Clinical perspectives15 Adolescent Deliberate Self-Harm: Issues of Development, Culture, Biology, and Treatment Clinical perspectives15 แพทย์หญิงรัชนี ฉลองเกื้อกูล 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% กรีดแขนอย่างน้อย 1 ครั้ง 30 % กรีดแขนมากกว่า 4 ครั้ง F > M

Frequncy > 4 < 3 Age 14.9 14.9 Female 66 42 Race 74 91 CSA 63 34 PTSD 16 7 Condom use 39 73 Sharing cutting 20 5 Alcohol use 30 19

สาเหตุ: 57 % กรีดเมื่อ sad หรือ upset 35 % กรีดเพื่อ hurt themselves 15 % ทำตามเพื่อน/ to look cool สรุป พบบ่อยใน 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: Frequent self-cutting ( 4 times or more) was associated with unprotected sex and sexual abuse Frequent self-cutters were likely to endorse distress or self-harm as motivations to self-cut

Less frequent cutters were more likely to endorse motivations such as the desire “ to look cool” “ because friends do it”

Conclusion Infrequent cutting is determined by social, experimental and developmental factors Frequent self-cutting is a method to relieve distress or to inflict self-harm 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 Identify sites that both support self-harm and support those that are seeking help

Result: No existing medical literature involving Internet & self-harm behavior Google search engine: “Bill of Rights for People Who Harm Themselves”

Google search engine: A number of sites dealing with self-cutting as a way of coping with stress often demonstrating techniques of cutting or BLOGS of experience A number of sites provided help for those who want to seek help

Bill of Rights for People Who Harm Themselves

BLOG may increased danger for a risk teen Conclusion มีการใช้ internet สูงขึ้น ขณะเดียวกันก็มีรายงานการทำร้ายตนเองสูงขึ้น แต่ข้อมูลไม่เพียงพอที่จะสรุปความสัมพันธ์ จำนวน website ที่เกี่ยวกับ suicide / self-harm ที่มากขึ้น แสดงถึง concern BLOG may increased danger for a risk teen ผู้บรรยายแนะนำว่าให้ถามคนไข้ว่ามี BLOG ไหม ถ้ามีขอดูได้ไหม

Self-Cutting: Where is the Pain? Maryland Pao M.D. NIMH

Objective: Review neural circuits involved in normal pain sensitivity and pain processing How they relate to self-cutting behaviors

Pain Ass. with actual and potential tissue damage Sensory may last beyond the clinical Early damage in infancy  prolonged structure effect Social pain เป็น pain from social injury or social relationship

Self-cutter Early separation and negative response, bullying, sexual/physical abuse  disrupted neural circuits ซึ่งเป็น social distress and unpleasant มากกว่า physical pain Cut for release distress feel real

Treatment assess attachment style assess physical pain history role of CBT teach social skills to help develop better social support

Conclusion 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 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

SIB is a model to study gene-brain-behavior relationship SIB,DSH เป็น stress related behavior disorder สัมพันธ์กับโรค eating disorder, cluster B personality disorder, PTSD

DSH เป็น coping Activate by emotional arousal Terminate by self injury HPA dysfunction Self-regulation of hyperarousal or dissociative state

Polyvagal theory 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 Life Threatening Safe Dangerous Social engagement system: I am happy, facial express, make eye contact myelinated vagus Defensive strategies: flight, fight, anxious, discomfort Sympathetic Defensive strategies: death feigning, shut down, immobilize, freeze unmyelinated vagus

Psychosocial approach  social engagement system  environmental stressors Enhance communicating skills Develop appropriate self soothing Enhance mood & emotional regulation Monitor drug use & sexual behavior

Medication Dopamine antagonist สามารถลด self injury, self biting ( เกี่ยวข้องกับ receptor D1/D5, D3 แต่ receptor D2 ไม่เปลี่ยนแปลง self injury, self biting) ดังนั้น ยาที่ใช้ ควรเป็นกลุ่ม Mood Stabilizer Atypical antipsychotics Antidepressants D1 antagonists

Thank You

CLINICAL PERSPECTIVES 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.