Emergency department visits for attempted suicide and self harm in the USA: 2006-2013

AIMS

To characterise and identify nationwide trends in suicide-related emergency department (ED) visits in the USA from 2006 to 2013.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2013. E-codes were used to identify ED visits related to suicide attempts and self-inflicted injury. Visits were characterised by factors such as age, sex, US census region, calendar month, as well as injury severity and mechanism. Injury severity and mechanism were compared between age groups and sex by chi-square tests and Wilcoxon rank-sum tests. Population-based rates were computed using US Census data.

RESULTS

Between 2006 and 2013, a total of 3 567 084 suicide attempt-related ED visits were reported. The total number of visits was stable between 2006 and 2013, with a population-based rate ranging from 163.1 to 173.8 per 100 000 annually. The frequency of these visits peaks during ages 15-19 and plateaus during ages 35-45, with a mean age at presentation of 33.2 years. More visits were by females (57.4%) than by males (42.6%); however, the age patterns for males and females were similar. Visits peaked in late spring (8.9% of all visits occurred in May), with a smaller peak in the fall. The most common mechanism of injury was poisoning (66.5%), followed by cutting and piercing (22.1%). Males were 1.6 times more likely than females to use violent methods to attempt suicide (OR = 1.64; 95% CI = 1.60-1.68; p < 0.001). The vast majority of patients (82.7%) had a concurrent mental disorder. Mood disorders were the most common (42.1%), followed by substance-related disorders (12.1%), alcohol-related disorders (8.9%) and anxiety disorders (6.4%).

CONCLUSIONS

The annual incidence of ED visits for attempted suicide and self-inflicted injury in the NEDS is comparable with figures previously reported from other national databases. We highlighted the value of the NEDS in allowing us to look in depth at age, sex, seasonal and mechanism patterns. Furthermore, using this large national database, we confirmed results from previous smaller studies, including a higher incidence of suicide attempts among women and individuals aged 15-19 years, a large seasonal peak in suicide attempts in the spring, a predominance of poisoning as the mechanism of injury for suicide attempts and a greater use of violent mechanisms in men, suggesting possible avenues for further research into strategies for prevention.

Clusters of suicides and suicide attempts: detection, proximity and correlates

BACKGROUND

A suicide cluster is defined as a higher number of observed cases occurring in space and/or time than would typically be expected. Previous research has largely focused on identifying clusters of suicides, while there has been comparatively limited research on clusters of suicide attempts. We sought to identify clusters of both types of behaviour, and having done that, identify the factors that distinguish suicide attempts inside a cluster from those that were outside a cluster.

METHODS

We used data from Western Australia from 2000 to 2011. We defined suicide attempts as admissions to hospital for deliberate self-harm and suicides as deaths due to deliberate self-harm. Using an analytic strategy that accounted for the repetition of attempted suicide within a cluster, we performed spatial-temporal analysis using Poisson discrete scan statistics to detect clusters of suicide attempts and clusters of suicides. Logistic regression was then used to compare clustered attempts with non-clustered attempts to identify risk factors for an attempt being in a cluster.

RESULTS

We detected 350 (1%) suicide attempts occurring within seven spatial-temporal clusters and 12 (0.6%) suicides occurring within two spatial-temporal clusters. Both of the suicide clusters were located within a larger but later suicide attempt cluster. In multivariate analysis, suicide attempts by individuals who lived in areas of low socioeconomic status had higher odds of being in a cluster than those living in areas of high socioeconomic status [odds ratio (OR) = 29.1, 95% confidence interval (CI) = 6.3-135.5]. A one percentage-point increase in the proportion of people who had changed address in the last year was associated with a 60% increase in the odds of the attempt being within a cluster (OR = 1.60, 95% CI = 1.29-1.98) and a one percentage-point increase in the proportion of Indigenous people in the area was associated with a 7% increase in the suicide being within a cluster (OR = 1.07, 95% CI = 1.00-1.13). Age, sex, marital status, employment status, method of harm, remoteness, percentage of people in rented accommodation and percentage of unmarried people were not associated with the odds of being in a suicide attempt cluster.

CONCLUSIONS

Early identification of and responding to suicide clusters may reduce the likelihood of subsequent clusters forming. The mechanisms, however, that underlie clusters forming is poorly understood.

Main predictors for repetition of suicidal behaviour among women referred to a single public sector tertiary care hospital in Iran

OBJECTIVE

To assess the main predictors for repetition of suicidal behaviour among women.

METHODS

This cross-sectional study was conducted at Loghman Hakim Hospital, Tehran, Iran, in 2014, and comprised women patients. The patients were divided into two groups, i.e. women repeating suicide and women without repeating suicide. Data was collected through a checklist and then analysed with SPSS 20.

RESULTS

Of the 300 women, 121(40.3%) repeated suicide and 179(59.7%) did not. The overall mean age was 26.9±9.1 years (range: 14-80 years). High prevalence of psychological drug usage, alcohol use, history of self-mutilation (self-harm), psychotic disturbances, sexual relationships, as well as smoking and opium addition was revealed as major factors in repeated suicidal behaviour in women when compared with other women. The result of multivariate logistic regression model showed two factors of self-mutilation (odds ratio =2.692, p=0.002) and underlying psychotic disorders (odds ratio = 2.780, p<0.001) as main predictors of suicide in women. In this regard, demographic characteristics could not predict repeating suicidal attempts (p>0.05).

CONCLUSIONS

The presence of underlying psychotic disorders and self-mutilation were main predictors for repetition of suicidal behaviour.

[The phenomenon of covert self-mutilation in the surgical routine]

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

Psychotic experiences and psychological distress predict contemporaneous and future non-suicidal self-injury and suicide attempts in a sample of Australian school-based adolescents

BACKGROUND

Recent cross-sectional studies have shown psychotic experiences (PEs) are associated with suicidal ideation and behaviours. We aimed to examine associations between psychotic experiences (including persistent PE), and contemporaneous and incident non-suicidal self-injury (NSSI) and suicide attempts.

METHOD

Participants were from an Australian longitudinal cohort of 1896 adolescents (12-17 years). NSSI and suicide attempts were measured using the Self-Harm Behaviour Questionnaire. Items from the Diagnostic Interview Schedule for Children were used to assess psychotic experiences, and the General Health Questionnaire-12 measured psychological distress.

RESULTS

Adolescents both psychologically distressed and endorsing psychotic experiences had increased odds of contemporaneous and incident NSSI and attempted suicide. Psychotic experiences alone did not predict future risk. Persistent psychotic experiences were associated with increased risk of NSSI and suicide attempts.

CONCLUSIONS

Psychological distress with accompanying psychotic experiences and persistent psychotic experiences are important predictors of NSSI and suicide attempts. Screening these phenotypes in adolescents will assist in discerning those adolescents most at risk, providing opportunities for targeted suicide prevention strategies.

Switching suicide methods in order to achieve lethality: a study of Greek suicide victims

This article focused on the relation between the method of last attempted suicide and the method used during the subsequent completed suicide. Using the method of psychological autopsy, the authors studied all suicide cases from the Athens Greater Area during a 2-year period. Twenty-four percent of the victims had history of previous suicide attempts. The majority of the suicide attempters switched to a different method (p < 0.001) for their final act. This difference is primarily due to the individuals who had chosen self-poisoning or wrist cutting in their last attempted suicide. Both of these groups switched to hanging or jumping from a height for their final attempt. Individuals who attempted suicide by hanging or jumping became completers using mainly the same methods.

The role of dissociation in self-injurious behavior among female adolescents who were sexually abused

The study aimed to examine the role of dissociation (persistent versus peritraumatic) in self-injurious behavior among at-risk Israeli female adolescents. In addition, the relationship between childhood sexual abuse, depression, dissociation, and potency was investigated. A convenience sample of 93 female adolescents aged 12 years to 18 years were recruited from institutions for at-risk adolescent girls in Israel. Participants were administered an anonymous self-report questionnaire that included six measures: Demographics, Dissociative Experiences Scale, Center for Epidemiologic Studies Depression Scale, the Peritraumatic Dissociative Experiences Questionnaire, the Traumatic Events Questionnaire, and the Potency Scale. Results indicated that childhood sexual abuse increases the risk for self-injurious behavior more than threefold. Higher levels of persistent dissociation were found among girls who reported child sexual abuse compared to those who did not. Self-injurious behavior was predicted by persistent dissociation. Girls who engaged in self-injurious behavior had lower potency and higher depression levels, regardless of childhood sexual abuse history.

[Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic]

Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group. This study aimed to provide a first overview by assessing demographic characteristics and developmental trajectories of a group of gender variant boys and girls referred to the specialised Gender Identity Clinic in Hamburg. Data were extracted from medical charts, transcribed and analysed using qualitative content analysis methods. Categories were set up by inductive-deductive reasoning based on the patients' parents' and clinicians' information in the files. Between 2006 and 2010, 45 gender variant children and adolescents were seen by clinicians; 88.9% (n = 40) of these were diagnosed with gender identity disorder (ICD-10). Within this group, the referral rates for girls were higher than for boys (1:1.5). Gender dysphoric girls were on average older than the boys and a higher percentage of girls was referred to the clinic at the beginning of adolescence (> 12 years of age). At the same time, more girls reported an early onset age. More girls made statements about their (same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions. More girls than boys revealed self-mutilation in the past or present as well as suicidal thoughts and/or attempts. Results indicate that the presentation of clinically referred gender dysphoric girls differs from the characteristics boys present in Germany; especially with respect to the most salient age differences. Therefore, these two groups require different awareness and individual treatment approaches.

Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up

The main objective of this study was to assess the reasons for episodes of self-mutilation engaged in by patients with borderline personality disorder (BPD) over 16 years of prospective follow-up. Two hundred and ninety patients meeting both DIB-R and DSM-III-R criteria for BPD were interviewed every 2 years. The authors divided the borderline patients into two groups: those with a more extensive and those with a less extensive lifetime history of self-mutilation at study entry. These groups were not significantly different than one another on either of the interpersonally directed reasons for self-mutilation studied. However, those in the more extensive group were significantly more likely to report each of the five internally directed reasons studied. The results of this study suggest that borderline patients with a more extensive history of self-mutilation are best distinguished from those with a less extensive history by episodes of self-harm that are motivated, at least in part, by dysphoric inner states.

Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada

OBJECTIVES

We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada.

METHODS

We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries.

RESULTS

An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy).

CONCLUSIONS

Past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to nonprescribed hormone use and self-performed surgeries. Promoting training initiatives for health care providers and jurisdictional support for more accessible services may help to address trans people's specific needs.

[The prevalence of suicide attempts among children and adolescents]

Suicide is the act of a fatal outcome. People who think about suicide perceive death as a way to avoid problems. Suicide attempts by children and young people likely to arise from the fact that the identified single or co-occurring mental disorders.

THE AIM OF STUDY

was to illustrate the suicide problem, which is increasingly frequent attempts to take their own life for children and youth. Its main objective is to determine the prevalence and determinants of suicide attempts made by young people.

MATERIAL AND METHODS

The study group consisted of patients Babinski Hospital in Lodz. The study included 18 patients, 9 boys and 9 girls. Research methodology is based on the stories of young patients diseases. In order to verify the prevalence of trial and / or thoughts, suicidal tendencies among children and adolescents, was used as a research,tool - a survey of its own design. The survey consists of 21 questions about basic information on the state of social, physical and mental patients.

RESULTS

Subjective verification made disseminate ideas, trends and / or suicide attempts among children and adolescents in most reflects the actual collection of information gathered by various authors.

CONCLUSIONS

Children coming from families reconstructed and largely incomplete exhibit suicidal behavior. The main risk factors indicating the attempt on his own life are mental disorders: depression and behavioral disorders. Family situation of young people: conflicts between the father and the mother, violence, physical / mental, has a significant effect on the risk of an attempt on his own life. Superficial self-mutilation, is the main way to make a suicide bombing.

[Psychopathy and suicidal behaviour in a sample of mentally disordered offenders]

Empirical literature has yielded a positive association between psychopathy levels and suicide attempts. This association is centred around impulsivity and disinhibitory facets of psychopathy, whereas suicide and emotional poverty remain independent. Evidence about the relation between suicide and psychopathy in mentally disordered offenders is not conclusive. The present work explores the relation between several measures of antisocial personality, suicide attempt and deliberate self mutilation in a sample of inmates from a forensic psychiatric hospital. Results support the association between disinhibitory aspects of personality and suicide in this population.

Relationship between cumulative BMI and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder

We examined the relationship between cumulative body mass index (BMI) and symptomatic, psychosocial, and medical outcomes in patients with borderline personality disorder (BPD). Two hundred female borderline patients were weighed and measured during their index admission. They were subsequently interviewed at six-, eight-, and 10-year intervals. Over 10 years of prospective follow-up, increases in cumulative BMI were significantly associated with self-mutilation and dissociation (but not suicide attempts). Increases in cumulative BMI were also significantly associated with having no life partner, a poor work or school history, being on disability, being rated with a GAF score in the fair or poor range, and having a low income. In addition, increases in BMI were related to having two or more other medical conditions and using costly forms of health care. Increases in cumulative BMI may be a marker for adverse symptomatic, functional, and medical outcomes in patients with BPD.

Self inflicted burn; a high tide

OBJECTIVE

To highlight the demographic profile, various methods of self inflicted burn, and to probe into the problem by knowing various precipitating factors that may lead to self inflicted burn in our part of the country.

PATIENTS AND METHODS

This is a study of 154 cases of self-inflicted burns treated at the Burn Emergency Unit of Liaquat University of Medical and Health Sciences Jamshoro Pakistan, during a period of 08 years. These self inflicted burns, were divided into two groups, those with suicidal intent called suicide attempter and those who mutilate themselves as self immolator. Except that these patients throughout the period of their hospital stay were under surveillance of a psychiatrist, they were managed according to the routine protocol of our unit. The patients were analyzed with respect to age, sex, method used for self inflicted burns, place of burn, psychiatric history, interpersonal problems, total body surface area (TBSA) burnt, depth of burn and outcome. The continuous variables were compared using t-test while for categorical data chi-square test was used. SPSS 15 was used as statistical software.

RESULTS

The prevalence of self inflicted burns was 9.80% with a consistent rise in number of self inflicted burns from 2001 through 2008. The self immolators were significantly younger then suicide attempters. Males dominated in self immolators, while in suicide attempters female outnumbered males. The mean TBSA affected was significantly higher in suicide attempters when compared to self immolators. The mean hospital stay did not differ significantly in both groups. The mortality for self immolators was 6.38%, in contrast to suicide attempter where it was 33.65%.

CONCLUSION

The radical change in the socioeconomic condition of common people, traditional joint family system, political system and justice, has reflected as increased prevalence of self infliction both as self mutilators and suicide attempters.

Penile self-mutilation - two cases in one family

Male genital self-mutilation is an infrequently reported event in the general medical literature. The majority of cases deal with a single episode of self-mutilation. These cases are usually focused on surgical repair. We present an extremely rare situation of two cases of male genital self-mutilation occurring in the same family. Both patients were treated for schizophrenia. Both patients had religious psychotic experiences and guilt feelings associated with sexual conflicts. Both patients had an experience of setting fire. Although they were close relatives, the younger did not imitate the older one when he mutilated his genitals. The possible causes of such behavior have been analyzed in the light of the recent literature.

Practical review of self-mutilation in horses

Self-mutilation in horses includes biting, stomping and kicking, rubbing, and lunging into objects. Based on the author's clinical experience, three distinct types of self-mutilation are proposed and described. Type I represents normal behavioral response to continuous or intermittent physical discomfort. Type II, seen in stallions and geldings, can be recognized as self-directed intermale aggression. The behavior includes the elements and order of the natural interactive sequence typical of encounters between two stallions, except that the stallion himself is the target of his intermale behavior. Type III involves a more quiet, often rhythmically repetitive or methodical behavioral sequence of a stereotypy, for example nipping at various areas of the body in a relatively invariant pattern, stomping, or kicking rhythmically against an object. The prevalence of the various types of self-mutilation in horses is not known. In one survey, results suggested that self-mutilation of one form or another has been observed in as many as 2% of domestic stallions. Among and between stallions, self-mutilation varies in frequency and intensity, and can reach levels that are fertility and/or life threatening. Careful evaluation of the horse's behavior is often necessary to distinguish the specific type. Type I self-mutilation, where physical discomfort is the root cause, can be eliminated by relieving the discomfort. For Types II and III, understanding of intermale interactive behavior of horses and the environmental factors that may trigger or exacerbate the self-mutilative form, can be useful in guiding humane management or behavior modification. Pharmacologic interventions may be a useful adjunct to management and nutritional changes.

The 10-year course of physically self-destructive acts reported by borderline patients and axis II comparison subjects

OBJECTIVE

The purpose of this paper was to determine the frequency and methods of two forms of physically self-destructive acts (i.e. self-mutilation and suicide attempts) reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up.

METHOD

Two hundred and ninety borderline patients and 72 axis II comparison subjects were interviewed about their physically self-destructive acts during their index admission and at five contiguous 2-year follow-up periods.

RESULTS

It was found that a high percentage of borderline patients reported multiple acts and methods of each of these two forms of physically self-destructive behavior prior to their index admission. It was also found that the percentage of borderline patients reporting multiple acts and methods declined significantly over time. However, these acts remained significantly more common among borderline patients than axis II comparison subjects.

CONCLUSION

The course of self-mutilation and suicide attempts among borderline patients is initially more serious and ultimately more benign than previously recognized.

A critical review of explanatory models for self-mutilating behaviors in adolescents

The present paper presents critical reviews of studies that have explored models of adolescent self-mutilation. Current definitional problems were addressed, as well as a proposal for a classification system of self-mutilation. Seven historically significant explanatory models were included, the sexual/sadomachistic model, the depersonalization model, the interpersonal/systemic model, the suicide model, the physiological/biological model, the affect regulation model, and the behavioral/environmental model. Each model was briefly described, and studies were critiqued according to methodology, research design, and basis upon which authors provided support or rejection of a model. Suggestions for improvement in the literature were made throughout the paper. Studies often overlapped within the models, and the strongest empirical support was shown for the behavioral/environmental model, which included components of the affect regulation model, interpersonal/systemic model, and depersonalization model. Explaining adolescent self-mutilation is a complex task, and evidence provided in this paper suggests that aspects of several models, or an integration of models, likely contribute to the understanding of this phenomenon.

[Self aggressive-behaviours in prison]

Suicide among prisoners is a relatively well documented public health issue. On the other hand, data about self-aggressive behaviours in prisons are scarce, despite the fact that this problem seems to be highly prevalent. We conducted a retrospective study over a fifteen months period in a remand prison situated in the French speaking area of Switzerland. During this time period, 161 self-aggressive behaviours were recorded, corresponding to 80 inmates. The most frequent acts were self-cuttings and self-mutilations, followed by strangulations. All these patients were male and their mean age was 25. Some of these behaviours (ingesting cutting objects and sewing of the lips) were specific to some ethno-cultural groups. Copycat behaviours play a significant role in closed communities such as prisons. These results underline the necessity of taking into account self-aggressive behaviours in penitentiary institutions.

Tooth and lip mutilation practices and associated tooth loss and oral mucosal lesions in the Makonde People of southeast Tanzania

OBJECTIVE

To determine the prevalence of tooth and lip mutilation (TLM) and the prevalence of tooth loss and the associated oral mucosal lesions among adults in south east Tanzania.

DESIGN

A cross sectional, clinical study and questionnaire administration.

SETTING

Rural population in southeast Tanzania.

SUBJECTS

Randomly selected 217 adults aged 40 years and older.

RESULTS

About 16% of all participants performed tooth mutilation. There were more females (20.6%) than males (11.3%) who performed tooth mutilation but the difference was not statistically significant. There was only about 17% of participants in the age group 40-54 years who performed tooth mutilation while there was 50% and 32% in the age groups 55-64 years and 65-95 years and the difference was statistically significant (P < 0.001). Tooth loss due to mutilation was significantly (P < 0.001) less than tooth loss due to other reasons in the anterior teeth and there was no tooth loss due to mutilation in the posterior teeth. Lip mutilation in form of piercing the upper lip and inserting a wooden stick called "ndonya" was found only in women. No oral mucosal lesions were found in this study group.

CONCLUSION

Tooth mutilation does not lead to significant tooth loss and lip mutilation and the use of "ndonya" does not cause oral mucosal lesions in this society. Extraction of anterior teeth due to other reasons was significantly higher than extraction following mutilation while in the posterior teeth there was no tooth loss due to tooth mutilation.

Subclinical self-harm: range of behaviors, extent, and associated characteristics

This study examined characteristics associated with mildly injurious (fingernail biting, skin picking, etc.) and more injurious (cutting, burning, etc.) self-harm (SH) in an undergraduate sample (N = 280); 31% reported mildly injurious SH within the past 3 years with no more injurious SH, whereas 20% reported more injurious SH within the past 3 years. SH was not associated with significant general negative affect or history of physical or sexual abuse, although more injurious SH was associated with a history of emotional abuse. A portion of both groups reported negative affect regarding their histories of SH. Both types of SH were associated with other impulsive and disordered eating behaviors, some obsessive-compulsive characteristics, and more somatic symptoms. Similarities and differences with clinical SH are discussed, as well as implications for further research and treatment. Arguments for and against a continuum view of self-harm, as ranging from mild to severe in injuriousness or clinical significance, are also discussed.

Characteristics and predictors of self-mutilation: a study of incarcerated women

BACKGROUND

Research on self-mutilating behaviour and incarcerated adults has found that nearly 50% of people in prison participated in it (Holley and Alborleda-Florez, 1988). This is an enormous liability for the criminal justice system as well as a human concern.

AIMS/HYPOTHESES

The research question for this study was to explore whether a history of childhood abuse in a sample of incarcerated women would increase their likelihood of self-mutilation.

METHODS

Participants were 256 female inmates from five prisons in a large southern state who volunteered to attend a 12-week trauma and abuse psychosocial intervention group. The participants were evaluated for childhood abuse, criminal history, risk-taking behaviour and self-mutilation. Data are presented regarding individual, criminal, abuse, family and risk-taking behaviours comparing self-mutilators (n = 109) with non-self-mutilators (n = 147).

RESULTS

The self-mutilation group was more likely to report higher rates of emotional, sexual and physical abuse and on clinical significance scales of anxiety, depression, dissociation, impaired self-reference, anger, tension reduction and intrusive experiences. The self-mutilation group was also younger and was more often Caucasian. The results of the regression model suggest that a history of suicide attempts, emotional abuse, sexual abuse, bingeing and vomiting and impaired self-reference are predictors of self-mutilation.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Recommendations and implications for practice are discussed.

Reported childhood onset of self-mutilation among borderline patients

The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.

National study of US emergency department visits for attempted suicide and self-inflicted injury, 1997-2001

STUDY OBJECTIVE

We describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey, a national probability sample of ED visits. All visits for attempted suicide or self-inflicted injury (E950 to E959) during 1997 to 2001 were included in these analyses.

RESULTS

During the 5-year period, there were approximately 412,000 annual ED visits for attempted suicide and self-inflicted injury, or 0.4% of all ED visits. The annual visit rate was 1.5 (1.3 to 1.7) visits per 1,000 US citizens. The mean patient age was 31 years, and visits were most common among patients aged 15 to 19 years, at a rate of 3.3 (95% confidence interval 2.1 to 4.4). ED visit rates were higher among female patients (1.7) than male patients (1.3) and among blacks (1.9) than whites (1.5). Visit rates did not differ by metropolitan status or US region. The most common method of injury was poisoning (68%), followed by cutting or piercing (20%). One third of visiting patients were admitted to the hospital, with 31% of admissions going to the ICU. A psychiatric disorder was coded for 55% of visits, with depressive disorder accounting for 34% and alcohol abuse for 16%.

CONCLUSION

ED visits for attempted suicide and self-inflicted injury are relatively common, serious, and most frequent among adolescents and young adults. Self-poisoning is the most common method. The high prevalence of psychiatric and substance abuse disorders in this population suggests these issues should be considered during management and disposition.

Clinical correlates of self-mutilation in Turkish male substance-dependent inpatients

OBJECTIVE

The aim of this study was to evaluate the prevalence of self-mutilation (SM) in male substance-dependent inpatients, and to investigate the relationship of SM with childhood abuse and neglect, axis I disorders and personality disorders.

METHODS

Participants were 112 consecutively admitted male substance dependents (56 alcohol and 56 drug). Substance dependence was diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I, Turkish version). Patients were evaluated by the Childhood Abuse and Neglect Questionnaire, SCID-I, SCID-II, Beck Depression Inventory and Beck Anxiety Inventory.

RESULTS

Among substance-dependent patients, SM was found to be present in 33% (SM group). Mean age and educational status were lower in the SM group. Moreover rates of being single, history of childhood physical and emotional abuse and neglect, suicide attempt history and personality disorder were higher. Mean depression and anxiety scores were also higher in the SM group. Personality disorder, physical abuse, suicide attempt history and drug dependency were predictors for SM.

CONCLUSIONS

SM is more common in drug dependents than alcohol dependents. Also results of this study suggest that among Turkish substance dependents SM might be related to the presence of personality disorder and childhood physical abuse and suicide attempts.

Emergency treatment of young people following deliberate self-harm

OBJECTIVE

To examine national patterns in the emergency department assessment and treatment during visits by young people, aged 7 to 24 years, who are seen following an episode of deliberate self-harm.

METHOD

An analysis was conducted of a nationally representative sample of hospital emergency department visits from the 1997-2002 National Hospital Ambulatory Medical Care Survey focusing on visits by persons aged 7 to 24 years related to deliberate self-harm. National census data were used to derive population-based rates of emergency department visits for deliberate self-harm overall and stratified by sex, age, race, and ethnicity. Demographic, clinical, and treatment characteristics of the visits are presented including comparisons of visits that resulted in an inpatient admission with those that resulted in discharge to the community.

RESULTS

Among young people aged 7 to 24 years, the annual rate of emergency visits with self-harm was 225.3 per 100,000. A mental disorder was diagnosed in 56.0% of these visits including depressive disorders in 15.1% and substance use disorders in 7.3%. Approximately one half of the visits (56.1%) resulted in an inpatient admission. As compared with visits resulting in discharge to the community, emergency department visits that resulted in inpatient admission were significantly more likely to result in the patients receiving a mental disorder diagnosis (63.8% vs 45.7%; P = .03), especially a depressive disorder (22.5% vs 5.8%; P = .005), and receiving psychotropic medications (18.0% vs 4.7%; P = .007), intravenous fluids (39.2% vs 22.3%; P = .02), gastric lavage (24.1% vs 9.8%; P = .02), and a specific antidote for poisoning (12.2% vs 1.3%; P = .02).

CONCLUSIONS

Mental disorders are diagnosed in roughly one half of emergency department visits by young people following an episode of deliberate self-harm. Systematic mental health assessments in the emergency department of young people following an episode of deliberate self-harm may improve detection of mental disorders.

Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population

This study attempted to determine the prevalence of childhood trauma among women in the general population as assessed in a representative sample from a city in central Turkey. The Dissociative Experiences Scale (DES) was administered to 628 women in 500 homes. They were also asked for childhood abuse and/or neglect. DES was administered to 251 probands. Mean age of the probands was 34.8+/- 11.5 years (range 18-65). Sixteen women (2.5%) reported sexual abuse, 56 women (8.9%) physical abuse, and 56 women (8.9%) emotional abuse in childhood. The most frequently reported childhood trauma was neglect (n= 213, 33.9%). The prevalence of suicide attempts was 4.5% (n= 28). Fourteen probands (2.2%) reported self-mutilative behavior.

Self-mutilation in substance-dependent patients and relationship with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality

OBJECTIVE

Aim of this study was to evaluate the prevalence of self-mutilation (SM) in Turkish male substance-dependent patients, and to investigate the relationship of SM with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality.

METHODS

Participants were 136 consecutively admitted males with substance dependence (96 alcohol and 40 drug). Substance dependence was diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I), Turkish version. Patients were investigated with the childhood abuse and neglect questionnaire, Toronto alexithymia scale (TAS-20) and temperament and character inventory (TCI).

RESULTS

Among substance-dependent patients 34.6% was considered as a group with SM. Rates of being single and unemployed, histories of physical and sexual abuse and suicide attempts were higher in the SM group. Current age, age at first substance use and age at regular substance use were lower in the group with SM. Mean of TAS-20 and 'difficulty in identifying feelings' (DIF) and 'difficulty in describing feelings' (DDF) subscales of TAS-20 were higher in SM group. There were no significant differences between groups in terms of TCI subscales. Age, childhood physical abuse and suicide attempt history predicted SM in logistic regression.

CONCLUSIONS

Young substance users with childhood physical abuse histories could be the target population to prevent self-mutilating behavior. This study also suggests that whenever self-mutilating behavior is present, the possibility of childhood abuse, alexithymia and suicide attempts must be evaluated.

Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder

The goal of this study was to examine the relationship between self-mutilation and symptoms of depression and anxiety in a nonclinical population. Self-mutilators reported significantly more symptoms of depression and anxiety than did the control group. When the group of self-mutilators was divided into individuals who cut themselves and individuals who harm themselves in other ways, we found that the between-group differences were primarily due to individuals with a history of cutting. Yet when symptoms of borderline personality disorder (BPD) were statistically controlled, all significant between-group differences in depressive and anxious symptoms were reduced to nonsignificant. These findings highlight the importance of assessing symptoms of BPD in self-mutilators, regardless of diagnosis.

Case study: delicate skin cutting: management beyond the skin and implications of superficial habitual self-mutilation

A 16-year-old girl accompanied by her mother was noted to have several thin, well healed brown lines on the distal third of her left flexural forearm (Figure). She admits to having recently made these marks by skin cutting. She feels depressed and at times feels life "is not worth living." She denies alcohol or substance abuse or true suicidal ideation, plan, or intent. Her mother describes her as previously well adjusted and a good student who has become erratic and moody in the past 6 months, with worsening school performance. Her father had a history of depression and alcoholism and died 3 years ago. She is undergoing psychotherapy and pharmacotherapy with sertraline with good results. She has not cut her skin in 3 months. Her mood and behavior have improved.

The frequency of culturally derived dental modification practices on the Cape Flats in the Western Cape

The people living on the Cape Flats (Western Cape) have been practicing dental modification by having their incisors removed for at least 60 years. A survey, by means of a questionnaire, of eight adjoining areas in the Northern Suburbs was done to investigate the current prevalence of this practice. Three groups of study subjects (scholars, working people and retired people) were included to gain a perspective of the community in general. The individual ages ranged between 15 and 83 years old. A total of 2 167 individuals participated in this study of which 41% had modified their teeth. More males (44.8%) than females (37.9%) were involved in this practice. The percentage incidence was overwhelmingly higher in lower income areas. 'Race' and social class are both important factors. Of people who called themselves 'coloured', 74.5% modified their teeth, but 39.8% of 'blacks' and 31.6% of 'whites' within the sample had also practiced tooth removal. The frequency of tooth removal for those who identified themselves as South African was much lower (22.9%). This suggests that dental modification is a phenomenon of ethnicity and community and those who perceive themselves to be part of a broader national fabric are less likely to practice it.

Self-burning versus self-cutting: patterns and implications of self-mutilation; a preliminary study of differences between self-cutting and self-burning in a Japanese juvenile detention center

The purpose of the present paper was to examine the differences in clinical features between self-cutters and self-burners, to clarify clinical implications of self-mutilating behaviors other than self-cutting. Subjects were 201 delinquent adolescents consecutively entering a Japanese juvenile detention center from February 2003 to March 2003. The subjects were assessed using a self-reporting questionnaire to evaluate self-mutilation, traumatic events, and problematic behaviors. Beck Depression Inventory-2 (BDI-2) and Adolescent Dissociative Experience Scale (A-DES) were also tested. Subjects were classified into four groups according to self-mutilating behaviors: non-self-cutting or -burning (NSCB), self-cutting (SC), self-burning (SB), and self-cutting and self-burning (SCB). The questionnaire answers and scores of the BDI-2 and A-DES were compared between the four groups. Of 201 subjects, 33 (16.4%) had cut their wrists or forearms at least once, and 72 of 201 (35.8%) had burned themselves at least once. The SC and SCB group had traumatic events, problematic behavior, and various types of self-mutilating behavior more frequently than the other two groups. The SCB group reported additional types of self-mutilating behavior more than the SC group. The SCB group also experienced multiple body customizations compared to the SC group, and exhibited higher scores on the BDI-2 and A-DES than the other three groups. The self-burning without self-cutting may have limited clinical implications. However, the self-burning with self-cutting may suggest depression and dissociation, as well as possible indication of self-mutilating behavior.

Association between seclusion and restraint and patient-related violence

This study assessed the effect of an intervention designed to reduce the use of seclusion and restraint on reported episodes of patient-related violence on an acute inpatient psychiatric service. Results showed a significant decrease in the total number of episodes of seclusion and restraint between the 12 months before and after the intervention. However, the number of episodes of assault on patients and staff increased significantly. Efforts to decrease seclusion and restraint may be accompanied by an increased risk of harm to psychiatric patients and staff, and intensive safety monitoring and staff training should accompany all such efforts.

Self-mutilation in young children following brachial plexus birth injury

Brachial plexus injury in adults commonly produces persistent pain. Pediatric textbooks and case series suggest that perinatal brachial plexus injury is very rarely associated with pain, though this is difficult to determine in preverbal infants. Some of these young children self-mutilate the affected extremity, which may or may not reflect pain. This study was designed to characterize the clinical presentation and course of self-mutilation following perinatal brachial plexus injury. In this retrospective chart review, 280 patients were identified as having a perinatal brachial plexus injury from 1990-2002. Self-mutilation behavior was defined as excessive mouthing of or biting of any part of the affected limb, and/or loss of any parts of the affected limb secondary to biting and infection. Case reports were generated which described the severity of the primary injury, the types of surgical interventions, the duration and temporal relationship of behavior with surgical interventions and the nature of the self-mutilation behavior. Eleven patients demonstrated self-mutilating behavior, yielding a cumulative incidence of 3.9%. The median age of onset of this behavior was 17 (IQR=11-21) months, the median onset of the behavior was 8 (IQR) months after surgery and the median duration of this behavior was 6 (IQR=4-7) months. The incidence of self-mutilation among children who had undergone surgery was 6.8% (9 of 133 children) compared to the 1.4% (2 of 147 children) for non-surgical patients (P<0.05). Seven of 24 children (29.1%) who underwent brachial plexus dissection demonstrated self-mutilation, which was significantly different from the incidence of self-mutilation in children who did not have surgery (P < 0.001). Self-mutilation behavior in our population occurred more frequently in children following brachial plexus microsurgery. The reasons for this association are unclear, but may be related to either the surgery or the severity of the initial injury or both.

Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behavior?

OBJECTIVE

Studies show that childhood sexual and physical abuse predict repeated suicide attempts and self-mutilation. Little is known about the importance of sexual and physical abuse when compared to other severe childhood adversities with respect to chronic suicidal behavior.

METHOD

Seventy-four subjects, 65% of whom were women, consecutively admitted to a general hospital after having made a suicide attempt, were interviewed as part of the intake interview about prior suicide attempts and self-mutilation and received DSM-IV diagnoses. Sexual abuse, physical abuse, neglect, antipathy from parents, loss of parents, and severe discord in the family before the age of 18, were covered by the Childhood Experience of Care and Abuse (CECA) interview schedule.

RESULTS

The prevalence of severe sexual abuse was 35%, severe physical abuse 18%, neglect 27%, antipathy 34%, loss of caregiver 37% and exposure to family violence 31%. Physical and sexual abuse were independently associated with repeated suicide attempts when controlling for the effects of the other childhood adverse factors. No other childhood adversity was related to chronic suicidal behavior. The odds ratio of exposure to sexual or physical abuse was highest among those who both repeated suicide attempts and self-mutilated.

CONCLUSION

Physical and sexual abuse are significantly and independently associated with repeated suicidal behavior.

Affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts

The purpose of this study was to examine affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts. Forty-seven adolescents with a history of multiple suicide attempts (MA) were compared to 74 single suicide attempters (SA) on psychiatric diagnosis, depressive symptoms, affect regulation, self-mutilation, alcohol use, and hopelessness. Results revealed that the MA group was more likely to be diagnosed with a mood disorder, and reported more severe depressive symptoms and anger, in comparison to the SA group. Behaviorally, the MA group had higher rates of disruptive behavior disorders and higher levels of affect dysregulation and serious self-mutilation than the SA group. Further, greater levels of hopelessness were reported by the MA than the SA group. After controlling for a mood disorder diagnosis, only differences in anger, affect dysregulation, and serious self-mutilation remained significant. Overall, results suggest that treatment with adolescent suicide attempters might specifically target anger and affect dysregulation to reduce risk for future suicidal behavior.

Habitual self-mutilation in Japan

The purpose of the present study was to clarify the relationship between bulimic behavior, dissociative phenomenon and sexual/physical abuse histories in Japanese subjects with habitual self-mutilation. Subjects consisted of 34 female outpatients who had cut their wrists or arms on more than 10 occasions. Two age-matched groups, which consisted of 31 general psychiatric outpatients and 26 non-clinical volunteers, served as controls. They were assessed with the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, Adolescent Dissociative Experience Scale, and an original self-reporting questionnaire concerning various problematic behaviors and sexual/physical abuse histories. The habitual self-mutilation and the two control groups were compared. The habitual self-mutilation group had significantly higher scores on the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, and Adolescent Dissociative Experience Scale than either of the two control groups (P < 0.001). Furthermore, the habitual self-mutilation group more frequently had a history of illicit psychoactive drug use (P = 0.001), shoplifting (P < 0.001), suicide attempts (P < 0.001), overdosing with medicine (P < 0.001), sexual abuse (P = 0.011), and childhood physical abuse (P = 0.001) than the general psychiatric controls. These results are consistent with those in Western studies. Habitual self-mutilation is likely to coexist with depression, bulimia, and dissociation. Such patients frequently have clinical features similar to those of 'multi-impulsive bulimia'. Evidence supports the association between habitual self-mutilation and sexual/childhood physical abuse in Japan.

Two models of adolescent self-mutilation

Currently little research exists examining the theoretical underpinnings of self-mutilation (SM) in community samples of adolescents. Two models, the hostility and anxiety reduction models, were simultaneously tested in order to determine whether SM in adolescence was characterized by greater feelings of anxiety and hostility. Four hundred and forty students were screened for the presence of SM. Sixty-one students who indicated that they hurt themselves as well as a comparison group of non-SM students completed the Hostility and Direction of Hostility Questionnaire (HDHQ), the Beck Anxiety Inventory (BAI), and an interview. Results indicate support for the hostility model of SM. Students who SM reported significantly more anxiety and more intropunitive and extrapunitive hostility. In addition, prior to self-mutilating feelings of both hostility and anxiety were described. Results are discussed with reference to both theoretical models.

Repetitive self-mutilation among Japanese eating disorder patients with drug use disorder: comparison with patients with methamphetamine use disorder

Repetitive self-mutilation and drug use disorder are less prevalent in Japan, although the prevalence of eating disorder is comparable with rates in Western countries. However, repetitive self-mutilation has not previously been described in relation to eating disorder and drug use disorder in Japan. Subjects consisted of 19 patients with eating disorders and drug use disorders (ED+DUD) and 12 patients with methamphetamine use disorders (MAP). Subjects were drawn from 180 patients who were referred because of eating disorders and 22 patients who were referred because of methamphetamine-related problems. All subjects underwent a semistructured interview. Repetitive self-mutilation tended to be more prevalent among ED+DUD patients than MAP patients. Conversely, history of oppositional defiant disorder and antisocial personality disorder tended to be more prevalent in MAP patients than in ED+DUD patients. The low prevalence of repetitive self-mutilation appears to be due to low risk factors in Japan, even though the pathogenesis of these behaviors seems to be universal.

Situational determinants of inpatient self-harm

Auto-aggressive individuals have a higher likelihood of engaging in interpersonal violence, and vice versa. It is unclear, however, whether ward circumstances are involved in determining whether aggression-prone patients will engage in auto-aggressive or outwardly directed aggressive behavior. The current study focuses on the situational antecedents of self-harming behavior and outwardly directed aggression of psychiatric inpatients. Inwardly and outwardly aggressive behavior were monitored on a locked 20-bed psychiatric admissions ward for 3.5 years with the Staff Observation Aggression Scale-Revised (SOAS-R). A map of the ward was attached to each SOAS-R form, enabling staff members to specify locations of aggressive incidents. Time of onset, location, and provoking factors of auto-aggressive incidents were compared to those connected to aggression against others or objects. Of a total of 774 aggressive incidents, 154 (20%) concerned auto-aggressive behavior. Auto-aggression was significantly more prevalent during the evening (i.e., 50% compared to 32%), and reached its highest level between 8 and 9 P.M. (17% compared to 7%). The majority of self-harming acts (66%) were performed on patients' bedrooms. Outwardly directed aggression was particularly common in the day-rooms (24%), the staff office (19%), the hallways of the ward (14%), and the dining rooms (10%). Provoking factors of auto-aggressive behavior are less often of an interactional nature compared to outwardly directed aggression. The results suggest that a lack of stimulation and interaction with others increases the risk of self-injurious behavior. Practical and testable measures to prevent self-harm are proposed.

Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients

This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.

Are suicide attempters who self-mutilate a unique population?

OBJECTIVE

Individuals who mutilate themselves are at greater risk for suicidal behavior. Clinically, however, there is a perception that the suicide attempts of self-mutilators are motivated by the desire for attention rather than by a genuine wish to die. The purpose of this study was to determine differences between suicide attempters with and without a history of self-mutilation.

METHOD

The authors examined demographic characteristics, psychopathology, objective and perceived lethality of suicide attempts, and perceptions of their suicidal behavior in 30 suicide attempters with cluster B personality disorders who had a history of self-mutilation and a matched group of 23 suicide attempters with cluster B personality disorders who had no history of self-mutilation.

RESULTS

The two groups did not differ in the objective lethality of their attempts, but their perceptions of the attempts differed. Self-mutilators perceived their suicide attempts as less lethal, with a greater likelihood of rescue and with less certainty of death. In addition, suicide attempters with a history of self-mutilation had significantly higher levels of depression, hopelessness, aggression, anxiety, impulsivity, and suicide ideation. They exhibited more behaviors consistent with borderline personality disorder and were more likely to have a history of childhood abuse. Self-mutilators had more persistent suicide ideation, and their pattern for suicide was similar to their pattern for self-mutilation, which was characterized by chronic urges to injure themselves.

CONCLUSIONS

Suicide attempters with cluster B personality disorders who have a history of self-mutilation tend to be more depressed, anxious, and impulsive, and they also tend to underestimate the lethality of their suicide attempts. Therefore, clinicians may be unintentionally misled in assessing the suicide risk of self-mutilators as less serious than it is.

Childhood sexual abuse, dissociation, and adult self-destructive behavior

Female college students reporting a history of childhood sexual abuse (N=175) and not reporting a history of childhood sexual abuse (N=260) were compared on indices of six self-destructive behaviors, including drug use, alcohol abuse, binge eating, self-mutilation, risky sex, and suicidality. The samples were also compared on two measures of dissociation, the Trauma Symptom Checklist dissociation subscale and the Dissociative Experiences Scale. The CSA group had significantly higher mean scores on all the indices of self-destructive behavior except self-mutilation (where the mean difference approached significance), and on both measures of dissociation. One or both dissociation measures were related significantly to each index of self-destructive behavior except binge eating. Multiple regression mediation analyses provided support for the hypothesis that dissociation mediates the relationships between CSA and both drug use and alcohol abuse. Dissociation also explained significant variability when added to the regressions of risky sex and suicidality on CSA.