Thursday 13 September 2007

Deliberate Self Harm

We know Deliberate Self Harm (DSH) is common. One study talking to over 350 interested parties found about 1 in 15 children doing it from age 12 upwards. Other studies quote up to 1 in 7 in certain subgroups. So it matters. We know DSH invariably is nothing to do with suicide. We know that in younger folk (12 to early 20's) it's usually concealed (e.g. cutting arms then hiding the cuts under clothes) and is not about overt attention seeking.

Some groups seem at higher risk than others.

The National Institute of Health and Clinical Excellence has guidelines about this.

One key issue is that the self harm is a way for the young person to cope. They've often no better way to cope, which is why they cut. Stopping the cutting is stopping them coping. Thus, guidance is (sensibly) directed at looking at the causes of the DSH and addressing these rather than simply abolishing the self harm behaviour.

All well and good.

But, the crunch . . . just how do you explain to a terrified parent that we're going to accept their 19 year old teenager is still cutting themselves?

We'll offer alternatives (many distraction techniques work brilliantly) and CBT (which has established benefits after just a couple sessions) and medication (lorazepam can give similar relief that cutting does and works quickly to de-escalate distress) to try and reduce cutting and we'll give advice on cutting safely, but it's the loneliness and college pressure he's put himself under that needs sorting out then (invariably) the DSH diminishes and stops.

A difficult management plan to sell . . .


Polly said...

That's very sad...

What normally happens to these patients? Are they normally managed okay with what you have mentioned or do they deteriorate further? Maybe a bit of both?...

Calavera said...

But what else can you do? What do those parents want you to do? Hospitalise them and watch them 24/7?

And does Lorazepam actually work to stop cutting?? I had no idea about that...

The Shrink said...

Polly, in children and young adults, outcomes thankfully are good (since it's usually caused by difficulty coping rather than by major or pervasive mental illness).

Mostly the behaviour's a (maladaptive) way for them to cope. When they mature a little and learn to cope better, or situations change, or they have other coping strategies, things invariably improve.

Role of schools, colleges, peers, social work and health largely are to help those self harming find better coping strategies, remove causes (isolation, pressure, bullying) and spot those who need more formal support from mental health services. A non-judgemental approach is crucial in success . . . it's one of those areas where it's not so much what you do as how you do it that counts (which is why the evidence base for it is so woeful as it's difficult to critique that).

Cal, there's obviously no "anti-cutting" pill, but lorazepam (as a fast acting benzodiazepine) quickly reduces feelings of distress to more manageable levels, with the less intense and overwhelming feelings it can indeed mean folk can then have emotions/thoughts that they can cope with, so don't feel the need to cut.

Ms-Ellisa said...

Coping with Sadness or stress?
Would you really think that prescribing drugs would be the way to go,even if the teen seemed not to have any "unsafe" outbursts eg suicide attempts?
I've always believed that it wasn't about attention, but this is the first time I see an actual doctor saying it and that the precentage is that high.

The Shrink said...

Would you really think that prescribing drugs would be the way to go,even if the teen seemed not to have any "unsafe" outbursts eg suicide attempts?


If there are no "unsafe" elements and it's not reaching diagnostic criteria for significant mental illness (so as you suggest it's more psychological dysfunction as sadness and stress rather than psychiatric illness) then medication is not indicated.

Even in younger folk with Deliberate Self Harm, medication often isn't used at all. If it is, it's just a small part of the overall care plan that's put in to place to effect change.

Spirit of 1976 said...

I find DSH fascinating, in a slightly morbid way. My degree dissertation was on DSH "contagion" (the passing of self-harming behaviours from person-to-person, for the benefit of anyone reading this thread who isn't involved in mental health services).

I think there's an interesting and under-explored interpersonal dimension to DSH. A lot of the research papers I looked at showed a correlation between knowledge of another's self-harm and actually engaging in self-harm oneself.

Some clinicians I've met seem to assume that if a person has "copied" their self-harming behaviour from another (e.g. from other children in school, from fellow patients in psychiatric units, or from self-harming rock stars such as Marilyn Manson, Sid Vicious, Iggy Pop or Richey Edwards) then this automatically means that the self-harmer is "just attention-seeking" and "not a real self-harmer". Personally I think such a view is simplistic and downright wrong.

The other thing clinicians say about DSH that gets me annoyed is "if they're doing it on their lower arms and wearing short sleeves, they're just doing it for attention". Quite a few self-harmers I know say that the reason they don't conceal their scars isn't because they want attention. It's just because they don't care if someone sees them or not.

Like I said, I'm fascinated by DSH. I think I must like the look of blood or something.

Elaine said...

Hello there to the Shrink, I welcomed your comments on my blog, and have read your sympathetic comments on Dr Andrew Brown's blog. This is the first time I have read your blog. I find it interesting, and have marked it for future reading.

(ps good luck with the washing!)

BenefitScroungingScum said...

Hello, I've wandered my way here from your comment on Dr J's blog.
As a largely self supporting patient group we struggle with how to deal with those who self harm. It seems relatively common as a 'coping mechanism' when, usually as teenagers, they are struggling to come to terms with all that chronic pain brings.
Interestingly I once heard someone describe it as a method of pain control in the absence of all others. Something to do with the mix of (is it hormones?) released when they cut producing the bodies natural pain killing agents and therefore being a method of pain management. Sadly that made a great deal of sense.
Those I've come across have generally not done brilliantly, largely I suspect due to not being able to access the physical health services they needed in the first place which may have been what led them to cut? Bendy Girl

The Shrink said...

BendyGirl, welcome. You're right, it can be a struggle to support such folk, within the NHS just because it's a struggle isn't a good enough reason for it not to happen though :-) They still need and deserve support but it invariably is hit and miss how well this is delivered.

As Zarathustra said, DSH is complex.

Usually the DSH is about coping with distress. Sometimes it's about a need to "feel alive" and feel pain, see life blood. It can give a mix of hormones as you say (catecholamines like adrenaline, pain relief from endorphins).