This thesis presents four studies that examine the potential role that intrusive thoughts, dissociation and mindfulness in self-harming behaviours in young people and adults. A large online study was conducted with students and staff at a UK university. This examined a range of risk factors for self-harm derived from the literature, including dissociation, family background/trauma history and intrusive thoughts. This study was followed up with a qualitative study investigating triggers of self-harm, and the role of intrusive thoughts. A third study then looked at these factors in young people who were inpatients in an American psychiatric hospital, and who had all expressed intent to self- harm or commit suicide. This study also introduced a measure of trait mindfulness in order to investigate this potential way of dealing with intrusive thoughts. Finally, the risk factors identified in these studies were further investigated with an online survey with undergraduate students at a second UK university, dissociation, mindfulness and thought suppression. Intrusive thoughts were found to differ in content, frequency and effect between people with experience of self-harm and those without. A subgroup of potentially maladaptive behaviours were found to be associated with high scores on the predictors of self-harm, and therefore potentially predictive of self-harm. In the young people in hospital, the extent to which they reacted to their intrusive thoughts was inversely associated with the extent to which they were naturally mindful. Trait mindfulness scores were lower for those individuals with a history of childhood trauma, and for those meeting diagnostic criteria for Borderline Personality Disorder, in which self-harm is a key feature. These findings together suggest that mindfulness skills may play an important role in both dealing with intrusive thoughts and for protecting against self-harm. Overall, intrusive thoughts and dissociation were associated with experience of self- harming behaviours, while mindfulness skills were negatively associated with self-harm. Some potentially maladaptive behaviours (including smoking and eating pathology) represent risk factors for self-harm, and therefore may provide professionals with a way of identifying people for early intervention, if further longitudinal research shows evidence of progression. Alternatively, the differences in mindfulness between this group and the self-harmers may indicate that mindfulness training could benefit people who self-harm.

Author: Madeleine Ahlström and Hanna Puonti Title: To meet the invisible population - A qualitative study of men with deliberate self-injury [Att möta de osynliga - En kvalitativ studie om killar med självskadebeteende] Supervisor: Anders Östnäs Assessor: Jan Petersson   This study aims to provide a picture of the underlying causes why men deliberately hurt themselves. It also aims to provide a picture revolving how men self-harm and what the direct effects are from their self-harm. The study describes their behaviour and how the behaviour has evolved over time. There is also a focus in the study to illustrate how society´s operative approach towards men makes their self-harm invisible, and make them an invisible population that neither the scientists nor the general population chooses to see. Self-injury is strongly associated with girls and their way of harming themselves. Men have been excluded from studies of self-injury, also have there been very few scientists that found them of interest to study.   This is a study with a qualitative approach wich executed eight semi-structured interviews with men who have had a behavior of self-injury. The study takes on a hermeneutic approach to knowledge, to have the possibility to interpret in the analysis of the empirics. To analyse the data we have used a qualitative content analysis according to Graneheim and Lundman (2004). The results has been analysed by Antonovsky´s (2005) KASAM theory. The study has found that men have a self-injury that is multifaceted. The men in the study use different behaviours to manage various emotional factors that affect them. Deliberate self-injurious behaviours become a coping strategy for the men when they didn’t have other strategies to cope with when their faced difficulties.

This thesis comprises a narrative exploration of the lived experience of being someone who has self-injured. Self-injury, like pain, emotions, sensation and social life, is understood and examined as inherently embodied. The thesis is intended to contribute to sociological approaches to the study of embodiment and to sociological understandings of self-injury. Twelve participants were recruited in non-clinical sites. The sample was heterogeneous in terms of their experience of self-injury, contact with medical and psychiatric services, socio-economic background, household type, age and sexuality. Both men and women were interviewed in an attempt to counter the relative neglect of men in previous research. Two interviews were carried out with each participant: the first was a life-story interview, while the second explored self-injury more directly. The approach to data collection and analysis was intended to be collaborative, and comprised both narrative and thematic techniques. The thesis demonstrates the importance of studying self-injury as an embodied, socially situated and socially mediated behaviour. An embodied approach underlines the importance of the visibility of self-injury. The existence of visible marks and scars created by self-injury were important aspects of the lived experience of participants. The ways in which these marks were negotiated in social life represented a key focus of analysis. My analysis reveals the importance and utility of attending to the practical and material aspects of self-injury in attempting to understand the behaviour. I highlight the diverse ways in which self-injury is practised, and the equally various meanings and understandings it holds for practitioners A variety of complex and contradictory justifications for self-injury are critically examined. These justifications share a concern with pain, incarnate, suggesting that self-injury is: a method of transforming emotional pain into physical pain; a way of relieving emotional pain; painful; painless; attention-seeking; private. A sociological, narrative analysis illuminates the ways in which these understandings and justifications can be located within biographical, interpersonal and socio-cultural contexts. By locating these justifications within socio-cultural contexts, the complexities and contradictions of the accounts become understandable. My analysis confirms the importance of attending to socio-cultural understandings of bodies, emotions, authenticity and morality in exploring narratives about self-injury.

När ett barn har ett självskadebeteende påverkas föräldrarna, de hamnar i konflikter med varandra, familjedynamiken vänds upp och ned och syskonen hamnar i skymundan. Sjukskö-terskan har därför en viktig roll, att inte bara vårda och se till det sjuka barnet, utan se famil-jen som en helhet. Författarna till examensarbetet har valt att belysa föräldrars upplevelser av att ha barn med självskadebeteende. I Sverige är psykisk ohälsa bland barn och unga ett växande problem. Personer med självska-debeteende upplever oftast även någon form av psykisk ohälsa. Drygt 2,300 kvinnor och 1,300 män i åldern 15-29 år vårdades år 2011 för själskadebeteende men det finns olika typer av vårdformer samt söker inte alla hjälp, därför finns troligtvis ett stort mörkertal. Självskadebeteende och självmordsförsök ses allmänt som en komplikation vid psykisk ohälsa, där den vanligaste ohälsan är depression. Självskadebeteende och självmordsförsök skall dock inte förväxlas som samma fenomen, då självmordsförsök handlar om att avluta sitt liv. Självskadebeteende definieras med att avsiktligt skada sin kropp, utan avsikt till själv-mord. Föräldrar till barn med självskadebeteende kan känna sig misslyckade och maktlösa. De kän-ner även en skuld och skam över barnets beteende. Det är känslomässigt ansträngande för dem att hantera situationen. Det är därför av stor vikt att de får rätt handledning och stöd för att på bästa sätt kunna hjälpa sitt barn. Föräldrarna kunde känna en avsaknad av kunskap och förståelse gällande deras barns självskadebeteende. Sjukvårdpersonalen kan stötta föräldrarna genom att förmedla kunskap och information. De ska även undervisa, motivera, ge rådgivning samt emotionellt och praktiskt stöd till hela familjen. Insatserna bör utföras av sjuksköterskan i ett nära samarbete med andra yrkesgrupper för att få en så bra familjeorienterad vård som möjligt. / Background: Mental illness is a growing problem in society and is increasingly seen in younger people. Deliberate self-harm is seen as a complication of mental illness. Self-harm means that people intentionally injure themselves as a habit and with more or less severe de-gree, but with no intention to take their own life. Aim: The aim of the study is to illustrate parents’ experiences of their child’s deliberate self-harm behavior. Method: A literature-based study based on analysis of ten qualitative articles. Results: The results are presented in three main themes and ten subthemes. The first main theme is "A roller coaster of feelings", with three subthemes "First battle", "Feelings of guilt and shame" and "Anxiety and fear". The second main theme is "Parenthood and family rela-tionship" with four subthemes "Changing positions of power", "Parents in conflict", "Not being enough as a parent" and "A changed relationship". The last main theme is "Parents ex-perience of support" with three subthemes "The insufficient support", "Feeling seen" and "To get support from the surroundings". Conclusion: Health care professionals need to create a good relationship with both parents and patients, which can be done by meeting the parents' feelings and being responsive.

This study examines the impact features of nonsuicidal self-injury (NSSI) have on predicting a suicide attempt in a sample of young adult self-injurers. Participants completed the Inventory of Statements About Self-Injury, the Self-Harm Behavior Questionnaire and demographics questionnaires to assess lifetime self-injury frequency, number of different methods used, severity of methods, the desire to stop self-harming, functions, the experience of pain, and response latency. Results indicated that NSSI frequency, high severity methods, and endorsing more intrapersonal functions predicted the presence of a suicide attempt. Additionally, those who experienced pain while selfinjuring were found to be significantly more likely to report a history of suicide attempt compared to those who did not feel pain. Given extant literature, these findings suggest that in general the relationship between NSSI and suicidality is more complex than suggested and differs depending on which feature of suicidality is being measured (e.g. ideation, threats, gestures, plans, or attempts). Aside from other important implications discussed, researchers should individually evaluate facets of suicide when establishing risk.

Background: Self-harm is used to describe a group of diseases where the persons intention is to hurt thereself. This collective name includes conditions such as anorexia, burning, poisoning and self-cutting. The act of self-harm is almost never related to the patients' wish of death, it's more of a tool for the person to calm herself. Previous research shows that nurses often see these patients as troublesome often because of a lack of knowledge. There's just a few studies that examine the patients' views. Aim: The aim of this study was to describe how patients with self-harm was experiencing the meeting with the nurse. Method: The study was designed as a literature based study based on 12 qualitative articles. All articles are read and analyzed by Friberg (2012) model with the analysis of qualitative research. Results: The result of this study showed that the nurse plays a big part in how the patients experienced their treatment. If the patient feels that the nurse doesn't see, hear or respect her, the patient starts to feel that she is not worth health care. For the patient to feel and get better it's essential that there is a functional relationship between the patient and the nurse. Conclusion: Patients who self-harm is a difficult patientgroup to treat if there is a lack of knowledge. But these patients are dependent on the care that the nurse is providing them. Therefore a caring and trusting relationship is a must to provide high quality care.

The notion that acts of deliberate self-harm serve an expressive or communicative function is the central premise upon which many of the main functional models of selfharm are based. However despite the importance of this notion, very little empirical evidence exists to support it. Within this project the notion that acts of DSH serve an expressive or communicative function was explored in detail. Four studies investigating the expressive and communicative qualities of acts of DSH, the content which such behaviours serve to express, and the dynamics by which several different modalities of DSH do this were performed utilising Internet methods of data collection. The use of online methods of data collection findings of this project only apply to the sub-group of individuals who engage in DSH and also participate in online discussion forums. Photographs of words and phrases engraved into the skin along with detailed first person narratives of past episodes of deliberate self-harm were used as data sources in this project. Due to their high frequency of occurrence, acts of skin-cutting, self-burning, self-hitting, and self-poisoning were the main modalities of deliberate self-harm investigated in the four studies. Acts of skin-cutting, self-burning, self-hitting, and self-poisoning were all reported to serve expressive functions which allowed emotions and issues to be released or discharged from the body. Conversely, acts of skin-cutting and self-poisoning were also reportedly used to communicate emotional distress and a need for support from others. The content expressed or communicated by such behaviours, and indeed the dynamics by which they did so depended largely upon the modality by which injuries were inflicted. However in general the content expressed and communicated by the acts of deliberate self-harm reported in this project typically related to the events which preceded such behaviours, how they were interpreted, the types of psychological experiences they represented, and the emotions which they evoked. Such events were overwhelmingly interpersonal in nature, and typically involved the dissolution or disruption of relationships with primary support group members. The dynamics by which acts of deliberate self-harm reportedly served these functions differed widely, however the concept of symbolism was central to all modalities. The data collected within this project relating to the expressive and communicative functions of acts of skin-cutting, self-burning, self-hitting, and selfpoisoning was finally collated with the existing literature on the subject.

Aims: The initial aim of this thesis was to understand the relationship between non-psychotropic medication and risk of suicidality. This was achieved by conducting a systematic review, which, among other conclusions, identified the need for improved estimation of risk of suicide and attempted suicide associated with antiepileptic drugs (AEDs). This stimulated this programme of research which sought to estimate the risk of suicide and other causes of unnatural death in people with epilepsy, the role of AEDs in fatal poisonings, the risk of self-harm in people with epilepsy and factors associated with self-harm amongst those people with epilepsy. Methods: Cohorts of individuals with prevalent epilepsy were identified separately in two population-based linked-primary care datasets: the Clinical Practice Research Datalink (CPRD) in England and the Secure Anonymised Information Linkage (SAIL) in Wales. Individuals were matched on age, gender and general practice to up to 20 people without epilepsy. The risks of cause-specific types of unnatural death (e.g. suicide, accident) were estimated using stratified Cox proportional hazards models, adjusted for level of deprivation. From each of the prevalent epilepsy cohorts, individuals with incident epilepsy, no history of self-harm and who were new users of the AEDs; carbamazepine, lamotrigine or valproate, were identified. The risk of first self-harm event associated with each AED compared to valproate was estimated using Inverse Probability of Treatment Weighting propensity score analysis. Estimates from each dataset were combined in a random effects meta-analysis. In the CPRD, the risk of self-harm in the incident epilepsy cohort versus a comparison cohort was estimated using a stratified Cox proportional hazards model. From this cohort, a nested case-control study was constructed. Individuals with a first self-harm event (cases) were matched to up to 20 people with no history of self-harm (controls). Conditional logistic regression was used to estimate the risk of self-harm associated with various factors including history of mental illness diagnoses, referrals and AED utilisation. Results: There were 44,678 and 14,051 people in the prevalent epilepsy cohorts and 891,429 and 279,365 in the comparison cohorts, in the CPRD and the SAIL respectively. Increased risks of suicide (HR 2.15, 95%CI 1.51-3.08) and accidental death (HR 2.97, 95%CI 2.54-3.48) were observed for people with epilepsy versus the comparison cohort, from the deprivation-adjusted meta-analysed estimates. Overall, AEDs were involved in 9.7% (95%CI 3.6%-19.9%) of the 62 poisoning deaths in people with epilepsy. There were 5,107 new users of carbamazepine, lamotrigine or valproate with incident epilepsy in the CPRD and 2,654 in the SAIL. No increased risk of self-harm was evident for carbamazepine (HR 1.53, 95%CI 0.89-2.64) or lamotrigine (HR 1.35, 95%CI 0.79-2.29), compared to valproate, from the meta-analysed estimates. In the CPRD, there were 11,690 individuals with incident epilepsy and 215,569 in the comparison cohort. The deprivation-adjusted hazard ratios for first self-harm event were 5.31 (95%CI 4.08-6.89) in the year following diagnosis and 3.31 (95%CI 2.85-3.84) in subsequent years. The nested-case control study derived from this incident epilepsy cohort included 273 cases of first self-harm and 3,790 controls. An increased risk of self-harm was associated with history of a mental illness diagnosis (OR 4.08, 95% CI 3.06-5.42) or referral to specialist psychiatric services (OR 3.41, 95% CI 2.63-4.43), compared to none; or being prescribed no AEDs (OR 1.47, 95% CI 1.01-2.12) or two AEDs (OR 1.84, 95% CI 1.33-2.55) in the 90 days prior to index date, compared to a single AED. Augmentation of AED treatment carried an elevated risk (OR 2.12, 95% CI 1.38-3.26) whereas there was no evidence to indicate that switching from one AED to another altered risk (OR 0.69, 95% CI 0.21-2.23). Conclusions: Compared to those without the condition, people with epilepsy are at an elevated risk of unnatural death, including suicide and accidental death, and nonfatal self-harm. The risk of self-harm is particularly elevated in the year following diagnosis of epilepsy but persists beyond this. Factors associated with increased risk of self-harm within the epilepsy population include prior mental illness and referral to psychiatric services. There was no evidence of difference in the risk of self-harm associated with carbamazepine or lamotrigine compared to valproate, but further replication of this result would be beneficial. However, treatment with multiple AEDs and augmentation of AED treatment increase the risk of self-harm within this population. These may be markers of uncontrolled epilepsy.

This study described self-injury within a general adolescent population. This study involved secondary analysis of data gathered using the middle school Youth Risk Behavior Survey (YRBS) from 1,748 sixth- and eighth-grade students in eight middle schools in a large, southeastern county in Florida. A substantial percentage of students surveyed (28.4%) had tried self-injury. The prevalence of having ever tried self-injury did not vary by race or ethnicity, grade, school attended, or age but did differ by gender. When controlling for all other variables in the multivariate model including suicide, having ever tried self-injury was associated with peer self-injury, inhalant use, belief in possibilities, abnormal eating behaviors, and suicide scale scores. Youth who knew a friend who had self-injured, had used inhalants, had higher levels of abnormal eating behaviors, and higher levels of suicidal tendencies were at increased risk for having tried self-injury. Youth who had high belief in their possibilities were at decreased risk for having tried self-injury. During the past month, most youth had never harmed themselves on purpose. Approximately 15% had harmed themselves one time. Smaller proportions of youth had harmed themselves more frequently, including two or three different times (5%), four or five different times (2%), and six or more different times (3%). The frequency of self-injury did not vary by gender, race or ethnicity, grade, or school attended. Almost half of students surveyed (46.8%) knew a friend who had harmed themselves on purpose. Peer self-injury demonstrated multivariate relationships with gender, having ever been cyberbullied, having ever tried self-injury, grade level, and substance use. Being female, having been cyberbullied, having tried self-injury, being in eighth grade, and higher levels of substance use placed youth at increased risk of knowing a peer who had self-injured. Chi-squared Automatic Interaction Detection (CHAID) was used to identify segments of youth at greatest and least risk of self-injury, frequent self-injury, and knowing a friend who had harmed themselves on purpose (i.e., peer self-injury).

The purpose of this study is to describe how, and if, discourses about self-harm in young people has been changed from the late 90-s until today. We chose to do this by studying films where the content of self-harm is a big factor. The study is built on a narrative research, we did however analyze it as a discourse method. The issues we have concentrated on are: Is there a significant quality that describes an individual who cut themselves? How can this phenomenon be seen from a gender point of view? Is there a specific group of people who is labeled as a person who cut themselves from the public? The result from this study show us that self-injury, from symptoms of a (bad) mental state, is a strong discourse where the views from the society lets it become more acceptable. However, there are other reasons for self-harm that is developed by the social difficulties, which is illustrated in these films. Norms and beliefs around what is male or female have not been changed from the beginning of the time period we have studied until today. Self-mutilation is still seen as a typical female thing – a woman problem. The persons who are pointed out as cutting themselves are typical white, young, dramatic girls. These girls also exhibit depth - and shame for the problem and its environment.