MHM Magazine

8 | MENTAL HEALTH MATTERS | 2023 | Issue 3 MHM or feeling disconnected from others. Others may feel a sense of ‘pain relief’, or a sense of control, or excitement or to stop a dissociative experience. It may also serve as an interpersonal function for the adolescent, as it may elicit positive re-enforcement, in the form of attention from others, or may assist in avoiding difficult situations, or the threat of self-harm may cause adults or peers to decrease interpersonal pressure. FUNCTIONS OF SELF HARM AFFECT REGULATION • Anxiety • Frustration • Depression CHANGE COGNITIONS • Distraction from problems • Stopping suicidal thoughts SELF PUNISHMENT STOP DISSOCIATION INTERPERSONAL • Secure care and attention • Fit in with pee RISK FACTORS FOR SELF HARM There are multiple and variable predisposing factors that contribute to self-harm and includes the following: 1. Sociodemographic and educational factors a. Female gender b. Low socioeconomic status c. LGBTQ+ adolescents d. Poor academic achievement 2. Individual negative life events and family adversity a. Parental separation or divorce b. Death of a parent c. Adverse childhood experiences d. History of physical or sexual abuse e. Parental psychopathology f. Marital or family discord g. Bullying h. Interpersonal difficulties 3. Psychological and psychiatric factors a. Psychiatric disorders especially anxiety, depression, and ADHD b. Drug and alcohol misuse c. Low self-esteem d. Poor problem solving e. Perfectionism f. Hopelessness THE SIGNS TO LOOK OUT FOR? 1. Unexplained cuts, bruises, or burns, often on wrists, arms, thighs and chest 2. Wearing long sleeves and trousers or tights, even in hot weather 3. Refusing to get changed in front of other people, for example for PE or in changing rooms 4. Signs of hair pulling 5. Changes in eating habits - over- eating or under-eating 6. Exercising excessively ASSESSMENT AND TREATMENT OF SELF HARM 1. Complete a comprehensive assessment that includes the following: a. History and physical examination b. Identify co-morbid psychiatric conditions c. Suicide risk assessment d. History of physical or sexual abuse e. Substance abuse history f. Evaluation of risk factors g. Evaluation of social support and family functioning 2. Identify the function and characteristics of the self-harm a. Antecedents- situations/ stressors leading to self-harm b. Characteristics-frequency, intensity, duration 3. Develop a therapeutic alliance based on acceptance and validation strategies (non-judgmental) 4. Treat co-morbid psychiatric conditions 5. Target behavioural interventions for self-harm based on behavioural analysis and the need for the following: a. Affective language skills b. Self-soothing skills c. Communication skills 6. Provide psychoeducation for the patient and the family 7. Monitor response to behavioural interventions for reducing self-harm 8. Consider dialectical behaviour therapy(DBT) (treatment of choice for self-harm) and family therapy CONCLUSION Self-harm among adolescents is common and has increased significantly. While many adolescents with self-harmmay not have severe psychopathology, adolescents presenting with self-harm should have a thorough psychiatric assessment that includes screening for suicidal ideation and risk factors. It’s important to assess family and other interpersonal supports as part of the treatment plan. Pharmacological treatment is indicated for the treatment of comorbid psychiatric conditions. Psychotherapy is the treatment of choice, to assist with the development of more adaptive coping skills and should be initiated early. References available on request. CASE EXAMPLE Rachel was a 15-year-old girl whose parents were currently going through a divorce. Her father had moved out of the house and she was seeing him once a week. They had shared a very close relationship and Rachel secretly hoped that her parents would get back together. She was at home when her father came to fetch her for her weekly visits when she heard her parents arguing. She immediately went upstairs to her bedroom, locked the door, and cut herself on the wrist several times with a razor blade. Although she wore long sleeves to his house that evening, her father spotted the wounds and brought his daughter to the emergency room, saying his daughter had tried to kill herself. Rachel, however, stated emphatically that she did not want to die. “I cut myself because it made me feel better,” she said. A consulting psychiatrist interviewed Rachel in the emergency room. A nurse had warned the psychiatrist that Rachel was “borderline” and “gamey,” stating, “She just cut herself for attention. Don’t let her manipulate you.” However, after an extensive interview with Rachel, there were insufficient criteria to merit a diagnosis of borderline personality disorder. In fact, despite her obvious problems coping with distress, Rachel did not meet the criteria for any major mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (DSMV) Rachel explained to the psychiatrist that she cut herself because it was “calming.” She said that a year ago she first started pinching herself as a way to hurt herself. One day she saw her brother’s razor blades and started cutting herself on her arms. “It helps me chill,” she said. “My mind slows down, I stop crying, and I just feel better.” She said the razor slicing into her skin did not hurt badly—just enough for her to “feel alive.” She felt so much better after cutting herself that afternoon that she was able to concentrate on her homework and not think any more of her parent's conflictual relationship and impending divorce.