400 words short essay question

Self-Harm/Self-Injurious Behaviour

�  “The deliberate alteration or destruction of body tissue without conscious suicidal intent.” (Favazza, 1993, p. 134)

�  Most common forms �  Cutting (arms, legs, torso) �  Burning

�  Most common sites of injury �  Arms, legs

Essential Features of Self-Harm in Adolescents

�  Not a suicide attempt �  Sense of relief from intolerable negative feelings

and mounting tension

�  Tend to be depressed, sensitive to interpersonal rejection, and irritable

�  Common precipitants are situations leading to feelings of rejection, helplessness, anger, or guilt

�  Considered to be an expression of emotional pain �  In other words, it can be considered a coping strategy

Essential Features (cont’d) �  Addictive qualities �  Significant feelings of shame, guilt, and

embarrassment accompanied

�  Not a unique symptom of BPD �  Can be highly repetitive �  Often accompanied by suicidal ideation �  Simply put, self-harm is a sign of an adolescent

who is experiencing significant distress

Self-Harm in Adolescence �  Typically begins in early-mid adolescence (12-15

years)

�  Estimates of prevalence range from14-39% �  Prevalence in adolescent psychiatric inpatient

populations has been reported to be as high as 61%

�  No sex differences (girls start earlier though) �  In comparison, estimated to occur in 4% of the

general adult population and 21% of the adult psychiatric inpatient population

�  Prevalence in adolescents on the rise

Functions of Self-Harm �  Cope with feelings of depression, anxiety/fear �  Release unbearable tension �  Express frustration and anger �  Feel pain in one particular area

�  To feel something at all/something physical

�  Distraction from unpleasant memories �  Punish self �  Stop suicidal ideation �  Relieve feelings of numbness/emptiness

Factors Associated with Self-Injury

�  Having friends who had recently self-injured (contagion effect)

�  A history of self-injury in the family �  Drug use �  Low self-esteem �  Attachment disruptions �  Interpersonal loss/conflict/rejection �  Inhibited emotional expression

How do you treat self-injury? �  Talk about it openly and without judgment

�  No cold turkey

�  Enhancing self-worth

�  Addressing underlying distress �  Self-injury is a sign of distress

�  Distress tolerance techniques

�  The ‘slash your stuffy’ talk

Nonsuicidal Self-Injury �  In the last year, the individual has, on 5 or more days,

engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent).

�  Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behavior that the individual know, or has learned, is not likely to result in death.

�  The individual engages in the self-injurious behavior with one or more of the following expectations:

�  To obtain relief from a negative feeling or cognitive state.

�  To resolve and interpersonal difficulty. �  To induce a positive feeling state. �    �  Note: The desired relief or response is experienced

during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly performing it

�  The intentional self-injury is associated with a least one of the following: �  Interpersonal difficulties or negative feelings or

thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.

�  Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.

�  Thinking about self-injury that occurs frequently, even when it is not acted upon.

�  The behaviour cannot be socially sanctioned

Suicide �  Includes suicidal ideation, suicidal attempts, and

completed suicide

�  Estimated that at least 1/5 adolescents experience suicidal ideation �  <10% of youth attempt suicide

�  Youth suicide rate has doubled in past 3 decades

�  Suicide is one of the leading causes of death of 15-24 year olds �  Also, youth have largest proportion of death due to

suicide of any age group

Trends, Risk Factors, etc. �  Most common methods

�  OD, wrist cutting, hanging, firearms

�  Males more likely to complete but females more likely to attempt

�  Attempted suicide rate doubles through adolescence, peaking at 17-18

�  Associated with a variety of diagnoses �  Depression/Bipolar, psychotic disorders, personality disorders

�  Biggest risk factors �  Feelings of hopelessness, depression, previous attempts,

impulsivity, subtance use, antisocial behaviour, exposure to suicide (contagion), recent interpersonal loss/rejection/ humiliation

Assessing Risk �  Problems associated with such a low base-rate �  Empirical risk factors not reliable for assessing risk

�  60-70% of people who committed suicide had no history of attempts

�  Ideation, intention, planning �  The more planning, the more severe the risk

�  Intensity, duration, frequency of ideation �  Lethality of means/access to means �  Hopelessness, impulsivity, recent stressors key �  Consider all risk factors mentioned

What to do? �  Speak directly and openly when assessing

�  Relationship, relationship, relationship �  Check-ins in between sessions; increased frequency of sessions

�  When to breach confidentiality �  Importance of incorporating family members/friends (support)

�  The “what are you trying to kill” question

�  Safety plans and problem solving skills �  Hospitalization?

�  “Contracting for safety” and “Reasons for Living”

�  Continuous assessment �  Issues with this though?

�  Facilitating future orientation

Suicidal Behavior Disorder •  Suicide attempt within last 24 months –  But not a non-suicidal self-injury

•  Not applied to suicidal ideation or preparatory acts

•  Act not initiated in state of delirium or confusion

•  Act not undertaken solely for political or religious reasons

•  Current: Not more than 12 months since attempt

•  In early remission: 12-24 months since attempt

Anxiety Disorders

Anxiety �  One of the most common disorders/pathologies

�  Between 8 and 30% of young people

�  Generally not an acute condition �  Difficulties persist into adolescence and adulthood

�  ½ dx w/ anxiety disorder have illness duration of 8 years

Basic Experience of Anxiety �  2 elements

�  Negative emotion (fear is bad ‘mkay) �  Physiological arousal/tension

�  Sweating, shaking, increased heart rate, hyperventilating/ difficulty breathing, dizziness, stomach aches (body aches), nausea

�  “Fear alarm” �  Fight/flight �  Problem when it goes off too easily

�  Sensitivity

�  How anxiety helps

Cognitive and Behavioural Effects

�  When “fear alarm” goes off à search for danger

�  Can’t find any? �  Look inward: “Something’s wrong with me” �  “Something bad is going to happen” �  Causes general apprehension, nervousness, worrying,

difficulty concentrating

�  Behavioural response: aggression vs. peace out... �  Restlessness, agitation common manifestations �  Avoidance behaviour negatively reinforced through

reduced anxiety

Fear vs Anxiety vs Panic �  Fear: immediate alarm reaction to danger

�  Present oriented

�  Anxiety: apprehension and lack of control over upcoming events perceived as threatening �  Future oriented �  No danger actually present

�  Panic: activation of fight/flight in the absence of threat/danger

Common Fears/Anxieties/ Worries

�  Infants �  Loud noises (0-6 months) �  Strangers (8 – 18 months) �  Separation (6 – 18 months)

�  Toddlers �  Dark, animals fire, water, thunderstorms (2-3 years)

�  Childhood �  Separation again, death (4-5 years) �  Imaginary monsters, germs/illness, natural disasters/

accidents (5-7 years) �  School/performance anxiety (5-11 years)

�  Adolescence �  Interpersonal relationships/rejection, future, personal

appearance/sexuality

Anxiety Disorders �  Slightly different from DSM IV

�  No more disorders first diagnosed in infancy/ childhood �  Separation anxiety and selective mutism moved

�  OCD à Obsessive-Compulsive and Related D/O �  PTSD à Trauma and Stressor-related D/O

�  Several anxiety disorders �  Fundamentally different vs. different manifestations

of similar underlying issues???

Separation Anxiety �  Developmentally inappropriate and excessive fear or anxiety

concerning separation from home or from those to whom the individual is attached, as evidenced by at least three of the following:  �  distress when anticipating or experiencing separation �  worry about losing major attachment figures or about possible harm

to them, such as illness, injury, disasters, or death. �  worry about experiencing an untoward event (e.g., getting lost, being

kidnapped, having an accident, illness) that causes separation �  reluctance or refusal to go out, away from home, to school, to work �  fear or reluctance about being alone or without major attachment

figures �  reluctance to sleep away from home or to go to sleep without being

near attachment figure �  repeated nightmares involving the theme of separation  �  repeated complaints of physical symptoms (e.g., headaches,

stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated 

�  Fear/anxiety persistent for at least 4 weeks in children/adolescents and 12 months in adults

�  Causes clinically significant distress or impairment in social, academic, occupational or other important areas of functioning

�  Not better explained by another mental disorder

Generalized Anxiety Disorder

�  Excessive anxiety and worry about a number of events or activities for at least 6 months

�  Difficult to control worry �  Anxiety and worry associated with 3 of following symptoms

(only 1 required in kids) �  Restlessness/keyed up �  Easily fatigued �  Difficulty concentrating �  Irritability �  Muscle tension �  Sleep disturbance

�  Not better explained by other disorder

Specific Phobia �  Marked fear or anxiety about a specific object or situation

�  E.g., flying, heights, animals, injections, blood

�  Phobic object/situation almost always provokes immediate fear or anxiety �  In kids, may be expressed by crying, tantrums, freezing or

clinging

�  Phobic object/situation is actively avoided or endured with intense fear or anxiety

�  Fear is out of proportion to the actual danger posed by the specific object or situation, and to the sociocultural context

�  Lasts for 6 months or more

Specify �  Animal (e.g., spiders, insects, dogs)

�  Natural Environment (e.g., heights, storms, water)

�  Blood-Injection-Injury (e.g., needles invasive medical procedures)

�  Situational (e.g., airplanes, elevators, enclosed places)

�  Other (e.g., situations that may lead to choking or vomiting; in children, loud sounds or costumed characters).

Social Anxiety Disorder �  Marked fear or anxiety about one or more social

situations in which the person is exposed to possible scrutiny by others. �  Social interactions (having a conversation; meeting

unfamiliar people), being observed (eating or drinking), or performing in front of others (giving a speech)

�  Fear of acting in a way, or showing anxiety symptoms, that will be negatively evaluated �  E.g., will be humiliating, embarrassing, lead to rejection, or

offend others

�  The social situations almost always provoke anxiety �  In kids, may be expressed by crying, tantrums, freezing,

clinging, shrinking, or failing to speak in social situations

�  The social situations are avoided or endured with intense fear or anxiety.

�  The fear or anxiety is out of proportion to the actual threat posed by the social situation, and to the sociocultural context.

�  Lasting for 6 months or more

Selective Mutism �  Consistent failure to speak in specific social situations

in which there is an expectation for speaking (e.g., at school) despite speaking in other situations

�  The disturbance interferes with educational or occupational achievement or with social communication. 

�  Lasts at least one month

�  The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.  �  Or communication disorder/autism

Panic Attack �  4 (or more) symptoms develop abruptly and reach a peak within

10 minutes �  Palpitations/accelerated heart rate �  Sweating �  Trembling or shaking �  Sensations of shortness of breath or smothering �  Feeling of choking �  Chest pain or discomfort �  Nausea or abdominal distress �  Feeling dizzy, unsteady, lightheaded or faint �  Chills or heat sensations �  Paresthesias (numbness or tingling sensations) �  Derealization (feelings of unreality) or depersonalization (being

detached from oneself) �  Fear of losing control or going crazy �  Fear of dying

Panic Disorder �  Recurrent unexpected panic attacks

�  Followed by 1 month or more of one or both of the following: �  Persistent concern or worry about additional panic

attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”)

�  A significant maladaptive change in behaviour related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)

Agoraphobia �  Marked fear or anxiety about two or more of the

following five situations �  Public transportation �  Open spaces �  Enclosed places �  Standing in line or being in a crowd �  Being outside the home alone.

�  Fear or avoid these situations due to thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms

�  The agoraphobic situations almost always provoke fear or anxiety.

�  The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

�  The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations, and to the sociocultural context.

�  Lasts for 6 months or more

Obsessive-Compulsive Disorder

�  Presence of obsessions, compulsions, or both:

�  Obsessions are defined by:  �  Recurrent and persistent thoughts, urges or images

that are experienced, at some time during the disturbance, as intrusive and inappropriate and that in most individuals cause marked anxiety or distress 

�  Attempt to ignore or suppress the thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

The OC Disorder �  Compulsions are defined by: 

�  Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

�  Aimed at preventing or reducing distress or preventing some dreaded event or situation �  Either are not connected in a realistic way with what they

are designed to neutralize or prevent or are clearly excessive.

�  Obsessions or compulsions are time consuming (e.g., take more than 1 hour per day), or cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

�  Specify if: �  With good or fair insight �  With poor insight �  With absent insight/delusional

�  Specify if: �  Tic-related

Associated Features �  Cognitive biases

�  I see threats everywhere �  Hypervigilance �  Tendency to catastrophize and ruminate

�  Somatic complaints �  Stomach aches, headaches, nausea, dizziness, sleep

�  Social difficulties �  Kids sense the fear �  Screen doors...

A Note on Comorbidity/ Misdiagnosis

�  Anxious kids throw tantrums, refuse to do things, assert control over environment

�  What else does this remind you of?

Theories and Causes �  Psychodynamic: you know this one, right? �  Behavioural/Learning

�  Classical conditioning �  Avoidance/negative reinforcement

�  Attachment: everybody now... �  Existential/neurotic anxiety �  Temperament

�  Physical reactivity/behavioural inhibition �  Response to novel situations �  Path to anxiety depends on environmental fit

�  Genetics �  Physiological sensitivity runs in families

�  Neuro factors �  HPA, limbic system (amygdala), hippocampus, frontal

cortex are more sensitive to detecting and relaying info about danger

�  Family (sha la la la) �  Overprotection/overcontrol �  Critical/rejecting (not so much accentuating the positive) �  Modeling �  Expecting negative outcomes �  The usual attachment/coregulation stuff

Therapy �  This is some zen shit �  Acceptance is key

�  Don’t fight it kids. Be an anxiety lover, not a fighter

�  Exposure is essential �  Graded exposure/fear ladders

�  Cognitive techniques �  Focus on reappraisal/offset worries �  What’s the worst that could happen? How likely is that? Is that

even so bad? What are more likely things that would happen?

�  Psychoeducation key for panic in particular

�  Dumbo’s feather