Psychiatry - November 2008 - (Page 24)

TABLE 2. Assessment and treatment of nonsuicidal self injury in adolescents intentions, and that the teenager needs more effective skills to replace self injury. Table 1 lists the functions of NSSI. 1. Complete a comprehensive diagnostic evaluation, including the following: • Medical history and physical examination • Identification of comorbid psychiatric illness • Assessment of suicide risk • History of physical and sexual abuse • Substance abuse history • Evaluation of risk factors • Evaluation of family functioning and social supports CASE EXAMPLE, CONTINUED The psychiatrist asked Tina what other actions she could take to feel calmer and distract herself from her emotional pain. “I don’t know,” she said, shaking her head. The psychiatrist asked her what she had done before she first discovered the effects of harming herself. “I don’t know,” she said again. “I never hurt then like I do now.” TREATMENT STRATEGIES 2. Conduct a functional behavioral analysis of the NSSI identifying the following: • Antecedents (situations/stressors leading to self harm) • Behavior characteristics (e.g., frequency, intensity, duration of NSSI) • Consequences (e.g., emotional relief, care and attention from others) 3. Develop a therapeutic alliance based upon acceptance and validation strategies 4. Treat primary psychiatric disorders first 5. Target behavioral interventions for NSSI based upon behavioral analysis and need for the following: • Affective language skills • Self-soothing skills • Communication skills 6. Provide psychoeducation for the patient and family 7. Initiate cognitive problem-solving skills treatment 8. Monitor response of behavioral interventions for reducing NSSI 9. Consider family therapy and dialectical behavior therapy (DBT) Self injury in adolescence has only recently been recognized as a commonly occurring phenomenon. Consequently, there are few randomized, controlled trials for the specific treatment of NSSI in adolescents. In adults, the therapeutic intervention with the most research demonstrating efficacy in reducing self-harming behavior is dialectical behavioral therapy (DBT).32,33 DBT uses a combination of individual and group therapy to teach skills in emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self management. The intensive treatment requires the individual clinician to be on call for these patients at all times. DBT has been adapted for adolescents with features of borderline personality,34 with the additional expectation that the group therapist is on call at all times for the parents. The clinical and financial demands of DBT have led to applications of less intensive treatments to reduce self harm, but these treatments are still under study. Treatment is based on a thorough psychiatric evaluation, with a focus on acute safety issues, suicidal risk, and clarification of comorbid psychiatric conditions. Treating NSSI involves determining the needs that the behavior fulfills and helping the adolescent devise other, healthier ways to meet those needs. For example, if NSSI helps a teen to calm down, what other techniques might provide the same result? In the case of Tina, the psychiatrist might recommend that she develop mindful awareness skills, practice deep breathing exercises, use ice on her wrist to produce a physical distraction, talk to a friend about her emotions, or exercise strenuously. Improving affective language and other communication skills can be key in reducing NSSI.31 Since adolescents engaging in NSSI often have poor problem-solving abilities,27 it is important to improve these skills as well. Involving family in the support and treatment of adolescents with NSSI is also very important. Poor communication with family has been associated with suicidal behavior in some adolescents.35 Improving the family’s understanding of NSSI can be useful in decreasing conflicts. It can be helpful for the family to learn deescalation strategies and expand listening and communication skills. Family members can also help with safety plans and practicing problem solving skills.30 Pharmacological treatment of NSSI should primarily focus on any underlying psychiatric disorders. Currently, there are no specific medications approved for the treatment of NSSI. Since depression and anxiety often accompany NSSI, identifying and treating these disorders should be a top priority. Concerns about an increase in suicidal thoughts with adolescents using antidepressant medication36 should be reviewed with teens and their parents. While the protective effects of antidepressants appear to outweigh the risk of increased suicidal thoughts,37 medication use should be monitored regularly. Additional precautions are helpful when prescribing medications for selfharming adolescents. Prescribing larger quantities of potentially lethal medication should be avoided and benzodiazepines should be used cautiously due to the potential for behavioral disinhibition. Table 2 describes assessment and treatment of NSSI in adolescents. 24 Psychiatry 2008 [ N O V E M B E R ]

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Psychiatry - November 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Measuring Adverse Events in Psychiatry Nonsuicidal Self Injury in Adolescents Relative Tolerability of Alzheimer's Disease Treatments Biracial Identity Development and Recommendations in Therapy Depression and Cardiovascular Disease: Just an Urban Legend? Three Risk Management Basics Journal Watch Classified Advertising Information for Authors

Psychiatry - November 2008

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