Adolescent self-injurers: Comparing non-ideators, suicide ideators, and suicide attempters

Adolescent non-suicidal self-injury (NSSI) and suicidality are serious health concerns; however, factors that contribute to the transition from NSSI to suicide ideation and suicide attempts are unclear. To address this gap, we investigated whether demographic characteristics, child maltreatment, and psychiatric factors are associated with the level suicidality among adolescents with a history of self-injury. Participants were three groups of adolescent inpatient self-injurers (n = 397, 317 female), aged 13-18 years (M = 15.44, SD = 1.36): (a) non-ideators (n = 96; no current suicide ideation and no lifetime suicide attempts), (b) suicide ideators (n = 149; current ideation and no lifetime attempts), and (c) suicide attempters (n = 152; current ideation and at least one lifetime attempt). Participants completed interviews assessing psychiatric diagnoses, suicidality, and NSSI characteristics, as well as questionnaires on childhood trauma, psychiatric symptoms, and risky behavior engagement. Depression severity was associated with greater odds being a suicide ideator (p < 0.001, OR = 1.04) and an attempter (p < 0.001, OR = 1.05) compared to a non-ideator. Suicide attempters used more NSSI methods and reported greater risky behavior engagement than non-ideators (p = 0.03, OR = 1.29 and p = 0.03, OR = 1.06, respectively) and ideators (p = 0.015, OR = 1.25 and p = 0.04, OR = 1.05, respectively); attempters used more severe NSSI methods (e.g., burning). Our results identify a wide range of risk markers for increasing lethality in a sample at high risk for suicide mortality; future research is needed to refine risk assessments for adolescent self-injurers and determine the clinical utility of using risk markers for screening and intervention.

Testing a Revised Interpersonal Theory of Depression Using a Laboratory Measure of Excessive Reassurance Seeking

OBJECTIVE

This study tested whether core beliefs with themes of abandonment and rejection moderated the link between trait and behavioral excessive reassurance seeking (ERS) and interpersonal rejection.

METHOD

Participants were 118 women with high (n = 43; mean [M]_age = 18.58, standard deviation [SD]_age = 1.24) and low (n = 75; M_age = 18.58, SD_age = 1.24) levels of depression symptoms and their male romantic partners. Couples reported their depression, ERS, abandonment/rejection cognitions, and relationship quality. We also coded women's reassurance-seeking behavior during an audiotaped discussion task.

RESULTS

Among women with high levels of depression symptoms and low levels of abandonment/rejection core beliefs, behavioral ERS was associated with lower partner-reported relationship quality. Self-reported ERS was significantly associated with partner relationship quality, but the effect was not moderated by depression or core beliefs.

CONCLUSIONS

ERS is a potent predictor of stress and subsequent depression. Our findings underscore the need to better understand factors (e.g., cognitions, partner characteristics) that may determine whether ERS behaviors beget interpersonal stress and rejection.

Electrocortical Reactivity During Self-referential Processing in Female Youth With Borderline Personality Disorder

BACKGROUND

Borderline personality disorder (BPD) is debilitating, and theoretical models have postulated that cognitive-affective biases contribute to the onset and maintenance of BPD symptoms. Despite advances, our understanding of BPD pathophysiology in youth is limited. The present study used event-related potentials (ERPs) to identify cognitive-affective processes that underlie negative self-referential processing in BPD youth.

METHODS

Healthy females (n = 33) and females with BPD (n = 26) 13 to 22 years of age completed a self-referential encoding task while 128-channel electroencephalography data were recorded to examine early (i.e., P1 and P2) and late (late positive potential [LPP]) ERP components. Whole-brain standardized low-resolution electromagnetic tomography explored intracortical sources underlying significant scalp ERP effects.

RESULTS

Compared to healthy females, participants with BPD endorsed, recalled, and recognized fewer positive and more negative words. Moreover, unlike the healthy group, females with BPD had faster reaction times to endorse negative versus positive words. In the scalp ERP analyses, the BPD group had greater P2 and late LPP positivity to negative as opposed to positive words. For P2 and late LPP, whole-brain standardized low-resolution electromagnetic tomography analyses suggested that females with BPD overrecruit frontolimbic circuitry in response to negative stimuli.

CONCLUSIONS

Collectively, these findings show that females with BPD process negative self-relevant information differently than healthy females. Clinical implications and future directions are discussed.

Predicting suicide attempts in depressed adolescents: Clarifying the role of disinhibition and childhood sexual abuse

BACKGROUND

Suicide is the second leading cause of death among adolescents, and depressed youth are six times more likely to make suicide attempts as compared to non-depressed adolescents. The present study examined the unique and interactive effects of two well-established correlates of suicidality - childhood sexual abuse (CSA) and disinhibition - in predicting suicide attempts among depressed adolescents.

METHOD

Participants were 163 adolescents (125 females) aged 13-18 (M=15.60, SD=1.27) diagnosed with Major Depressive Disorder (n=95, 58.3%) and/or Dysthymia (n=69, 42.3%) recruited from an acute residential treatment service. Participants completed interviews assessing psychopathology and suicidality, self-report measures of depressive symptoms and CSA, and a computerized disinhibition task.

RESULTS

Consistent with hypotheses, CSA moderated the association between disinhibition and adolescents' report of their past year and lifetime suicide attempts. Specifically, higher disinhibition was associated with a greater likelihood of having made a suicide attempt among adolescents with a history of CSA, but not among those without. The same pattern of results held in analyses of suicide attempt frequency.

LIMITATIONS

Primary findings were based on observational, cross-sectional data, and therefore, causal relationships cannot be inferred. The gender imbalance in the sample precluded stratifying our analyses by gender. CSA was ascertained by self-report; replication of the results with more objective measures is warranted.

CONCLUSIONS

Our findings indicate that CSA and disinhibition may work together to predict elevated suicide risk, and these results have implications for early identification efforts in youth at high risk for suicide.

Identifying differences between depressed adolescent suicide ideators and attempters

BACKGROUND

Adolescent depression and suicide are pressing public health concerns, and identifying key differences among suicide ideators and attempters is critical. The goal of the current study is to test whether depressed adolescent suicide attempters report greater anhedonia severity and exhibit aberrant effort-cost computations in the face of uncertainty.

METHODS

Depressed adolescents (n=101) ages 13-19 years were administered structured clinical interviews to assess current mental health disorders and a history of suicidality (suicide ideators=55, suicide attempters=46). Then, participants completed self-report instruments assessing symptoms of suicidal ideation, depression, anhedonia, and anxiety as well as a computerized effort-cost computation task.

RESULTS

Compared with depressed adolescent suicide ideators, attempters report greater anhedonia severity, even after concurrently controlling for symptoms of suicidal ideation, depression, and anxiety. Additionally, when completing the effort-cost computation task, suicide attempters are less likely to pursue the difficult, high value option when outcomes are uncertain. Follow-up, trial-level analyses of effort-cost computations suggest that receipt of reward does not influence future decision-making among suicide attempters, however, suicide ideators exhibit a win-stay approach when receiving rewards on previous trials.

LIMITATIONS

Findings should be considered in light of limitations including a modest sample size, which limits generalizability, and the cross-sectional design.

CONCLUSIONS

Depressed adolescent suicide attempters are characterized by greater anhedonia severity, which may impair the ability to integrate previous rewarding experiences to inform future decisions. Taken together, this may generate a feeling of powerlessness that contributes to increased suicidality and a needless loss of life.

EMOTION-PROCESSING BIASES AND RESTING EEG ACTIVITY IN DEPRESSED ADOLESCENTS

BACKGROUND

Although theorists have posited that adolescent depression is characterized by emotion-processing biases (greater propensity to identify sad than happy facial expressions), findings have been mixed. Additionally, the neural correlates associated with putative emotion-processing biases remain largely unknown. Our aim was to identify emotion-processing biases in depressed adolescents and examine neural abnormalities related to these biases using high-density resting EEG and source localization.

METHODS

Healthy (n = 36) and depressed (n = 23) female adolescents, aged 13-18 years, completed a facial recognition task in which they identified happy, sad, fear, and angry expressions across intensities from 10% (low) to 100% (high). Additionally, 128-channel resting (i.e., task-free) EEG was recorded and analyzed using a distributed source localization technique (low-resolution electromagnetic tomography (LORETA)). Given research implicating the dorsolateral prefrontal cortex (DLPFC) in depression and emotion processing, analyses focused on this region.

RESULTS

Relative to healthy youth, depressed adolescents were more accurate for sad and less accurate for happy, particularly low-intensity happy faces. No differences emerged for fearful or angry facial expressions. Further, LORETA analyses revealed greater theta and alpha current density (i.e., reduced brain activity) in depressed versus healthy adolescents, particularly in the left DLPFC (BA9/BA46). Theta and alpha current density were positively correlated, and greater current density predicted reduced accuracy for happy faces.

CONCLUSION

Depressed female adolescents were characterized by emotion-processing biases in favor of sad emotions and reduced recognition of happiness, especially when cues of happiness were subtle. Blunted recognition of happy was associated with left DLPFC resting hypoactivity.

Acute and chronic stress exposure predicts 1-year recurrence in adult outpatients with residual depression symptoms following response to treatment

BACKGROUND

One of the strongest predictors of depression recurrence in those who respond to treatment is the presence of residual depressive symptoms. Our goal was to examine stressful life event exposure as a mechanism of recurrence in previously depressed patients with residual depression symptoms. That is, we predicted that higher levels of residual symptoms will significantly predict exposure to acute life events that will then heighten prospective recurrence risk.

METHODS

Participants included 68 adult outpatients with major depression (42 women; age 18-60) who completed a 12-month naturalistic follow-up after achieving remission in a 20-week randomized, open label trial of interpersonal psychotherapy, cognitive-behavioral therapy, or antidepressant medication. Depression recurrence was defined as the reemergence of an episode of major depression as determined by structured interview. Acute life events and chronic stressors were assessed at the end of follow-up using a contextual interview.

RESULTS

Posttreatment depression scores significantly prospectively predicted an increased risk for recurrence, and acute life events in the follow-up period. Cox regression survival analyses modeling life events as time-dependent covariates showed that life event exposure mediated the relation of residual symptoms to recurrence even controlling for chronic stress.

CONCLUSIONS

Our findings implicate residual symptoms in heightening depression recurrence risk through exposure to stressful life events. Depression recurrence adds significantly to the burden of the disorder. Therefore, rigorous follow-up of patients targeting the stressful context has the potential to prevent a lifelong pattern of illness.

Symptom specificity in the acute treatment of Major Depressive Disorder: a re-analysis of the treatment of depression collaborative research program

BACKGROUND

Antidepressant medications, Cognitive-Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) are equally efficacious in the acute treatment of Major Depressive Disorder (MDD). Nevertheless, remission rates remain unacceptably low. Examining the differential time course of remission of specific symptom clusters across treatments may provide a basis for assigning patients to treatments that have the highest chance of being effective.

METHODS

This study re-analyzed data from the NIMH Treatment of Depression Collaborative Research Project (TDCRP), which included 250 adult outpatients with MDD randomized to 16 weeks of CBT, IPT, imipramine+clinical management (IMI-CM), or pill placebo (PLA-CM). We derived four symptom factors from the 23-item Hamilton Depression Rating Scale, and three symptom factors from the Beck Depression Inventory. Within-subject hierarchical regression models were specified to examine the linear and quadratic patterns of symptom remission over five assessment points.

RESULTS

IMI-CM produced a more rapid rate of remission than CBT or IPT for both the somatic/vegetative and cognitive-affective symptoms of MDD. There were no statistically significant differences in the rates of improvement of any of the symptom factors between the IMI-CM and PLA-CM groups.

LIMITATIONS

Some core symptoms of depression were excluded due to low factor loadings. Past research has argued that the CBT arm in the TDCRP may have been weak.

CONCLUSIONS

We failed to find evidence that treatments act preferentially on specific symptom clusters. Therefore, the symptoms of MDD may be inter-dependent when it comes to their courses of remission in treatment.

Cortisol reactivity to social stress in adolescents: role of depression severity and child maltreatment

This study examined the hypothesis that depressed adolescents with a history of childhood maltreatment will show greater cortisol reactivity to psychological stress challenge than those without, and this relation will be moderated by level of depression severity. Seventy-one adolescents were exposed to the Trier Social Stress Test. Salivary cortisol was assessed at baseline, immediately before the challenge, after the challenge, and during an extended recovery period. Childhood maltreatment was assessed with a rigorous contextual interview and rating system. Adolescents with a history of maltreatment produced higher and more prolonged levels of cortisol in response to the challenge than did adolescents with no maltreatment, but only among those with a mild/moderate level of depression severity. Those with moderate/severe depression exhibited a blunted cortisol response regardless of child maltreatment history. These findings indicate that depression is a heterogeneous syndrome, and that both depression severity and child maltreatment history should be considered in studies examining biological stress reactivity.

Symptom specificity and the prospective generation of life events in adolescence

The purpose of the present study was to uncover patterns in the generation of life events from symptom profiles and specific depression symptoms in an effort to obtain a fine-grained understanding of the stress-generation phenomenon. A community sample of 161 adolescents completed the Beck Depression Inventory-II (A. T. Beck, 1996) at Time 1, and then 88 returned 1 year later for an assessment of life events using a rigorous contextual interview and rating system. Consistent with hypotheses, and controlling for baseline stress, cognitive-affective symptoms of depression prospectively predicted higher levels of dependent interpersonal life events. In contrast, somatic symptoms prospectively predicted higher levels of independent life events. Further examination of the types of events generated by specific symptoms suggests that different mechanisms may drive specific patterns of symptom-event generation and suggests that broadening the definition of independence may be necessary to capture the full context of event generation.

Primary and revision total hip replacement in patients who are Jehovah's Witnesses

The Jehovah's Witnesses do not accept allogeneic blood transfusion or certain types of autologous blood transfusion and, therefore, present the orthopaedic surgeon with a challenge in the management of perioperative blood loss. Accepting a patient who is a Jehovah's Witness as a surgical candidate requires the surgeon to be prepared medically to use known techniques to limit red blood cell loss or increase red blood cell mass, to resort to extraordinary means when necessary, and to be prepared philosophically to deal with catastrophic blood loss in a patient who may refuse even potentially life-saving transfusion. Issues pertinent to the management of intraoperative blood loss in the patient who is a Jehovah's Witness require careful delineation and specific treatment guidelines. The authors herein review their past and current experiences in the perioperative blood management of this patient population in an attempt to address this need.

Human performance evaluation of a metaphor graphic display for respiratory data

Metaphor graphics are data displays designed to look like corresponding variables in the real world, but in a non-literal sense of "look like". Evaluation of the impact of these graphics on human problem solving has twice been carried out, but with conflicting results. The present experiment attempted to clarify the discrepancies between these findings by using a complex task in which expert subjects interpreted respiratory data. The metaphor graphic display led to interpretations twice as fast as a tabular (flowsheet) format, suggesting that conflict between earlier studies is due either to differences in training or to differences in goodness of metaphor. Findings to date indicate that metaphor graphics work with complex as well as simple data sets, pattern detection as well as single number reporting tasks, and with expert as well as novice subjects.

Metaphor graphics to support integrated decision making with respiratory data

Support for data integration in the intensive care unit (ICU) often includes efforts to improve the display of data. An electronic version of a flowsheet (table of numbers) with optimal line graphs is by far the most common format in current ICU computer workstation technology, yet there is little evidence that this format provides particularly good support for human integration of data. The present work introduces a new form of graphic representation, one that is far more metaphoric, far more tailored to the intensive care unit than a line graph. This graphic system, called volume rectangles represents mechanical ventilator data in such a way that is easy to keep different types of variables conceptually separated, yet easy to see how they relate in a truly integrated way. Volume rectangles are one example of a general approach to display of data called the metaphor graphic approach, which is being evaluated in this and other contexts. Metaphor graphics are custom tailored visual displays designed to look like the real world situation from which the data is collected but not in a literal sense of 'look like'. Anecdotal observation suggests that such graphics are easy to learn, are remembered over long period, and are good decision support tools when the task is finding patterns in a mass of data.

Formulas for calculation of extraction volumes for commonly used pesticide residue extraction procedures

Formulas are presented for the calculation of extraction volume for pesticide residue procedures that use a single extraction with acetone, acetonitrile, or methanol, with or without prior dilution of these solvents with water. These formulas account for the volume change on mixing and for the volume contribution from the soluble sugars sucrose, glucose, and fructose. Results using these formulas are in agreement with the observed volumes of such mixtures within 0.3% throughout the following ranges, expressed as percent water in the mixtures: 15-38% for acetone, 4.8-59% for acetonitrile, and 9.3-33% for methanol.

Gastrointestinal blood loss and anemia in runners

Iron deficiency, with or without anemia, occurs commonly in long-distance runners, but the cause is unknown. The recent development of a simple quantitative assay for fecal hemoglobin, HemoQuant , allowed us to study whether gastrointestinal bleeding occurs in runners. Blood and stool samples were collected from 24 runners before and after a race of 10 to 42.2 km and from age- and sex-matched, nonrunning controls. The mean blood hemoglobin level and hematocrit were significantly lower in runners than in controls. Serum ferritin levels were below normal in 4 runners but in no controls. Fecal hemoglobin levels increased in 20 of 24 runners (p less than 0.01) after a race. Mean fecal hemoglobin level was 1.08 mg/g (range, 0.11 to 2.36) in controls and 0.99 mg/g (0.18 to 2.41) in runners before a race, but peaked at 3.96 mg/g (0.37 to 43.20) after a race. Competitive long-distance running induces gastrointestinal blood loss and may contribute to iron deficiency.

The tolerance of re-irradiation of heavily irradiated human skin

The clinical course of a group of 15 female patients treated with X-ray therapy for radiation-induced hypopharyngeal tumours is reviewed. Neither acute nor late skin reactions exceeded those expected in similar radical treatments of patients not previously irradiated. One patient appeared to have been cured by the treatment and four achieved two years' palliation. It is suggested that the tolerance of skin to re-irradiation following a long period may approach normal.

Re-irradiation of rat tails to necrosis at six months after treatment with a "tolerance" dose of x rays or neutrons

Rat tails were re-irradiated to necrosis levels at about six months after various fractionated treatments with 290 kV X rays or 14 MeV neutrons. The X ray dose required to produce necrosis in half of a group of tails (ND50), which had been heavily X-irradiated six months before, was 91+/-4% of the ND50 for aged controls. After prior neutron-irradiation, however, this value was 87+/-4% (neutrons in second treatment) or 75+/-5% (X rays in second course). The "effective" oxygenation of mouse tails at this time after X-irradiation was similar to that of controls; thus these percentage dose values indicate the remarkable tolerance of this organized tissue to a second course of X-irradiation, and the presence of more residual injury in neutron-irradiated tissues.

Evidence for conformeric states of rhodopsin

Spectrophotometric measurements of metarhodopsin II appearance are made on five different kinds of rhodopsin preparations. Although the preparations differ greatly in their rhodopsin: phospholipid ratio, the meta II kinetics in all of them are strikingly similar in certain respects. Meta II appearance kinetics in all of the preparations are best described by two and only two exponentials. The ratio of these two rates is always about 5. The fast fraction: slow fraction ratio depends upon temperature. These fractions are reversibly convertible in the dark, and are interconverted on a time-scale which is long compared to the meta II appearance rate. It is shown that the kinetics of the earlier step in the bleaching sequence, viz., lumi-leads to meta I, is also described by double exponentials. Again the ratio of rates is ca. 5 and the fast-slow fractions correspond to those found in the meta I leads to meta II step. It is proposed that these facts support an hypothesis for the existence of two conformeric states of rhodopsin which are in thermal equilibrium. Thermodynamic parameters associated with this proposed equilibrium are presented.

Tolerance of rodent tails to necrosis after "daily" fractionated X rays or D-T neutrons

The rat tail has been used as a model system to study the necrosis of an organized tissue following fractionated doses of collimated D-T neutrons or 290 kV X rays. RBE values for tail tolerance - 10 per cent of tails necrosing after the early skin reactions - rise from about 1-7 (single doses) to about 3-1 (16 fractions in 22 days). Neutron tolerance doses are almost independent of fractionation from 2 to 16 fractions. The tissues at risk are shown to be rather hypoxic. Early skin reaction levels can be used to predict the fraction of tails that will necrose. Early peak reactions for a given fraction of necrotic tails were slightly higher for neutrons than for X rays, and this difference was consistent for all the dose fractionation schedules employed.