Comportamentos autolesivos em adolescentes : características epidemiológicas e análise de fatores psicopatológicos, temperamento efetivo e estratégias de coping

Tese de doutoramento, Medicina (Psiquiatria e Saúde Mental), Universidade de Lisboa, Faculdade de Medicina, 2014

Self-harm in adolescence is a serious public health problema at a global level. High prevalence rates have been observed both in community and clinical samples, self-harm is associated with psychiatric morbidity and with a significantly increased risk of completed suicide. International data shows that about 10% of adolescentes have harmed themselves on at least one occasion. Research, identification and prevention of these behaviours are considered. Priorities in healthcare policies of the European Union and Portugal. Self-harm in adolescents is nowadays considered as the end result of complex interactions between genetic, biological, psychiatric, psychological, social and cultural factors. This thesis focuses on this topic, consisting of na integration of na extensive literature review and original research.The research aimed to identify the prevalence of self-harm in adolescentes in the Greater Lisbon area, to characterize in detail these behaviours as well as the young people who perform them, explore their association with psychopathological variables, affective temperamento and coping strategies used by.adolescents. The procedures and choices of instruments took into account two main criteria: their adaptation to international studies, in order to allow the comparison of results and; ease of replication. Self-harm was defined as [an] act with non-fatal outcome in which na individual deliberately did one or more of the following: initiated behaviour (e.g. self cutting,jumping from a height), which they intended to cause sefl-harm; ingested a substance in excesso of the prescribed or generally recognised therapeutic dose;ingested a recreational or illicit drug that was na act the person regarded as self-harm; ingested a non-ingestible substance or object’. A community sample of 1713 adolescents (56 % female, between 12 and 20 years old, mean age 16) from 14 public schools in the Greater Lisbon área was studied. These adolescentes answered na anonymous questionnaire in the contexto of the classroom, where the following were investigated: socio-demographic variables; health behaviours; negative life events; presence and characterization of self-harm (including method, underlying motivations, suicidal ideation, premeditation and help-seeking behaviours); presence of self-harm thoughts; opinion of young people on the subject; anxious and depressive symptoms; affective temperamento patterns; use of coping strategies. It was found that 7.3% of adolescentes had at least one episode of self-harm. The lifetime prevalence of self-harm was 10.5% for females and 3.3% for males, and the last year prevalence was 5.7% and 1.8% respectively. About half (46%) had more than one episode of self-harm. The most common methods were self cutting in 65%, followed by overdoses in 18%.The most frequently mentioned motivation was 'I wanted to get relief from a terrible state of mind'. About half of the males and a third of the females admitted to having thought seriously about dying in the contexto of self-harm episodes. About 6% of the sample reported thoughts of self-harm (without the associated behaviour), those were also more common in females (9.5% vs. 2.4%, respectively).The vast majority of young people with these behaviours denied having spoken to someone or asking for help, maintaining self-harm as a 'hidden behaviour', not detected by health or school services. In the study sample only 19% of youth reporting SH talked to someone about it or sought help before the event (preferentially directed to friends or family). More (37.3%), however,sought help after the most recente episode.Very few (13%) SH episodes led to hospital presentation, mostly cases of overdoses. It was observed that the probability of self-harm is significantly greater in females, in those living non-nuclear family systems and in those who failed at least one school year. Young people who self-harm have reported more depressive and anxiety symptoms, as well as higher rates of alcohol consumption, drunkenness, tobacco consumption and use of ilegal drugs. These adolescentes also reported greater number of negative life events, having stood out as independente predictors for both genders, exposure to self-harm or suicide of others and troubles with the police. Being bullied proved to be predictor of self-harm in males. Difficulties with friends and peers, as well as having been a victim of physical or sexual abuse were considered importante predictors. Of self-harm in females. A highly significant association between the presence of self-harm and depressive, cyclothymic and irritable subtypes of dominant affective temperamento was verified. The presence of these dominant subtypes can be considered as a marker of the innate vulnerability.It was also observed that adolescentes who self-harm, when compared with other young people, show a diferente profile of coping strategies utilization.The use of non-productive strategies was associated with self-harm in both genders, particularly avoidance, self-blame and tension reduction. Strategies involving consulting significant others for support were less used in the self-harm group.The preferential use of at productive coping style was negatively associated with the self-harm group. This profile of use of.coping.strategies. can be considered as a modifiable vulnerability factor. Regarding these results, it is concluded that self-harm among adolescentes in the Greater Lisbon área has a very relevant prevalence and should because for concern for policy makers in the health, area.It is noteworthy that there are possibilities of intervention in several of the factos that were dentified asn associated to self-harm in adolescents, those could be targeted in preventive strategies or at a clinical level.The consumption of substances, the depressive and anxious symptoms and the use of coping strategies, are some examples. Because selfOharm is a largely secretive behaviour, with scarce help-seeking, it becomes difficult to identify and refer these young people to the health services, this factor should be taken into consideration in the creations of prevention plans in this area. This thesis, as a whole, contributes to the further study of this subject, filling some gaps in presente knowledge. It can be used as a starting point for future studies (several suggestions are made), as a basis for intervention programs in this área (featuring a section in which the various strategies are discussed and a integrative proposal is presented). This work systematizes the main factos associated with self-harm in adolescence, demonstrating the importance of a broad and multidimensional understanding of the phenomenon. It stresses the importance of na active strategy for early identification and treatment of adolescentes with self-harm, that should be community based and with mandatory involvement of families, schools and primary health care.

Fundação para a Ciência e a Tecnologia (FCT, SFRH/SINTD/60042/2009, Programa de Formação Avançada em Investigação Clínica para Internos Doutorandos); Ministério da Saúde