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Age
Female
Race
CSA
PTSD
Condom use
Sharing cutting
Alcohol use
>4
<3
14.9
66
74
63
16
39
20
30
14.9
42
91
34
7
73
5
19
 สาเหตุ:
57 % กรีดเมื่อ sad หรือ upset
35 % กรีดเพือ่ hurt themselves
15 % ทาตามเพือ่ น/ to look cool
สรุป พบบ่ อยใน adolescent
จาก distress & attempt to regulate affect
Previous findings:

Demonstrate that self-cutting is associated
with
unprotected sex
drug use
suicidal behavior
history of sexual abuse
Recent Data:
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Frequent self-cutting ( 4 times or more)
was associated with unprotected sex
and sexual abuse
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Frequent self-cutters were likely to
endorse distress or self-harm as
motivations to self-cut
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Less frequent cutters were more likely to
endorse motivations such as the desire
“ to look cool”
“ because friends do it”
Conclusion
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Infrequent cutting is determined by social,
experimental and developmental factors
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Frequent self-cutting is a method to relieve
distress or to inflict self-harm
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Frequent self-cutters have greater sexual
risk and more emotional distress than
infrequent self-cutters
Deliberate Self-Harm by
Adolescents: Potential
Impact of The Internet
Norman E. Alessi M.D.
U. Of Michigan
Objective:

Examine role of internet in adolescent
self-harm behavior
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Identify sites that both support self-harm
and support those that are seeking help
Result:
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No existing medical literature involving
Internet & self-harm behavior
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Google search engine:
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“Bill of Rights for People Who Harm
Themselves”
Google search engine:
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A number of sites dealing with selfcutting as a way of coping with stress
often demonstrating techniques of
cutting or BLOGS of experience
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A number of sites provided help for those
who want to seek help
Bill of Rights for People Who
Harm Themselves
Conclusion
มีการใช้ internet สู งขึน้ ขณะเดียวกันก็มีรายงานการทาร้ าย
ตนเองสู งขึน้ แต่ ข้อมูลไม่ เพียงพอทีจ่ ะสรุปความสั มพันธ์
 จานวน website ที่เกีย
่ วกับ suicide / self-harm ที่มากขึน้
แสดงถึง concern
 BLOG may increased danger for a risk teen
 ผู้บรรยายแนะนาว่ าให้ ถามคนไข้ ว่ามี BLOG ไหม ถ้ ามีขอดู
ได้ ไหม
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Self-Cutting:
Where is the Pain?
Maryland Pao M.D.
NIMH
Objective:
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Review neural circuits involved in normal
pain sensitivity and pain processing
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How they relate to self-cutting behaviors
Pain
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Ass. with actual and potential tissue
damage
Sensory may last beyond the clinical
Early damage in infancy  prolonged
structure effect
Social pain เป็ น pain from social injury or
social relationship
Self-cutter
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Early separation and negative response,
bullying, sexual/physical abuse
 disrupted neural circuits
ซึ่ งเป็ น social distress and unpleasant มากกว่า
physical pain
Cut for release distress
feel real
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Treatment
assess attachment style
assess physical pain history
role of CBT
teach social skills to help develop
better social support
Conclusion
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Self-cutters are reported to experience
early separation, bullying in school, and
sexual/physical abuse more frequently
than non-cutters
Traumatic pain events that disrupt
normal development of various pain
pathways may lead to different structural
and functional connectivity in CNS
Interventions for
Deliberate Self-Harm and
Self-Injurious Behavior
James C. Harris M.D.
Johns Hopkins Hospital
Self-Mutilation
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Superficial – episodic & compulsive; e.g.
self-cutting, skin picking
(most common in adolescent)
Repetitive/Stereotypic – function as self
stimulation; e.g. head banging,
self biting
Severe but infrequent – e.g. self-blinding,
amputation; associated with
psychosis, intoxication
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SIB is a model to study gene-brainbehavior relationship
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SIB,DSH เป็ น stress related behavior
disorder สัมพันธ์กบั โรค eating disorder,
cluster B personality disorder, PTSD
DSH เป็ น coping
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Activate by emotional arousal
Terminate by self injury
HPA dysfunction
Self-regulation of hyperarousal or
dissociative state
Polyvagal theory
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Describes a feedback loop and a
schema to understand how
environmental context and subjective
experience can influence physiological
state, and how physiological state can
limit ability to deal with environmental
challenge
Environment
challenge
Nervous system
Safe
Social
engagement
system:
I am happy, facial
express, make
eye contact
myelinated
vagus
Dangerous
Defensive
strategies:
flight, fight,
anxious,
discomfort
Sympathetic
Life
Threatening
Defensive
strategies:
death feigning,
shut down,
immobilize,
freeze
unmyelinated
vagus
Psychosocial approach
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 social engagement system
 environmental stressors
Enhance communicating skills
Develop appropriate self soothing
Enhance mood & emotional regulation
Monitor drug use & sexual behavior
Medication
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Dopamine antagonist สามารถลด self injury, self biting
( เกี่ยวข้องกับ receptor D1/D5, D3 แต่ receptor D2 ไม่เปลี่ยนแปลง self injury,
self biting)
ดังนั้น ยาที่ใช้ ควรเป็ นกลุ่ม
• Mood Stabilizer
• Atypical antipsychotics
• Antidepressants
• D1 antagonists
CLINICAL PERSPECTIVES
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A presentation on a particular topic
related to treatment, research method,
service delivery, or clinical care that is
evidence-based and includes the “art”
and clinical wisdom of the practice of
child and adolescent psychiatry.