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self-harm by Mind Map: self-harm

1. forms

1.1. cutting

1.1.1. most common

1.2. fist banging

1.3. eating disorders

1.3.1. bulimia

1.3.2. anorexia

1.4. scratching

1.5. burning

1.6. Hair pulling (trichotillomania)

1.7. substance abuse

1.7.1. overdosing

1.7.2. alcohol

1.7.3. drug

1.7.4. noxious substances

1.8. interfering with wound healing

2. Phenomenology

2.1. before self-harming

2.1.1. overwhelmed by emotions tense fearfull isolation dissociation anxious angry

2.1.2. emotion regulation

2.2. during self-harming

2.2.1. absence of pain

2.2.2. control

2.2.3. anger, tension and dissociation dissapears

2.3. after self-harming

2.3.1. positive emotions (common) calm satisfaction relief release

2.3.2. negative emotions (rare) guilt disgust

3. associated diagnoses

3.1. impulse disorder

3.1.1. similar to eating disorders or kleptomania

3.2. borderline personality disorder

3.3. depression

3.4. dissociative identity disorder

3.5. obsessive compulsive disorder

3.6. alcoholism

3.7. substance abuse

3.8. eating dissorders

3.9. schizophrenia

3.10. anxiety disorder

3.11. adjustment disorder

3.12. personality disorders

4. importance of intervention

4.1. correlated with antisocial behviour

4.2. associated with

4.2.1. increased suicide

4.2.2. sexual behaviours at high risk for HIV

4.2.3. physical illness and complaints

4.2.4. sexual dysfunction

4.2.5. symptoms of depression

4.2.6. psychiatric and emotional distress

5. risk factors (Gratz, 2003).

5.1. environmental risk factors

5.1.1. bullying

5.1.2. childhood separation and loss

5.1.3. psychological abuse

5.1.4. physical abuse

5.1.5. childhood sexual abuse

5.1.6. childhood trauma

5.1.7. familial risk factors neglect maternal emotional neglect paternal emotional neglect insecure attachment insecure paternal attachment parental deprivation divorce pathological family relations emotional distancing invalidating family environment bereavement

5.2. individual risk factors

5.2.1. biological Altered cortisol response low serotogenic functioning genetic predisposition

5.2.2. emotional dysregulation emotional vulnerability emotional reactivity: sensitivity to emotional stimuli emotional intensity: extreme emotional reactions inability to self-soothe

5.2.3. physiological decreased psychophysiological response

5.2.4. dissasociation

5.3. population

5.3.1. adolescents

5.3.2. young adults

5.3.3. single females

5.3.4. asylum seekers, minority ethnic groups, people in institutional care or custody such as prisoners, sexual minorities, veterans and those bereaved by suicide

6. Background information

6.1. intention

6.1.1. non-suicidal

6.1.2. sexual

6.2. possible outcomes

6.2.1. under-employed and lower vocational achievement despite education

6.2.2. suicide

6.3. secret private and intimate act

6.4. onset: 13-14 years of age

6.5. 15%-20% lifetime prevalence

6.6. worldwide phenomenon, prevalence is similar

6.7. more common in psychiatric populations

6.8. contributing factors

6.8.1. genetic predisposition and psychiatric, psychological, familial, social, and cultural factors

6.8.2. media and contagion is increasingly important

7. most influential factos

8. intrapersonal functions

8.1. emotion regulating functions

8.1.1. affect regulation express self hate acute negative affect before DSH decreased negative affect and relief after DSH intent: to alleviate negative affect outcome: negative affect and arousal are reduced with DSH regulate overwhelming affect sense of control 'need to express or control anger, anxiety, or pain that cannot be expressed verbally or through other means'

8.1.2. anti-dissociation to end depersonalisation dissociation maintain sense of self conectedness to the world

8.1.3. self-punishment

8.1.4. externalize emotional pain making it physical and tangible therefore easier to understand and less abstract physical evidence of emotional pain making their emotions real, justified and tolerable validates the emotion

8.1.5. escape forget worries, fears, emotional pain

8.1.6. relaxation relieve anxiety release tension release anger reduce stress

8.1.7. sense of security, safety & protection.

8.1.8. empower prove themselves they can cope with that pain

8.1.9. anti-suicide drive model (psychoanalysis) replace or avoid suicide, compromise between drives to live and die

8.2. relieve unpleasant thoughts and feelings

8.2.1. relieve feelings of guilt, loneliness, alienation, self-hatred, and depression

8.2.2. stop racing thoughts self reinforcement SH decreases tension and dissociation through affect regulation function

8.2.3. end flashbacks bad memories

8.3. sensation-seeking

8.3.1. generate excitment endorphines

8.4. sexual drive model (psychoanalysis)

8.4.1. 'Self-mutilation stems from conflicts over sexuality, menarche, and menstruation'

9. Dialectical Behaviour Therapy (DBT) (Brodsky, & Stanley, 2013)

9.1. combines cognitive behavioural and supportive intervention

9.1.1. including behavioral skill training, contingency management, cognitive modification, and exposure to emotional cues

9.1.2. supportive techniques such as reflection, empathy, and acceptance

9.1.3. group therapy focusing on the development of interpersonal skills, skills aimed at tolerating distress, and emotion regulation skills

9.2. particularly effective with adolescents

9.3. outcomes

9.3.1. enables them by providing tools to achieve the lives they want to lead

9.3.2. learn to explore emotions regulate and respond to emotions

9.3.3. significant reduction in the frequency of self-harm after 12 months of DBT

9.4. 5 core skills

9.4.1. mindfulness experience emotion without SH

9.4.2. distress tolerance alternatives to SH how to deal with impulse

9.4.3. emotion regulation understand and control painful feelings

9.4.4. the middle path minimise extreem thoughts, not everything is black and white, search for middle ground

9.4.5. interpersonal effectiveness how to meet their needs promote self-respect behaviours

9.5. targets: pupils who have difficulty engaging and remaining in treatments

9.6. dialectic

9.6.1. accept and validate SHs as they are

9.6.2. help SHs to change

9.7. addresses emotion regulation, impulse control and problem-solving skills

9.8. 4 stages

9.8.1. stage 1: stabilising the patient and achieving behavioural control decrease SH behaviours decrease behaviours that interfere with therapy decrease behaviours that interfere with quality of life increase behavioural skills

9.8.2. stage 2: address past traumas

9.8.3. stage 3: develop self-esteem and managing day to day problems

9.8.4. stage 4: promote individual capacity to develop and have new experiences

9.9. assumptions

9.9.1. Pupils are doing the best they can

9.9.2. pupils want to improve

9.9.3. pupils need to do better try harder and have motivation to change

9.9.4. pupils may not have caused their problems but need to solve them

9.9.5. current life is unbearable

9.9.6. pupils cannot fail in therapy

9.9.7. BPD clinicians need support

9.10. most integrated and effective approach

10. negative behaviour replacement strategy

10.1. muscular pain through exercise

10.2. the release of chemicals through exercise can reinforce this healthier behaviour

11. functions (Suyemoto, 1998)

11.1. intergroup functions

11.1.1. competition with peers

11.1.2. social status admiration ability to endure pain strength courage

11.2. interpersonal functions

11.2.1. environmental interpersonal-influence communicate 'Self-mutilation creates environmental responses that are reinforcing to the individual while simultaneously serving the needs of the environment by sublimating and expressing inexpressible and threatening conflicts and taking responsibility for them' social contagion modelling vicarious reinforcement

11.2.2. boundaries (self-psychology) maintain sense of self in relation to others, set boundaries between the self and others. Not to loose their identity

12. social and behavioural learning theory (intergroup level of analysis)

12.1. family relationships

12.2. deflect attention from dysfunctional environment

12.3. behaviours are maintained through

12.3.1. operant conditioning

12.3.2. classical conditioning

12.4. intermittent reinforcement schedules make behaviours difficult to erradicate

12.5. learning principles provide a non-judgemental explanation of behaviours

12.6. social contagion (Rosen, Walsh, & Rode, 1990)

12.7. modeling, imitation, and identification (Simpson & Porter, 1981)

12.7.1. learn from parents

12.7.2. self-care through self-injury

12.8. behaviours reinforced by (Offer and Barglow, 1960)

12.8.1. attention and concern from others

12.8.2. social status

13. psychoanalytic and object relations developmental theory (interpersonal)

13.1. explains prevalence in adolescents

13.1.1. differentiation from the mother

13.1.2. need to separate from infantile love objects extreme defensive manouvers against infatile love objects reversed affect intolerable for the ego

13.2. individuals may display

13.2.1. inability to express emotion and conflict between self and others

13.2.2. perceived abandonment early object relations results in due to

13.2.3. difficulty verbalizing emotions and needs, especially anger and feelings around loss express overwhelming emotions difficulty with verbal expression lack of symbolising function SH because language cannot be used to distance the individual from emotions and regulate affect SH = primative evocative symbol 'However, SH fails to communicate the information in which the primitive feeling is embedded or help the self-mutilator obtain mastery over the emotion through the use of symbolic communication. ' express and contain affect and need

13.3. linked to self psychology

13.4. rooted in ego psychology

14. Psychodynamic therapy (Levy, Yeomans, & Diamond, 2007)

14.1. patients learn to

14.1.1. accept emotions

14.1.2. express feelings verbally

14.1.3. tolerate intense emotions

14.1.4. make unconscious impulses conscious

14.1.5. alternative ways to control emotions

14.1.6. alternative ways of interacting with others

14.1.7. evoke soothing representations

14.2. most commonly used in SH

14.3. a good relationship with therapist

14.3.1. the best approach is to combine education, identification with the therapist, and a balance between permissiveness and limit setting

14.3.2. individual becomes more open honest and trusting decreasing interpersonal difficulties increasing self-esteem reducing self-harm sense of safety

14.3.3. technical neutrality non-judgmental, non-critical stance

14.4. most common improvement outcomes

14.4.1. an increased ability to cope with feelings, especially sexual and angry feelings

14.4.2. increased verbal expression of feelings

14.4.3. learning to use more constructive means to channel impulses

14.4.4. control of psychotic delusions

14.4.5. improved social adjustment

15. Neurobiology of SH (Groschwitz, & Plener, 2012)

15.1. Behaviour reinforcement

15.1.1. SH releases endorphines pleasurable feelings pain killers enkephalins euphoria stress relief

15.2. Neurotransmitter differences

15.2.1. decreased serotonin activity found in SHs

15.2.2. decreased serotonin lack of constraint difficult to resist the impulse to SH impulsive behaviour higher levels of stress influences mood and aggression reduced mean frontal binding index

15.3. Trauma

15.3.1. systematic abuse causes stress response system to become under responsive to stress chemicals altered structure and chemistry of brain constant state of fear and anxiety altered stress response system Stress chemicals: Epinephrine, Dopamine and Norephrine. abused girls have been found to have higher levels of these chemicals these chemical may trigger hyper arousal state of anxiety in SH these hormones are released through flashbacks and nightmares engraining the traumatic memory

15.3.2. Catecholamines are released in the brain during sexual abuse.

15.4. addiction

15.4.1. Endogenous opioids (petrochemicals) released when in danger or injured act as pain killers traumatic thoughts trigger segregation of natural opiates (endorphine response) analgesic effect addiction to opioids and their calming effect is created absence of stress or traumatic triggers opiate withdrawal and cravings through SH opiates are released lack of pain when SH cravings are reduced

15.5. Genetic predisposition for high physical, cognitive and emotional reactivity

16. non-competitive exercise therapy (Berger, & Owen, 1988)

16.1. effects are comparable to antidepressants

16.2. stress reduction

16.3. mood enhancement

16.4. similar set of chemicals are released during exercise than during SH

16.4.1. reduce cravings

16.4.2. endogenous opioids animal studies report addiction to exercise due to the release of opioids

16.4.3. serotonin

17. research is still in its infancy, however findings seem to be supportive

17.1. supervision is needed in order to avoid the use of exercise in a self-destructive manner

18. treatment not recommended

18.1. if SH derives from childhood trauma and this is focused on during therapy as self harming is likely to increase