Nonsuicidal selfinjury Dr Claire Kelly Mental Health First

Non-suicidal self-injury Dr Claire Kelly Mental Health First Aid Training and Research Program ORYGEN Research Centre

Overview • What is NSSI? – Types of NSSI – Terminology • Why do people engage in NSSI? – Motivations – Outcomes • Controversies • Stigma 2

Overview • Associated mental disorders • Treatment • What do you do if someone has injured themselves? – Guidelines for first aid for NSSI – ALGEE • …Questions? 3

What is NSSI? • 3 main types of NSSI: 1. Major self-injury or major self-mutilation • • Usually a result of psychosis Single large injury (removing an eye, selfcastration or cutting off a digit or limb) 2. Stereotypic self-injury • • Usually associated with intellectual disability or brain injury, occasionally Autism Repeated self-injury such as banging a head on the wall or self-punching over and over again 4

What is NSSI? 3. Compulsive self-injury • • • Usually associated with personality disorders and depressive disorders Can be a pattern over weeks, months or years This is the type of injury we are talking about. 5

What is NSSI? • Types of self-injury: – Cutting, scratching, ripping, tearing, burning, or pinching skin – Carving words or patterns into skin – Interfering with healing of wounds – Banging or punching objects or self – Self-poisoning when this is NOT intended to be a suicide attempt 6

Terminology • Non-suicidal self-injury – Deliberately inflicting physical harm on oneself without conscious intent to die. • Use a term which best reflects what you intend to say. 7

Who engages in NSSI? • Estimates vary: – – 4% in general population (lifetime) 7 - 21% in clinical populations (review) 60% in psychiatric inpatients (review) 13% - 23% of children and adolescents (lifetime) based on reviews – 3 -47% in previous 12 months based on multiple crosssectional studies • Exact numbers hard to estimate • Lets say “a lot”. 8

Motivations for self-injury To escape from an intolerable state - Emotional pain, numbness - Suicidal feelings Wanting to change others’ behaviours - Can be a morbid form of help-seeking - Can be a way to get noticed 9

Motivations • Feeling unreal or non-human – Seeing blood or feeling pain can stop this • Feeling dissociated – Can bring self back ‘into the body’ • “It should show on the outside” – Scars, wounds and dressings can express emotional pain and suffering – Showing desperation to others • To die* - not addressed here. 10

Outcomes • Common theme: – Current state is intolerable – SI can change the state enough to make it tolerable • Most people stop when they have what they need • Some can lose control – Most injuries are superficial – Can accidentally cause more serious damage or die 11

Controversies • A history of NSSI is associated with increased suicide risk • Relationship is very strong – but poorly understood • Some people argue that there is always suicidal ideation - even if person is not aware of it • Others argue that the person’s intent should be accepted as spoken • NSSI must be taken seriously, as a future suicide is possible. 12

Stigma • Individuals presenting to emergency rooms may be treated badly • Stigma towards people with borderline personality disorder can be directed toward people who have self-injured • NSSI is frightening to people who see it, is usually ugly, can leave visible scars and can provoke disgust 13

Associated mental illnesses • Most commonly associated with borderline personality disorder (BPD) • Also associated with depressive disorders, anxiety disorders, eating disorders, and others 14

Treatment • Treating any underlying mental illnesses can decrease number and severity of SI episodes • Small trials and small numbers mean there is little strong evidence for any specific treatments for SI alone • Some people describe a spontaneous remission in the urge to self-injure 15

First aid for NSSI • Evidence base is very limited • No evidence base for first aid strategies • Guidelines developed by the team – Consensus method – Consumers and clinicians • Guidelines document provided 16

The MHFA Action Plan: 1. Assess the risk of suicide or harm 17

The MHFA Action Plan: 1. Assess the risk of suicide or harm • Risks associated with SI: – Accidental death • Overdose or arterial bleeding – Permanent damage to muscles/tendons • Resulting in limited mobility – Secondary harms from infection 18

The MHFA Action Plan: 1. Assess the risk of suicide or harm • Attend to any serious injuries first. – Heavy bleeding, arterial bleeding – Burns (especially to face, hands and feet) – Possible broken bones • If you are able to offer first aid, do so. • Call for emergency assistance as needed. • If the person has taken an overdose, regardless of their intention, call an ambulance. 19

The MHFA Action Plan: 1. Assess the risk of suicide or harm • Offer to attend to less serious injuries. • Ensure adequate first aid supplies are available. • Be aware that tending to injuries may be part of what the person needs to do for themselves. 20

The MHFA Action Plan: 1. Assess the risk of suicide or harm • ASK: “Are you having thoughts of suicide? ” • If YES: – Apply first aid for suicidal thoughts. • If NO: – Move on to the next action. 21

The MHFA Action Plan: 2. Listen non-judgementally • Always stay calm and do not express judgement • Do not express disgust or horror • Do not trivialise the feelings which have lead to the NSSI • Do not punish the person – Especially by threatening to withdraw care 22

The MHFA Action Plan: 2. Listen non-judgementally • If you suspect NSSI: – Don’t ignore signs - ask the person about what is happening. – Before talking to the person, consider your own state of mind: • Can you stay calm? • Can you help without saying something which may cause further hurt? • Can you cope with the person’s answer? • Ask the person if you can help them to feel better 23

The MHFA Action Plan: 2. Listen non-judgementally • If NSSI is confirmed: – Discuss SI calmly with the person – Remember that “stopping self-injury” is not the main aim • Main aim is to alleviate distress 24

The MHFA Action Plan: 3. Give reassurance and information • NSSI is a response to an intolerable emotional state • It is common • By getting help for the underlying problems, you can cope without it. 25

The MHFA Action Plan: 4. Encourage professional help-seeking • Self-injury is not an illness in itself • May need treatment for psychological distress or a mental illness • Make sure they know where they can get help, but don't force them to use it • A GP, psychiatrist or psychologist can help 26

The MHFA Action Plan: 5. Encourage self-help strategies • Talk to someone next time the urge hits • Develop your own methods for staying safe • Harm minimisation: – Ensure the person has adequate first aid supplies – This can reduce the risk of secondary harms from infections, etc. 27

Keeping safe • Ensure that the person has access to first aid supplies • Encourage them to speak to someone they trust next time they feel the need to injure themselves • Encourage them to find other ways to relieve pain • Encourage them to delay for as long as they can • Encourage them to do something distracting 28

Questions? 29