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Self harm
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How to manage self harmPPT Sommerkurs,
Storefjell 2007 Per Johan IsdahlUllevål
University HospitalFinn SkårderudLillehammer
University CollegeUllevål University Hospital
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Definition A non-life threatening, non-suicidal
self-inflicted bodily harm that is not socially
accepted
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• Psychopathology
• Self- and affect dysregulation
• Symptoms as repair and compensation
• The paradoxes of pain
• Concreteness of symptoms

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lady diana spencer Told in an
BBC-interview about cutting herself on arms and
legs.
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when one feels that nobody listens, anything
can happen it may hurt so badly inside that one
tries to harm oneself on the outside to get help.
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• of all disturbing patient behaviors,
  self-mutilation is the most difficult to
  understand and treat The typical clinician
  (myself included) treating a patient who
  self-mutilates is often left feeling a
  combination of helpless, guilty, furious,
  betrayed, disgusted and sad.
• Frances, A. (1987). J Personality Disorders,
  1316

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The dilemma of therapeutic alliance

• Put simply, no one loves self-mutilators.
• Armando R. Favazza

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Limitations in therapy - a reminder

• Therapists contribution
• Lack of understanding
• Provoked and scared
• Affective arousal leads to therapists impaired
  understanding
• The risk of iatrogenic interventions

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Definitions and descriptions
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Body modification as cultural, artistic and
religious practices piercing scarring tatooing p
ain
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Many names

• parasuicid
• wrist-cutting syndrome
• cutters
• deliberate self harm (DSH)
• self inflicted violence (SIV)
• bodily harm
• self-mutilation
• self harm

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Many ways

• - cut most frequent
• burn
• keep wounds open
• trichotillomania
• beat oneself
• breake legs
• physical activity (among athletes)
• misuse of insulin among diabetics

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Karl Menninger, 1938

• Psychoanalytical interpretation of self harm
• focal suicide, an act to survive through
  focusing death wishes to parts of the body.
• Can be motivated by
• religion
• psychosis
• organic disorders
• neurosis

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Winchel Stanley, 1991

• Self harm can be defined by context
• mental retardation
• psychosis
• in institutions
• personality disorders

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Armando R. Favazza, 1987

• Cultural practices
• Psychopathology
• coarse psychotic behaviour
• stereotyped autism, mental retardation
• moderate
• obsessive e.g. trichotillomania
• episodic
• repetitive self-mutilation loosing control
  over ones behaviour

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Important comorbid factors

• Sexual and physical abuse
• Traumas
• Alcohol and drugs
• Personality disorders

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Assessment questionnaires

• Self-Harm Inventory (Sansone et al. 1998)
• 22-items
• Self-harm behaviour items
• Eating disorders items
• High-letal items
• Self-Injury Survey (Simpson et al. 1994)
• More extensive
• Self-harm behaviour items
• Eating disorders items
• High-letal items

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phenomenologyfainomai, greek, I show myself
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Minding the woundTheir own descriptions

• Regulate affects, inner tensions and psychic pain
• To dissociate trauma
• Against emotional numbness and emptiness to
  feel something
• A sense of control
• Caring for oneself

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Pierre Janet (1859 1947)

• two of more mental processes are not integrated
  associated in consciousness, memory or
  identity.
• A defence mechanism against trauma, the memory is
  too much to endure

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Minding the woundTheir own descriptions

• Regulate affects, inner tensions and psychic pain
• To dissociate trauma
• Against emotional numbness to feel something
• A sense of control
• Caring for oneself

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Minding the woundTheir own descriptions

• - Creating equivalence between inner and outer
• Recalling positive memories care when hurt or
  sick
• To punish oneself - shamebased
• Take away the trauma/sexual abuse
• Communication to others
• - aggression
• - attention
• - position in hierarchy

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shame
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Shamebased syndromes (Kaufman, 1989)

• Addiction, eating disorders, related to abuse
• - and self harm

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shame

• Shame is a central affect in self harm, as in
  eating disorders both as cause and effect.
• (Skårderud, European Eating Disorders Review
  2007)