Externalizing the threat from within: A new direction for researching associations between suicide and psychotic experiences

A recent suicidal drive hypothesis posits that psychotic experiences (PEs) may serve to externalize internally generated and self-directed threat (i.e., self-injurious/suicidal behavior [SIB]) in order to optimize survival; however, it must first be demonstrated that such internal threat can both precede and inform PEs. The current study conducted the first known bidirectional analysis of SIB and PEs to test whether SIB could be considered as a plausible antecedent for PEs. Prospective data were utilized from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative birth cohort of 2232 twins, that captured SIB (any self-harm or suicidal attempt) and PEs at ages 12 and 18 years. Cross-lagged panel models demonstrated that the association between SIB at age 12 and PEs at age 18 was as strong as the association between PEs at age 12 and SIB at age 18. Indeed, the best representation of the data was a model where these paths were constrained to be equal (OR = 2.48, 95% CI = 1.63-3.79). Clinical interview case notes for those who reported both SIB and PEs at age 18, revealed that PEs were explicitly characterized by SIB/threat/death-related content for 39% of cases. These findings justify further investigation of the suicidal drive hypothesis.

Emotional Reactivity and Family-Related Factors Associated With Self-Injurious Behavior in Adolescents Presenting to a Child and Adolescent Psychiatric Emergency Service

Background: Adolescents presenting in a child and adolescent psychiatric emergency service show various psychiatric disturbances, most commonly suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI). It was postulated that especially disturbed emotion regulation contributes to self-injurious behavior of young people. This study aims to investigate the relevance of emotional reactivity (ER), as part of emotion regulation, during an acute crisis, how it relates to self-injurious behavior reinforcement and how a family as well as peers' history of self-injurious behavior are associated with self-injurious behavior of presenting adolescents. Additionally, crisis-triggering background factors were evaluated from the perspective of patients and their caregivers. Methods: A consecutive sample of 86 adolescents aged 11-18 years presenting to the emergency outpatient department due to self-injurious thoughts and behavior received a pretreatment psychiatric evaluation. Among other psychometric measures and structured clinical interviews, ER was measured via the Emotion Reactivity Scale (ERS). Family-related aspects were collected both through evaluation of history and through questionnaires filled in by custodians or parents. Results: Data analysis revealed that suicidal ideation was significantly related to family history with self-injurious behavior in comparison with a family background without such a history. A significant positive correlation was apparent between the ERS sensitivity score and occurrence of NSSI within the past year. A relationship between the ERS and distinct types of reinforcement as a motivation factor for NSSI was found. Post-hoc tests revealed a significant difference between boys and girls when no positive peers' history is present with boys having lower ERS scores than girls, but no difference when both groups had friends engaging in self-injurious behavior. There was only moderate agreement between parents and their children in naming reasons for the current crisis involving NSSI. Conclusion: Emotional regulation, especially ER, has an influence on patients' acute psychiatric symptomatology and when experiencing an acute crisis should be brought into focus early at psychiatric assessment. A history of self-injurious behavior taken from patient's family members and close circle of friends and agreement on reasons for the crisis should be routinely included in the exploration of a patient presenting with self-injurious behavior.

Korean University Students' Problematic Alcohol use, Depression, and Non-Suicidal Self-Injury During COVID-19 Lockdown

BACKGROUND

This study investigated depression, problematic alcohol use, and non-suicidal self-injury (NSSI) of university students in Korea during COVID-19 lockdown and evaluated the moderating effect of problematic alcohol use in the relationship between depression and NSSI.

METHODS

In this descriptive cross-sectional study, 234 Korean university students' data were used to analyze the relationship between depression and NSSI and the moderating effect of problematic alcohol use. To analyze the moderating effect, Hayes PROCESS macro (model 1) was used.

RESULTS

Of the participants, 69.7% were problematic alcohol drinkers and 58.1% were binge drinkers. Depression and NSSI scores were 13.948 and 0.901, respectively. Of the participants, 33.3% had experienced NSSI for 6 months. Depression was positively associated with NSSI among university students. Furthermore, problematic alcohol use had a conditional moderating effect on the relationship between depression and NSSI.

CONCLUSIONS

Problematic alcohol use had conditional moderating effects on the relationship between depression and NSSI. Additionally, since the COVID-19 pandemic is ongoing, to prevent NSSI, health care professionals in the university should screen students with problematic alcohol use and depressive symptoms.

Self-Injurious behavior in rhesus macaques: Issues and challenges

Some monkeys housed in research facilities develop abnormal behavior ranging from stereotypic to the more serious condition of self-injurious behavior (SIB). We initially sought to understand how and why monkeys engaged in SIB and more importantly why only a small percentage of laboratory monkeys, with seemingly similar housing and background, developed this disorder. Of particular importance was the recognition that different pathways might lead to SIB and that strong individual differences would affect the manifestation of this disorder and the response to treatment. We developed a comprehensive plan to identify effective treatment and prevention strategies. We started with characterizing the disorder in terms of prevalence and types of environments in which it was found. We then conducted observations on a cohort of SIB and control monkeys to identify conditions associated with SIB (e.g., disordered sleep) as well as clinical disease states and congenital defects that could be precipitating factors. We examined the environmental events that triggered episodes of SIB in monkeys with the disorder and evaluated three models that might explain the reinforcement contingencies associated with SIB, including tension reduction, self-stimulation, and social communication. Possible treatments for SIB such as environmental enrichment, social housing, and pharmacotherapy were tested by our group and others. To date, no single treatment has been found to abolish SIB, and each of these treatments is impacted by individual differences. To develop possible prevention strategies, we examined colony management and health records to find risk factors for SIB. These risk factors generalized to other facilities, and considerable effort was expended by all behavioral managers at these facilities to reduce early life stress exposure, to minimize the length of individual cage housing by emphasizing pair housing, and to reduce the possible stressfulness of various veterinary/medical procedures by implementing positive reinforcement training.

The Correlation between Oral Self-Harm and Ethnicity in Institutionalized Children

Oral self-harm was described in institutionalized children who share a lack of emotional attention; frequently these children experience feelings such as neglect, loneliness, isolation or lack of connection with the world. The aim of our paper was to conduct a cross-sectional study in order to assess the prevalence of this behavior and its correlation with ethnicity among children from three institutions located in the central part of Romania. We examined 116 children from three ethnic groups, Romanians, Hungarians and local Roma population aged between 10–14 years old. The oral soft tissues were evaluated by one dentist who recorded the lesions of lips, buccal mucosa, commissures and tongue; data were statistically analyzed at a level of significance of p < 0.05. We found oral self-harm lesions in 18.1% participants, with statistically significant higher odds in girls (p = 0.03). The results showed an association between ethnicity and the development of these lesions (Chi-square p = 0.04). The most frequent lesions were located at oral commissures (35.48%), buccal mucosa (29.03%) and upper lip (19.36%). Oral self-harm lesions have a high incidence among institutionalized children in Romania. Identification of these cases in early stages is important, as these conditions are known to be aggravated during adolescence and adulthood.

Fetal teratogenicity in a rhesus macaque (Macaca mulatta): Association with the chronic maternal treatment of amitriptyline

Amitriptyline is a tricyclic antidepressant commonly prescribed in humans for pain and sleep disorders and in non-human primates for self-injurious behaviors. Here, we report a clinical case on the teratogenic effect of maternal-fetal amitriptyline exposure.

[Adolescent with non-suicidal self-harm in a psychosocial adversity environment]

Non-suicidal harmful behaviors pose a health problem of increasing importance, with a prevalence in community samples of adolescents of 15-20 %. Self-harm can have adverse meaning, qualifying in intrapersonal or interpersonal; they are a risk and evolutionary factor, with an age of onset in early adolescence. We present the case of a 12-year-old adolescent with psychosocial risk factors, who went to the consultation for self-cuts in arms and legs, made with a razor, detected in the school. It was enhanced her self-steem an guided in regulation of emotions with multidisciplinary intervention (educational system, social services, infantile-juvenile Psychiatry and Pediatrics), with a positive evolution. It is vital to detect and approach this issue with the patient and the family to avoid future risks, especially psychic pathology. The intervention is done from Primary Care, but it is necessary the collaboration of other professionals.

Assessing Digital Risk in Psychiatric Patients: Mixed Methods Study of Psychiatry Trainees' Experiences, Views, and Understanding

BACKGROUND

The use of digital technology can help people access information and provide support for their mental health problems, but it can also expose them to risk, such as bullying or prosuicide websites. It may be important to consider internet-related risk behavior (digital risk) within a generic psychiatric risk assessment, but no studies have explored the practice or acceptability of this among psychiatrists.

OBJECTIVE

This study aimed to explore psychiatry trainees' experiences, views, and understanding of digital risk in psychiatry. We predicted that clinician awareness would be highest among trainees who work in child and adolescent mental health services.

METHODS

We conducted a cross-sectional survey of psychiatry trainees attending a UK regional trainees' conference to investigate how they routinely assess patients' internet use and related risk of harm and their experience and confidence in assessing these risks. We conducted focus groups to further explore trainees' understandings and experiences of digital risk assessment. Descriptive statistics and chi-squared tests were used to present the quantitative data. A thematic analysis was used to identify the key themes in the qualitative data set.

RESULTS

The cross-sectional survey was completed by 113 out of 312 psychiatry trainees (response rate 36.2%), from a range of subspecialties and experience levels. Half of the trainees (57/113, 50.4%) reported treating patients exposed to digital risk, particularly trainees subspecializing in child and adolescent psychiatry (17/22, 77% vs 40/91, 44%;P=.02). However, 67.3% (76/113) reported not feeling competent to assess digital risk. Child and adolescent psychiatrists were more likely than others to ask patients routinely about specific digital risk domains, including reckless web-based behavior (18/20, 90% vs 54/82, 66%; P=.03), prosuicide websites (20/21, 95% vs 57/81, 70%; P=.01), and online sexual behavior (17/21, 81% vs 44/81, 54%; P=.02). Although 84.1% (95/113) of the participants reported using a proforma to record general risk assessment, only 5% (5/95) of these participants prompted an assessment of internet use. Only 9.7% (11/113) of the trainees had received digital risk training, and 73.5% (83/113) reported that they would value this. Our thematic analysis of transcripts from 3 focus groups (comprising 11 trainees) identified 2 main themes: barriers to assessment and management of digital risk, and the double-edged sword of web use. Barriers reported included the novelty and complexity of the internet, a lack of confidence and guidance in addressing internet use directly, and ongoing tension between assessment and privacy.

CONCLUSIONS

Although it is common for psychiatrists to encounter patients subject to digital risk, trainee psychiatrists lack competence and confidence in their assessment. Training in digital risk and the inclusion of prompts in standardized risk proformas would promote good clinical practice and prevent a potential blind spot in general risk assessment.

Self-injurious behavior in epilepsy

Self-injurious behavior (SIB) can be described as an act involving self-inflicted destruction of tissue, right away or over a period of time. Patients with epilepsy have to deal with an often chronic and unpredictable disorder leading to adversity in many psychosocial variables such as employment, stigma, and overall quality of life. The above factors contribute toward SIB in these patients. Behavioral problems occurring in people with epilepsy can range from aggressiveness, mood fluctuations to SIB. We report a 23-year-old male, married, educated up to 10^th standard, referred from neurology department for psychiatric evaluation. The patient had gone to neurologist with the chief complaints of generalized tonic-clonic convulsions and was hospitalized for breakthrough seizure. There was a history of indulging in episodes of self-SIB since the past 8 months. He responded satisfactorily to adjustment of antiepileptic medication along with fluoxetine and low-dose risperidone. Early identification of such behavior in epilepsy patients should be done so that a holistic management is undertaken leading to better functioning and improved quality of life.

Increasing Trend and Characteristics of Korean Adolescents Presenting to Emergency Department for Self-Harm: A 5-Year Experience, 2015 to 2019

PURPOSE

Emergency department (ED) is a common treatment setting for adolescents with clinically serious self-harm. Here, we investigated the clinical characteristics and trends of adolescents with self-harm who visited the ED in one Korean university hospital. We also compared patients with a single ED visit to those with multiple ED visits to identify the risk factor of repeated visits.

MATERIALS AND METHODS

We retrospectively identified patients aged 12 to 18 years who presented to ED for self-harm from January 2015 to December 2019, based on electronic medical records. Self-harm included all thoughts and behaviors indicating intents to harm or hurt oneself, regardless of the degree of such attempt.

RESULTS

A total of 168 individuals (male:female=31:137; average 15.99±1.64 years) presented to ED following 304 episodes (45 and 259 episodes in males and females, respectively). The number of episodes steeply increased between 2016 and 2019, and the overall number during the study showed an increasing trend (p=0.043). Repeated ED visitors with self-harm showed more history of psychiatric treatment/admission (58.3% vs. 85.4%, p=0.002; 14.2% vs. 43.9%, p<0.001), history of child abuse (32.3% vs. 53.7%, p=0.013), and familial psychiatric history (13.4% vs. 31.7%, p=0.008) compared to those with a single visit.

CONCLUSION

Among Korean adolescents, the number of ED visits and repetition of ED visits for self-harm is on the rise. For adolescents presenting to ED with self-harm, the history of psychiatric treatment/admission, child abuse, and familial psychiatric history should be properly obtained to identify the risk for multiple ED visits.

Longitudinal relations of self-criticism with disordered eating behaviors and nonsuicidal self-injury

OBJECTIVE

Self-criticism has been proposed as a transdiagnostic predictor of disordered eating and nonsuicidal self-injury (NSSI). First, this study explored cross-sectional associations of multiple disordered eating behaviors, NSSI, and self-criticism. Second, it tested longitudinal relations of self-criticism with disordered eating and NSSI, adjusting for baseline levels of both behaviors.

METHODS

In Sub-study 1, undergraduates (N = 251, 79.5% female, M_age = 19.1 years) completed self-report measures of disordered eating, NSSI, and self-criticism at baseline and after 8 weeks. In Sub-study 2, community-based young adults with histories of disordered eating, NSSI, or both (N = 517, 88.8% female, M_age = 24.7 years) completed measures of disordered eating, NSSI, and self-criticism at baseline and after 4 weeks. All measures were completed online.

RESULTS

In Sub-study 1, both disordered eating and NSSI showed significant cross-sectional associations with self-criticism, and self-criticism was significantly related to binge eating, fasting, and NSSI at follow-up. In Sub-study 2, both behaviors again showed significant cross-sectional associations with self-criticism. Self-criticism showed significant longitudinal relations with fasting, purging, and excessive exercise. Longitudinal relations of self-criticism with NSSI varied across disordered eating behaviors.

DISCUSSION

NSSI showed cross-sectional associations with a range of disordered eating behaviors. Self-criticism reflects a common correlate of both disordered eating and NSSI. Evidence supported transdiagnostic longitudinal impact of self-criticism across multiple forms of disordered eating but provided more limited support for impacts on NSSI.

Sensitivity to Changing Environmental Conditions across Individuals with Subtype 2 Automatically Reinforced and Socially Reinforced Self-injury

Automatically reinforced Subtype 2 self-injurious behavior (ASIB) has been characterized as showing insensitivity to competing reinforcement contingencies in the contexts of both functional analyses and in treatment using reinforcement alone (Hagopian, Rooker, &Yenokyan, 2018). One question is whether this insensitivity is specific to Subtype 2 ASIB as response class in these contexts or whether it is represents a generalized response tendency of the individual that is evident across other response classes. To examine this question, we compared responding on a single-operant task under changing reinforcement schedules for three individuals with Subtype 2 ASIB, relative to a comparison group of three individuals with socially reinforced SIB (which is characterized by sensitivity to changes in reinforcement contingencies). As hypothesized, all individuals showed sensitivity to changes in contingencies. These results provide preliminary support that the insensitivity of Subtype 2 ASIB is a property specific to that response class in these contexts rather than a generalized response tendency of the individual.

Examining the Self-Harm and Suicide Contagion Effects of the Blue Whale Challenge on YouTube and Twitter: Qualitative Study

BACKGROUND

Research suggests that direct exposure to suicidal behaviors and acts of self-harm through social media may increase suicidality through imitation and modeling, particularly in more vulnerable populations. One example of a social media phenomenon that demonstrates how self-harming behavior could potentially be propagated is the blue whale challenge. In this challenge, adolescents and young adults are encouraged to engage in self-harm and eventually kill themselves.

OBJECTIVE

This paper aimed to investigate the way individuals portray the blue whale challenge on social media, with an emphasis on factors that could pose a risk to vulnerable populations.

METHODS

We first used a thematic analysis approach to code 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced the blue whale challenge. We then deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) safe messaging guidelines as a metric for the contagion risk associated with each video.

RESULTS

The thematic analysis revealed that social media users post about the blue whale challenge to raise awareness and discourage participation, express sorrow for the participants, criticize the participants, or describe a relevant experience. The deductive coding of the YouTube videos showed that most of the videos violated at least 50% of the SPRC safe and effective messaging guidelines.

CONCLUSIONS

These posts might have the problematic effect of normalizing the blue whale challenge through repeated exposure, modeling, and reinforcement of self-harming and suicidal behaviors, especially among vulnerable populations such as adolescents. More effort is needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects.

Clonidine as a Treatment of Behavioural Disturbances in Autism Spectrum Disorder: A Systematic Literature Review

BACKGROUND

Agitation and aggression are commonly cited reasons for psychiatry consultation for individuals diagnosed with autism spectrum disorder (ASD). While risperidone and aripiprazole do not carry Health Canada approval for management of ASD-associated irritability, both are used for this indication but are not universally effective and carry substantial risk of adverse effects. This necessitates use of off-label medications to assist in management of behavioral dysregulation. Clonidine, an alpha-2 receptor agonist, is approved in Canada for treatment of hypertension. The evidence base also supports its use for attention deficit/hyperactivity disorder (ADHD) and for tics in Tourette's disorder. This review focuses on examining the literature regarding clonidine as a treatment of challenging behaviours in the ASD population.

METHOD

Systematic search of MEDLINE, EMBASE, and PsycINFO databases resulted in 540 unique records. Ten publications were relevant to this review.

RESULTS

Two cross-over studies, one open-label case series, and seven case reports were identified. One of two controlled studies suggested benefit from clonidine versus placebo. Caregivers typically noted improvement in behaviour with clonidine versus baseline. Clonidine was generally well-tolerated. Sedation was the most consistently reported adverse effect. Despite being an anti-hypertensive medication, few discontinued clonidine due to hypotension or bradycardia.

CONCLUSION

Clonidine has a limited evidence base for use in the management of behavioural problems in patients with ASD. Most evidence originates from case reports. Given the paucity of pharmacological options for addressing challenging behaviours in ASD patients, a clonidine trial may be an appropriate and cost-effective pharmaceutical option for this population.

Emotional Response Inhibition: A Shared Neurocognitive Deficit in Eating Disorder Symptoms and Nonsuicidal Self-Injury

Eating disorder (ED) symptoms often co-occur with non-suicidal self-injury (NSSI). This comorbidity is consistent with evidence that trait negative urgency increases risk for both of these phenomena. We previously found that impaired late-stage negative emotional response inhibition (i.e., negative emotional action termination or NEAT) might represent a neurocognitive mechanism for heightened negative urgency among people with NSSI history. The current study evaluated whether relations between negative urgency and ED symptoms similarly reflect deficits in this neurocognitive process. A total of 105 community adults completed an assessment of ED symptoms, negative urgency, and an emotional response inhibition task. Results indicated that, contrary to predictions, negative urgency and NEAT contributed independent variance to the prediction of ED symptoms, while controlling for demographic covariates and NSSI history. Worse NEAT was also uniquely associated with restrictive eating, after accounting for negative urgency. Our findings suggest that difficulty inhibiting ongoing motor responses triggered by negative emotional reactions (i.e., NEAT) may be a shared neurocognitive characteristic of ED symptoms and NSSI. However, negative urgency and NEAT dysfunction capture separate variance in the prediction of ED-related cognitions and behaviors, distinct from the pattern of results we previously observed in NSSI.

Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients

OBJECTIVES

To evaluate effectiveness of Milieu Therapy in reduction of conflict and containment rates among schizophrenia patients.

METHODS

This study utilized quasi experimental non-equivalent control group pre-post design. One hundred schizophrenia patients admitted in acute psychiatric wards were non-randomly assigned to either of the experimental (n=50) or control group (n=50). The experimental group received both milieu therapy and routine hospital treatment. The Milieu Therapy intervention Included environmental modification and structuring ward activities, establishing effective interaction with patient, and teaching caregivers on managing conflict behavior of patient. The control group received only routine treatment in the hospital. Outcome measures on conflict and containment rates were evaluated for both the groups at baseline and at 2nd, 3rd and 15th day. The Patient-Staff Conflict Checklist Shift Report (PCC-SR) was used to collect information about rates of conflict and containment.

RESULTS

Compared with control group, the experimental group participants showed decrease in aggressive behavior, self-harm behavior and general rule breaking behavior at baseline and 2nd, 3rd and 15th day (F=4.61, p < 0.004, η2=0.04; F=11.92, p < 0.001, η2=0.11; F=6.94, p < 0.001, η2=0.06) over seven days interval.

CONCLUSIONS

The present study findings provided evidence for the effectiveness of integrating Milieu Therapy in psychiatric acute wards in reducing conflict behaviors among schizophrenia patients. Milieu therapy should be considered as an integral part of psychiatric care settings in these patients.

Comparison of the demographic and wound characteristics of non-suicidal and suicidal self-wrist cutting injuries

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

Self-injurious behavior and related mortality in children under 10 years of age: a retrospective health record study in Brazil

OBJECTIVE

To describe and analyze data on self-injurious behavior (SIB) and related mortality in children under 10 years old in Brazil.

METHODS

A descriptive study was performed using secondary public health care data extracted from the Hospital Information System (Sistema de Informações Hospitalares, SIH) and Mortality Information System (Sistema de Informações sobre Mortalidade, SIM) in Brazil. The databases are available for online access at http://datasus.saude.gov.br/.

RESULTS

In Brazil, according to SIH data, 11,312 hospitalizations of patients under 10 years of age were recorded from 1998 to 2018 as resulting from SIB (ICD-10 X60-X84 codes). Of these, 65 resulted in death. According to the SIM, from 1996 to 2016, 91 deaths related to SIB were recorded, 81 (89%) in children aged 5 to 9 years, nine (9.9%) in children aged 1 to 4 years, and one (1.1%) in a child below 1 year of age.

CONCLUSION

These results highlight the relevance of creating measures to better understand SIB and related mortality in this age group. They also reveal the vulnerability of children in Brazil and warrant further studies to address these issues.

Development and Implementation of a Brain Rest Protocol in Nonintellectually Challenged Youth With Head-Banging Behaviors

INTRODUCTION: Concussions as a result of mild traumatic brain injury (MTBI) in youth are often associated with athletic injury; however, they can also occur as a result of intentional self-injury by head banging. Despite the known neurological sequelae secondary to MTBI, assessment, interventions, and consequences of head banging in the nonintellectually disabled populations have not been well studied. AIMS: The intent of this nurse-led intervention was to develop a brain rest protocol at a residential treatment program serving youth who were between 12 and 19 years old in order to improve the quality of care and moderate negative sequelae resulting from MTBI. METHODS: A nursing assessment guided by an adaptation of the acute concussion evaluation and a strength-based intervention protocol was developed and applied to youth who engage in head banging. RESULTS: The result was a protocol that defined the process by which a youth would be assessed and treated after head banging. There are no outcome measures that would assist to measure the effectiveness of this intervention in the short or long term. CONCLUSION: This intervention filled a need for improved assessment and appropriate interventions in youth with head-banging behavior. It is feasible that the assessment and implementation of the brain rest protocol is the first step in understanding how to best evaluate and manage the sequelae of intentional head banging resulting from MTBI.

Using Wearable Physiological Monitors With Suicidal Adolescent Inpatients: Feasibility and Acceptability Study

Background

Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such monitors are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress.

Objective

This study aimed to evaluate the feasibility and acceptability of using a wearable behavioral and physiological monitor, the Empatica E4, to continuously assess a group of suicidal adolescent inpatients.

Methods

Participants (n=50 adolescent inpatients) were asked to wear an Empatica E4 on their wrist for the duration of their inpatient stay. In addition to assessing behavioral metadata (eg, hours worn per day), we also used qualitative interviews and self-report measures to assess participants’ experience of wearing the monitor.

Results

Results supported the feasibility and acceptability of this approach. Participants wore the monitor for an average of 18 hours a day and reported that despite sometimes finding the monitor uncomfortable, they did not mind wearing it. Many of the participants noted that the part of the study they enjoyed most was contributing to scientific understanding, especially if it could help people similar to them in the future.

Conclusions

These findings provide promising support for using wearable monitors in clinical samples in future studies, especially if participants are invested in being part of a research study.

Negative Emotional Action Termination (NEAT): Support for a Cognitive Mechanism Underlying Negative Urgency in Nonsuicidal Self-Injury

Negative urgency, the self-reported tendency to act impulsively when distressed, increases risk for nonsuicidal self-injury (NSSI). NSSI is also associated with impaired negative emotional response inhibition (NERI), specifically negative emotional action termination (NEAT), a cognitive process theoretically related to negative urgency. We previously found that adults with NSSI history had difficulty inhibiting behavioral responses to affective images depicting negative content (but not positive or neutral images) in an Emotional Stop-Signal Task. We sought to replicate this finding, determine whether this deficit extends to negative emotional action suppression (NEAS; an earlier stage of NERI), and explore whether impairment in these two stages of emotional response inhibition helps explain the relationship between negative urgency and NSSI. Eighty-eight adults with NSSI history (n = 45) and healthy control participants (n = 43) without NSSI history or psychopathology completed a clinical interview, symptom inventories, an impulsivity questionnaire, and behavioral assays of early and late NERI (NEAS and NEAT, respectively). The NSSI group had worse NEAT than the control group in the Emotional Stop-Signal Task, but no group differences in NEAS were observed in an Emotional Go/No-go task. However, both early and late stages of NERI accounted for independent variance in negative urgency. We additionally found that NEAT explained variance in the association between negative urgency and NSSI. These results suggest that impulsive behavior in NSSI may involve specifically impaired inhibitory control over initiated negative emotional impulses. This deficit in late response inhibition to negative emotional stimuli might reflect a cognitive mechanism or pathway to elevated negative urgency among people who self-injure.

Behavior of self-inflicted violence in patients with bipolar disorder: A systematic review protocol

BACKGROUND

Studies aimed at understanding the higher risk profiles for self-inflicted violence in individuals with BD become essential as a possible predictive risk measure for the presence of suicidal behavior, corroborating the expressive reduction of suicide deaths in young people who are in psychic suffering.

METHODS

The protocol was constructed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA-P) and the research question was constructed using guidelines from the Population Intervention Comparator Outcome Setting (PICOS) strategy. A third reviewer will be contacted, and two studies will be included in the selection, analysis and inclusion phases of the articles, in case of divergence, a third reviewer will be contacted. (1) methodological design studies of cohorts, case-control and cross-sectional; (2) Diagnosis of Bipolar disorder according to Diagnostic and statistical Manual of mental disorders V; (3) Studies with adult population and (4) Studies that consider at least one type of self-inflicted violence as a variable. The articles considered eligible will be analyzed by New Castle - Ottawa quality assessment scale/cross section studies (NOS) to evaluate the quality of the studies.

RESULTS

The identification of the characteristics of self-harm may subsidize professionals who work in the treatment of bipolar disorder with greater attention to these practices and monitoring of possible suicidal behaviors.

CONCLUSION

This study may represent one of the initial measures of evaluation on these correlations, which will allow to protocol the guidelines in the field of practice and contribute to improvements in public health indexes.

Suicidal and self-harm presentations to Emergency Departments: The challenges of identification through diagnostic codes and presenting complaints

BACKGROUND

The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce.

OBJECTIVE

To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia.

METHOD

All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard).

RESULTS

A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%).

CONCLUSION

Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.

Translating striatal activity from brain slice to whole animal neurophysiology: A guide for neuroscience research integrating diverse levels of analysis

An important goal of this review is highlighting research in neuroscience as examples of multilevel functional and anatomical analyses addressing basic science issues and applying results to the understanding of diverse disorders. The research of Dr. Michael Levine, a leader in neuroscience, exemplifies this approach by uncovering fundamental properties of basal ganglia function and translating these findings to clinical applications. The review focuses on neurophysiological research connecting results from in vitro and in vivo recordings. A second goal is to utilize these research connections to produce novel, accurate descriptions for corticostriatal processing involved in varied, complex functions. Medium spiny neurons in striatum act as integrators combining input with baseline activity creating motivational "events." Basic research on corticostriatal synapses is described and links developed to issues with clinical relevance such as inhibitory gating, self-injurious behavior, and relative reward valuation. Work is highlighted on dopamine-glutamate interactions. Individual medium spiny neurons express both D₁ and D₂ receptors and encode information in a bivalent manner depending upon the mix of receptors involved. Current work on neurophysiology of reward processing has taken advantage of these basic approaches at the cellular and molecular levels. Future directions in studying physiology of reward processing and action sequencing could profit by incorporating the divergent ways dopamine modulates incoming neurochemical signals. Primary investigators leading research teams should mirror Mike Levine's efforts in "climbing the mountain" of scientific inquiry by performing analyses at different levels of inquiry, integrating the findings, and building comprehensive answers to problems unsolvable without this bold approach.