Jo Borrill

Students who self-harm: Coping style, Rumination and Alexithymia

Counsellors working with students or other young adults may encounter individuals who have self-harmed, either with suicidal or non-suicidal intent. Recent US studies reported rates of self-injury of up to 37% of the student population, but studies in the UK have focussed primarily on younger adolescents. This study examined reported self-harm incidents (scratching, cutting, poisoning, overdose etc) from a sample of 617 university students. A total of 27% reported at least one incident of self-harm, with almost 10% having harmed themselves while at university. Gender differences were not significant but psychology students reported significantly more self-harm than other students. Participants reporting self-harm scored significantly higher on maladaptive coping styles, rumination, and alexithymia (specifically difficulty in identifying emotions) and these differences were most marked for students reporting repetitive and recent self-harm. Rumination and Alexithymia factor 1 (difficulty identifying feelings) emerged as the most robust factors predicting self-harm status. Comments from students who self-harmed at university highlighted the importance of accessible services and academic staff support. The implications of these findings for counselling interventions are discussed, including challenging negative rumination tendencies and developing mindfulness skills.

Acceptability of flexible sigmoidoscopy screening in older adults in the United Kingdom

Objectives To assess the acceptability of bowel cancer screening using flexible sigmoidoscopy (FS). Setting Adults aged 55 to 64 recruited from general practices in Welwyn Garden City and Leicester, which were the pilot and start up centres of a multicentred randomised controlled trial of FS screening (the ICRF/MRC Flexible Sigmoidoscopy Screening Trial). Methods Screenees (n=4422) were sent a three month follow up questionnaire that included measures of satisfaction with information given before the test, facilities at the test unit, attitudes of the staff, and explanation of the results. Measures of pain, embarrassment, feelings of being “in control” during the test, willingness to encourage others to have the test, and gladness to have participated were also included. In addition, semistructured telephone interviews were conducted with 60 screenees, stratified by screening outcome and gender. Results The follow up questionnaire was completed by 94% of screenees. Responses indicated a high level of satisfaction with the procedure: 99% were satisfied with the information given before the test, the facilities, the attitudes of the staff, and the explanation of their results; 91% reported only mild or no pain; 97% reported little or no embarrassment; and 99% were glad they had the test. Satisfaction ratings varied little by gender or outcome group. The quantitative results were reinforced by the qualitative data, which also revealed high acceptability. Conclusion In the context of a clinical trial with dedicated trial staff, FS is a well tolerated procedure. There are high levels of satisfaction with service provision and positive attitudes towards the programme.

Chlorpromazine for schizophrenia: a Cochrane systematic review of 50 years of randomised controlled trials

BackgroundChlorpromazine (CPZ) remains one of the most common drugs used for people with schizophrenia worldwide, and a benchmark against which other treatments can be evaluated. Quantitative reviews are rare; this one evaluates the effects of chlorpromazine in the treatment of schizophrenia in comparison with placebo.MethodsWe sought all relevant randomised controlled trials (RCT) comparing chlorpromazine to placebo by electronic and reference searching, and by contacting trial authors and the pharmaceutical industry. Data were extracted from selected trials and, where possible, synthesised and random effects relative risk (RR), the number needed to treat (NNT) and their 95% confidence intervals (CI) calculated.ResultsFifty RCTs from 1955–2000 were included with 5276 people randomised to CPZ or placebo. They constitute 2008 person-years spent in trials. Meta-analysis of these trials showed that chlorpromazine promotes a global improvement (n = 1121, 13 RCTs, RR 0.76 CI 0.7 to 0.9, NNT 7 CI 5 to 10), although a considerable placebo response is also seen. People allocated to chlorpromazine tended not to leave trials early in both the short (n = 945, 16 RCTs, RR 0.74 CI 0.5 to 1.1) and medium term (n = 1861, 25 RCTs, RR 0.79 CI 0.6 to 1.1). There were, however, many adverse effects. Chlorpromazine is sedating (n = 1242, 18 RCTs, RR 2.3 CI 1.7 to 3.1, NNH 6 CI 5 to 8), increases a persons chances of experiencing acute movement disorders, Parkinsonism and causes low blood pressure with dizziness and dry mouth.ConclusionIt is understandable why the World Health Organization (WHO) have endorsed and included chlorpromazine in their list of essential drugs for use in schizophrenia. Low- and middle-income countries may have more complete evidence upon which to base their practice compared with richer nations using recent innovations.

Self-inflicted deaths of women in custody

Studies of prison suicides have consistently reported higher numbers of deaths for men than women. However it is not clear whether male or female prisoners have higher rates of self‐inflicted deaths proportionate to their population. This paper explores the number, rate and patterns of self‐inflicted deaths of women in prison over the last ten years (1992‐2001) compared with death rates for male prisoners and identifies from 13 case studies possible precipitating factors and implications for prevention.The female prison population increased by 237% over the period 1992 to 2001, from an average annual figure of 1,577 to 3,739. During the same period there were 33 self‐inflicted deaths: an increase from one death in 1993/94 to a peak of eight in 2000. Just over half (51%) of the women were unsentenced/on remand; 14 (43%) had an open F2052SH at the time of death, compared with 28% of all self‐inflicted deaths in the general prison population between 1997‐2001, and nine were known to have self‐ harmed previously (27%).Of the 13 case studies, all but one had recently used illicit drugs. Many had shown disturbed and difficult behaviour throughout their short time in custody, including non‐compliance with medication for mental health problems and behaviour resulting in adjudications. The women all had multiple problems in the days and weeks prior to their deaths, including withdrawal from drugs, lack of contact with families, bereavement and relationship problems within the prison. However more than two thirds had recently been relocated, often against their wishes or to accommodation they found less acceptable.

Suicides by foreign national prisoners in England and Wales 2007: mental health and cultural issues

Self-inflicted deaths in prisons in England and Wales were at a 10-year low in 2006 but rose in 2007, largely attributed to an unexpected increase in self-inflicted deaths by foreign national (FN) prisoners. All deaths were reviewed in detail using prison and clinical records and interviews with prison staff. This paper reports findings for the deaths of the 20 FN prisoners from non-EU countries. Similarities were found between these deaths and self-inflicted deaths of UK nationals in terms of method, location of death, index offence, and prevalence of mental illness. Additional factors found in the FNs included early anxiety, trauma symptoms in refugees from conflict, language issues, deportation fears, and cultural concepts of shame. These findings are discussed in relation to the entrapment model of suicide and the need for specialised mental health service provision.

The mental health consequences of dealing with self-inflicted death in custody

The impact of dealing with a death in custody was explored in 49 prison officers who had dealt with such an event in the period 3–7 months prior to the study. A 36.7% incidence rate of post-traumatic stress disorder (PTSD) was identified. Optimism, avoidance problem solving style, prior experience of suicide and level of involvement in the incident were direct mediators of the impact of the event for the total sample, while perceived control, emotional support and other aspect of problem-solving style had an indirect effect. Separate analysis of the PTSD and non-PTSD groups showed that the only mediator for the PTSD group was prior experience. For the non-PTSD group a range of variables mediated the impact. It is argued that this provides a case for preventive rather than treatment interventions.

Self‐inflicted deaths of prisoners serving life sentences 1988‐2001

Prisoners serving life sentences are known to be at a higher risk of suicide. This paper reports findings from a review of self‐inflicted deaths of life sentence prisoners over the years 1988‐2001 and an indepth analysis of 20 recent cases (1998‐2001) to identify the individual motivations and environmental triggers for self‐inflicted death in this population. There were 80 (9.5% of total prison suicides) self‐inflicted deaths among lifers in the study period. The prisoners were older and more likely to kill themselves a year or more into their sentence than were other prison suicides. Analysis of the 20 case studies showed that lifers who killed themselves less than a year into their sentence tended to be overtly suicidal from the start of their time in custody, to have committed domestic murders and to have killed themselves when faced with the reality of their sentence or tariff. Lifers who killed themselves more than a year into their sentence tended to have a previous history of self‐harm or suicide attempts but fewer signs of immediate risk. Problems in progressing through the lifer system seemed to be significant, including reduced status or a failed appeal, and inability to adjust following transfer. Other triggers included disrupted relationships in or out of prison. Among both early and late groups there was evidence of mental health problems contributing to the death. Warning signs immediately before the death included refusing food, work or medication. Mood and demeanour appear to be unreliable indicators of risk.

The Relationship between Self-Harm and Alexithymia

This paper presents a systematic review of the literature concerning the relationship between alexithymia and self-harm. Fifteen studies were selected following a systematic search of relevant databases. Results indicate significantly higher levels of alexithymia in women who self-harm compared with women who do not self-harm. Studies of men were less conclusive and require further investigation. A subsample of the studies found that childhood abuse and bullying were more likely to be associated with self-harm if alexithymia was present as a mediator. Other studies found that depression mediated between alexithymia and self-harm. The results indicate that the poor emotional cognition and expression associated with alexithymia may increase vulnerability to self-harm, particularly in women.

Religion, ethnicity, coping style, and self-reported self-harm in a diverse non-clinical UK population

Previous studies of ethnic and cultural differences in self-harm have focussed on overdose and suicide attempts by South Asian women. Research comparing ethnic groups has rarely examined religion or nationality. To achieve a more balanced approach this study examined self-harm methods and self-injury across gender, religion and ethnic group in a non-clinical population. Six hundred and seventeen university students completed a questionnaire asking whether they had ever harmed themselves, and the frequency and method of any self-harm. White participants and participants with no religious affiliation were more likely to report repeated incidents of self-harm, mainly scratching and cutting skin. Hindu religion was associated with lower levels of repeated self-harm. Asian males were less likely to report self-harm than both Asian females and other males. Black students were less likely to report cutting and scored highest on Rational coping style. The results raise questions about differential disclosure of self-harm across gender and culture.

Researching Suicide, Attempted Suicide and Near-Lethal Self-Harm by Offenders in Community Settings: Challenges for Future Research

Suicide is a serious international health problem and is more likely to occur in vulnerable populations such as offenders. There is an abundance of research into suicides of prisoners, but few studies have been carried out on suicides of offenders serving community sentences. This article identifies and evaluates the limited research that is available. Recommendations for future research are made, including how in-depth interviews can provide important information about near lethal incidents from the service users’ perspective, and how international comparisons could be helpful in understanding this problem further.