Self-cutting and prospective repetition of self-harm: studies of emergency department presentations in Ireland

Background Self-harm places an individual at increased risk of future self-harm and suicide, and indicates distress and maladaptive coping. Those who present to hospital with self-cutting form a significant minority of self-harm patients who are at increased risk of prospective repetition of self-harm and suicide compared with those presenting with intentional overdose. In addition to increased risk, there is emerging evidence of demographic, psychological, clinical, and social differences between those presenting with self-cutting and those presenting with overdose. Aim and Key Objectives The aim of the current doctoral work was to examine in detail the association between presenting with self-cutting and risk of prospective repetition. The objectives were: to identify evidence-based risk factors for repetition of self-harm among those presenting to emergency departments with self-harm; to compare demographic and presentation characteristics and prospective repetition across presentations of self-cutting only, self-cutting plus intentional overdose, and intentional overdose only; to compare prospective repetition and other characteristics within self-cutting presentations based on the type of treatment received; to compare self-cutting and intentional overdose patients on psychological risk and protective factors for repetition; and to examine the lived experience of engaging in repeated overdose and self-cutting. Methods The current doctoral work used a mixed-methods approach and is comprised of one systematic review and four empirical studies. The empirical studies were two registry-based prospective studies of Irish hospital presentations of self-harm, one prospective structured interview study, and one qualitative study using Interpretative Phenomenological Analysis. Results The systematic review identified several consistent and emerging risk factors for repetition of self-harm, compared to which self-cutting had a medium-sized effect. The registry studies demonstrated that the involvement of self-cutting, particularly less medically severe selfcutting, confers an increased risk of 1-month and 12-month repetition among Irish index selfharm presentations. The structured psychological study detected higher hopelessness and lower non-reactivity to inner experience among those presenting with self-cutting, and higher depression among those who repeated self-harm. Repeaters had lower baseline levels of protective psychological factors than non-repeaters and continued to have higher depression and hopelessness at follow-up. Finally, the qualitative study indicated that self-harm is a purposeful action taken in response to an overwhelming situation and is evaluated afterwards in terms of personal and social effects. Chosen method of self-harm seemed to be influenced by the desired outcome of the self-harm act, capability, accessibility and previous experience. Conclusion Despite limitations in terms of recruitment rates, the work presented in this thesis is innovative in examining the issue of the association between self-cutting and repetition from multiple perspectives. No one factor can reliably predict all repetition but self-cutting represents one consistent and easily detected risk factor for repetition. Those who present with self-cutting exhibit significant differences on demographic, clinical, and psychological variables compared with those presenting with intentional overdose, and seem to exhibit a more vulnerable profile. However, those who present with self-cutting do not form a discrete or homogenous group, and self-harm methods and levels of suicidal intent are liable to fluctuate over time.

Factors associated with self-cutting as a method of self-harm: findings from the Irish National Registry of Deliberate Self-Harm

Background: Research suggests that patients presenting to hospital with self-cutting differ from those with intentional overdose in demographic and clinical characteristics. However, large-scale national studies comparing self-cutting patients with those using other self-harm methods are lacking. We aimed to compare hospital-treated self-cutting and intentional overdose, to examine the role of gender in moderating these differences, and examine the characteristics and outcomes of those patients presenting with combined self-cutting and overdose. Methods: Between 2003 and 2010, the Irish National Registry of Deliberate Self-Harm recorded 42,585 self-harm presentations to Irish hospital emergency departments meeting the study inclusion criteria. Data were obtained on demographic and clinical characteristics by independent data registration officers. Results: Compared with overdose only, involvement of self-cutting (with or without overdose) was significantly more common in males than females, with an overrepresentation of males aged <35 years. Independent of gender, involvement of self-cutting (with or without overdose) was significantly associated with younger age, city residence, repetition within 30 days and repetition within a year (females only). Factors associated with self-cutting as the sole method were no fixed abode/living in an institution, presenting outside 9 a.m. to 5 p.m., not consuming alcohol and repetition between 31 days and 1 year (males only). Conclusion: The demographic and clinical differences between self-harm patients underline the presence of different subgroups with implications for service provision and prevention of repeated self-harm. Given the relationship between self-cutting and subsequent repetition, service providers need to ensure that adequate follow-up arrangements and supports are in place for the patient.

Suicide and deliberate self harm in older Irish adults

Background: Hospital-treated deliberate self harm and suicide among older adults have rarely been examined at a national level. Methods: The Irish Central Statistics Office provided suicide and undetermined death data for 1980-2006. The National Registry of Deliberate Self Harm collected data relating to deliberate self harm presentations made in 2006-2008 to all 40 Irish hospital emergency departments. Results: Rates of female suicide among older adults (over 55 years) were relatively stable in Ireland during 1980-2006 whereas male rates increased in the 1980s and decreased in more recent decades. Respectively, the annual male and female suicide and undetermined death rate was 22.1 and 7.6 per 100,000 in 1997-2006. Male and female deliberate self harm was 3.0 and 11.0 times higher at 67.4 and 83.4 per 100,000, respectively. Deliberate self harm and suicide decreased in incidence with increasing age. Deliberate self harm generally involved drug overdose (male: 72%; female 85%) or self-cutting (male: 15%; female 9%). The most common methods of suicide were hanging (41%) and drowning (29%) for men and drowning (39%) and drug overdose (24%) for women. City and urban district populations had the highest rates of hospital-treated self harm. The highest suicide rates were in urban districts. Conclusions: Older Irish adults have high rates of hospital-treated deliberate self harm but below average rates of suicide. Drowning was relatively common as a method of suicide. Restricting availability of specific medications may reduce both forms of suicidal behavior.

Risk of repeated self-harm and associated factors in children, adolescents and young adults

Background: Repeated self-harm represents the single strongest risk factor for suicide. To date no study with full national coverage has examined the pattern of hospital repeated presentations due to self-harm among young people. Methods: Data on consecutive self-harm presentations were obtained from the National Self-Harm Registry Ireland. Socio-demographic and behavioural characteristics of individuals aged 10–29 years who presented with self-harm to emergency departments in Ireland (2007–2014) were analysed. Risk of long-term repetition was assessed using survival analysis and time differences between the order of presentations using generalised estimating equation analysis. Results: The total sample comprised 28,700 individuals involving 42,642 presentations. Intentional drug overdose was the most prevalent method (57.9%). Repetition of self-harm occurred in 19.2% of individuals during the first year following a first presentation, of whom the majority (62.7%) engaged in one repeated act. Overall, the risk of repeated self-harm was similar between males and females. However, in the 20–24-year-old age group males were at higher risk than females. Those who used self-cutting were at higher risk for repetition than those who used intentional drug overdose, particularly among females. Age was associated with repetition only among females, in particular adolescents (15–19 years old) were at higher risk than young emerging adults (20–24 years old). Repeated self-harm risk increased significantly with the number of previous self-harm episodes. Time differences between first self-harm presentations were detected. Time between second and third presentation increased compared to time between first and second presentation among low frequency repeaters (patients with 3 presentations only within 1 year following a first presentation). The same time period decreased among high frequency repeaters (patients with at least 4 to more than 30 presentations). Conclusion: Young people with the highest risk for repeated self-harm were 15–19-year-old females and 20–24-year-old males. Self-cutting was the method associated with the highest risk of self-harm repetition. Time between first self-harm presentations represents an indicator of subsequent repetition. To prevent risk of repeated self-harm in young people, all individuals presenting at emergency departments due to self-harm should be provided with a risk assessment including psychosocial characteristics, history of self-harm and time between first presentations.

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

Mental health and suicidal behaviors in adolescents from a Portuguese island

Background: Adolescent suicidal behaviors are a public health priority. Objectives: Suicidal behavior is an understudied field in the Azores, and the few existing research studies with Portuguese adolescents only include young people from Mainland Portugal. This study aims at analyzing the adolescent student population from this island region so as to describe the current situation and plan community intervention projects in this area to meet the identified needs. Methodology: This is a non-experimental, quantitative and descriptive-correlational study with the purpose of describing phenomena and finding associations between variables. Results: The results showed that 17.9% of the 484 sampled adolescents reported self-harm behaviors, with 12.7% reporting self-cutting and 5.2% medication overdose or ingestion of toxic substances. Around 15.5% of the adolescents reported suicidal ideation. Additionally, they showed high levels of depressive symptoms (19.9%), ranging from moderate (12%) to severe (7.9%). Conclusion: Adolescents had more self-harm behaviors, more severe depressive symptoms, a lower self-concept and fewer coping strategies than similar populations in mainland Portugal.

Self-interrupted regenerative metal cutting in turning

A new approach is used to study the global dynamics of regenerative metal cutting in turning. The cut surface is modeled using a partial differential equation (PDE) coupled, via boundary conditions, to an ordinary differential equation (ODE) modeling the dynamics of the cutting tool. This approach automatically incorporates the multiple-regenerative effects accompanying self-interrupted cutting. Taylor's 3/4 power law model for the cutting force is adopted. Lower dimensional ODE approximations are obtained for the combined tool–workpiece model using Galerkin projections, and a bifurcation diagram computed. The unstable solution branch off the subcritical Hopf bifurcation meets the stable branch involving self-interrupted dynamics in a turning point bifurcation. The tool displacement at that turning point is estimated, which helps identify cutting parameter ranges where loss of stability leads to much larger self-interrupted motions than in some other ranges. Numerical bounds are also obtained on the parameter values which guarantee global stability of steady-state cutting, i.e., parameter values for which there exist neither unstable periodic motions nor self-interrupted motions about the stable equilibrium.

Self-interrupted regenerative turning

A preliminary study of self-interrupted regenerative turning is performed in this paper. To facilitate the analysis, a new approach is proposed to model the regenerative effect in metal cutting. This model automatically incorporates the multiple-regenerative effects accompanying self-interrupted cutting. Some lower dimensional ODE approximations are obtained for this model using Galerkin projections. Using these ODE approximations, a bifurcation diagram of the regenerative turning process is obtained. It is found that the unstable branch resulting from the subcritical Hopf bifurcation meets the stable branch resulting from the self-interrupted dynamics in a turning point bifurcation. Using a rough analytical estimate of the turning point tool displacement, we can identify regions in the cutting parameter space where loss of stability leads to much greater amplitude self-interrupted motions than in some other regions.

Self-healing Techniques for RF and mm-Wave Transmitters and Receivers

With continuing advances in CMOS technology, feature sizes of modern Silicon chip-sets have gone down drastically over the past decade. In addition to desktops and laptop processors, a vast majority of these chips are also being deployed in mobile communication devices like smart-phones and tablets, where multiple radio-frequency integrated circuits (RFICs) must be integrated into one device to cater to a wide variety of applications such as Wi-Fi, Bluetooth, NFC, wireless charging, etc. While a small feature size enables higher integration levels leading to billions of transistors co-existing on a single chip, it also makes these Silicon ICs more susceptible to variations. A part of these variations can be attributed to the manufacturing process itself, particularly due to the stringent dimensional tolerances associated with the lithographic steps in modern processes. Additionally, RF or millimeter-wave communication chip-sets are subject to another type of variation caused by dynamic changes in the operating environment. Another bottleneck in the development of high performance RF/mm-wave Silicon ICs is the lack of accurate analog/high-frequency models in nanometer CMOS processes. This can be primarily attributed to the fact that most cutting edge processes are geared towards digital system implementation and as such there is little model-to-hardware correlation at RF frequencies.

All these issues have significantly degraded yield of high performance mm-wave and RF CMOS systems which often require multiple trial-and-error based Silicon validations, thereby incurring additional production costs. This dissertation proposes a low overhead technique which attempts to counter the detrimental effects of these variations, thereby improving both performance and yield of chips post fabrication in a systematic way. The key idea behind this approach is to dynamically sense the performance of the system, identify when a problem has occurred, and then actuate it back to its desired performance level through an intelligent on-chip optimization algorithm. We term this technique as self-healing drawing inspiration from nature's own way of healing the body against adverse environmental effects. To effectively demonstrate the efficacy of self-healing in CMOS systems, several representative examples are designed, fabricated, and measured against a variety of operating conditions.

We demonstrate a high-power mm-wave segmented power mixer array based transmitter architecture that is capable of generating high-speed and non-constant envelope modulations at higher efficiencies compared to existing conventional designs. We then incorporate several sensors and actuators into the design and demonstrate closed-loop healing against a wide variety of non-ideal operating conditions. We also demonstrate fully-integrated self-healing in the context of another mm-wave power amplifier, where measurements were performed across several chips, showing significant improvements in performance as well as reduced variability in the presence of process variations and load impedance mismatch, as well as catastrophic transistor failure. Finally, on the receiver side, a closed-loop self-healing phase synthesis scheme is demonstrated in conjunction with a wide-band voltage controlled oscillator to generate phase shifter local oscillator (LO) signals for a phased array receiver. The system is shown to heal against non-idealities in the LO signal generation and distribution, significantly reducing phase errors across a wide range of frequencies.

Self-organized vegetation patterning as a fingerprint of climate and human impact on semi-arid ecosystems

Spatially periodic vegetation patterns are well known in arid and semi-arid regions around the world. Mathematical models have been developed that attribute this phenomenon to a symmetry-breaking instability. Such models are based on the interplay between competitive and facilitative influences that the vegetation exerts on its own dynamics when it is constrained by arid conditions, but evidence for these predictions is still lacking. Moreover, not all models can account for the development of regularly spaced spots of bare ground in the absence of a soil prepattern. We applied Fourier analysis to high-resolution, remotely sensed data taken at either end of a 40-year interval in southern Niger. Statistical comparisons based on this textural characterization gave us broad-scale evidence that the decrease in rainfall over recent decades in the sub-Saharan Sahel has been accompanied by a detectable shift from homogeneous vegetation cover to spotted patterns marked by a spatial frequency of about 20 cycles km-1. Wood cutting and grazing by domestic animals have led to a much more marked transition in unprotected areas than in a protected reserve. Field measurements demonstrated that the dominant spatial frequency was endogenous rather than reflecting the spatial variation of any pre-existing heterogeneity in soil properties. All these results support the use of models that can account for periodic vegetation patterns without invoking substrate heterogeneity or anisotropy, and provide new elements for further developments, refinements and tests. This study underlines the potential of studying vegetation pattern properties for monitoring climatic and human impacts on the extensive fragile areas bordering hot deserts. Explicit consideration of vegetation self-patterning may also improve our understanding of vegetation and climate interactions in arid areas. © 2006 The Authors.

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.

Defining the crime of aggression : cutting the Gordian knot ?

"Mémoire présenté à la Faculté des Études supérieures en vue de l'obtention du grade de LL.M. en Maîtrise en droit Option recherche"

Healthcare in continuum for an ageing population: national self monitoring or remote offshore monitoring for Australia?

Australia is a country, similar to other developed nations, confronting an ageing population with complex demographics. Ensuring continued healthcare for the ageing, while providing sufficient support for the already aged population requiring assistance, is at the forefront of the national agenda. Varied initiatives are with foci to leverage the advantages of lCTs leading to e-Health provisioning and assisted technologies. While these initiatives increasingly put budgetary constraints on local and federal governments, there is also a case for offshore resourcing of non-critical health services, to support, streamline and enhance the continuum of care, as the nation faces acute shortages of medical practitioners and nurses. However, privacy and confidentiality concerns in this context are a significant issue in Australia. In this paper, we take the position that if the National and state electronic health records system initiatives, are fully implemented, offshore resourcing can be a feasible complementary option resulting in a win-win situation of cutting costs and enabling the continuum of healthcare.

Healthcare in continuum for an ageing population - national self monitoring or remote offshore monitoring for Australia?

Australia is a country, similar to other developed nations, confronting an ageing population with complex demographics. Ensuring continued healthcare for the ageing, while providing sufficient support for the already aged population requiring assistance, is at the forefront of the national agenda. Varied initiatives are with foci to leverage the advantages of ICTs leading to e-Health provisioning and assisted technologies. While these initiatives increasingly put budgetary constraints on local and federal governments, there is also a case for offshore resourcing of non-critical health services, to support, streamline and enhance the continuum of care, as the nation faces acute shortages of medical practitioners and nurses. However, privacy and confidentiality concerns in this context are a significant issue in Australia. In this paper, we take the position that if the National and state electronic health records system initiatives, are fully implemented, offshore resourcing can be a feasible complementary option resulting in a win-win situation of cutting costs and enabling the continuum of healthcare.

Durability of Microtensile Bond to Nonetched and Etched Feldspar Ceramic: Self-adhesive Resin Cements vs Conventional Resin

Purpose: The objective of this study was to evaluate the effect of thermocycling (TC), self-adhesive resin cements and surface conditioning on the microtensile bond strength (mu TBS) between feldspathic ceramic blocks and resin cements.Materials and Methods: Fifty-six feldspathic ceramic blocks (10 x 7 x 5 mm) (Vita Mark II) were divided into groups according to the factors "resin cement" (3 cements) and "surface conditioning" (no conditioning or conditioning [10% hydrofluoric acid etching for 5 min + silanization]) (n = 8): group 1: conditioning+Variolink II (control group); group 2: no conditioning+Biscem; group 3: no conditioning+RelyX U100; group 4: no conditioning+Maxcem Elite; group 5: conditioning+Biscem; group 6: conditioning+RelyX U100; group 7: conditioning+Maxcem Elite. The ceramic-cement blocks were sectioned to produce non-trimmed bar specimens (adhered cross-sectional area: 1 +/- 0.1 mm(2)), which were divided into two storage conditions: dry, mu TBS immediately after cutting; TC (12,000x, 5 degrees C/55 degrees C). Statistical significance was deterimined using two-way ANOVA (7 strategies and 2 storage conditions) and the post-hoc Tukey test (p<0.05).Results: Resin cement and thermocycling affected the mu TBS significantly (p = 0.001). In the dry condition, group 5 (18 +/- 6.5 MPa) presented the lowest values of mu TBS when compared to the other groups. TC decreased the mean mu TBS values significantly (p<0.05) for all resin cements tested (9.7 +/- 2.3 to 22.1 +/- 6.3 MPa), except for the resin cement RelyX U100 (22.1 +/- 6.3 MPa). In groups 3 and 4, it was not possible to measure mu TBS, since these groups had 100% pre-test failures during sectioning. Moreover, the same occurred in group 2 after TC, where 100% failure was observed during thermocycling (spontaneous failures).Conclusion: Hydrofluoric acid etching and silanization of the feldspathic ceramic surface are essential for bonding self-adhesive resin cement to a feldspathic ceramic, regardless of the resin cement used. Non-etched ceramic is not recommended.