The association of non-suicidal self-injury and suicidal behavior according to DSM-5 in adolescent psychiatric inpatients

Nonsuicidal Self-Injury in Adolescents: Characterization of the Disorder and the Issue of Distress and Impairment

Nonsuicidal self-injury disorder (NSSID) is a condition in need of further study to assess the validity of the potential diagnosis and its suggested criteria. This study examined the NSSID diagnosis and investigated the distress/impairment criterion by comparing community adolescents who met all criteria for NSSID (n = 186) to adolescents with five or more nonsuicidal self-injury (NSSI) episodes (n = 314), and to a group of adolescents who met all criteria but negated that their NSSI caused them any distress or impairment, thus failing to meet criterion E (n = 29). The NSSID group delimited from the ≥ 5 NSSI group by reporting significantly more frequent and severe self-injurious thoughts and behaviors, as well as having more experiences of negative life events and higher levels of trauma symptoms. There were also some differences between the NSSID group and adolescents without distress/impairment, which together contribute valuable information on the potential NSSID diagnosis, as well as the discussion of criterion E.

Psychobiological response to pain in female adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with reduced pain sensitivity and alterations in top-down processing of nociceptive information. The experience of acute pain is characterized by reactivity of the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis, which to our knowledge has not been systematically investigated in the context of NSSI.

METHODS

Adolescents fulfilling DSM-5 diagnostic criteria for NSSI and matched healthy controls received cold pain stimulation. We obtained self-reports on psychological distress and measured blood pressure, heart rate variability (HRV) and saliva cortisol. Regression analyses were used to investigate group differences on observed difference scores, adjusting for confounding variables.

RESULTS

We included 30 adolescents engaging in NSSI and 30 controls in our study. Adolescents in the NSSI group showed a greater pain threshold. Groups significantly differed in their psychological response to pain. In patients with NSSI, mood and body awareness increased after painful stimulation; in controls it decreased. Tension increased in controls only. The HPA axis response to painful stimulation was increased in the NSSI compared with the control group. Analysis of ultra-short-term recordings of HRV revealed significant group differences during the anticipation of pain and recovery.

LIMITATIONS

Future studies should incorporate multiple measures of saliva cortisol and replicate the present findings in a naturalistic setting.

CONCLUSION

Compared with controls, individuals engaging in NSSI show psychological benefits in response to pain. Biological findings highlight decreased physiologic arousal before and prolonged arousal (ANS and HPA axis response) after painful stimulation in adolescents engaging in NSSI. Greater pain-inflicted autonomic arousal and cortisol secretion may counteract dissociative states, reduce negative affect and increase body awareness in adolescents engaging in NSSI, lending support for a neurobiological pathomechanism underlying the intraindividual and antisuicide functions of NSSI.

Psychological and physical pain as predictors of suicide risk: evidence from clinical and neuroimaging findings

PURPOSE OF REVIEW

Suicide is a multidimensional clinical phenomenon with complex biological, social and psychological risk factors. Therefore, it is imperative for studies to focus on developing a unified understanding of suicide risk that integrates current clinical and neurobiological findings. A recent line of research has implicated different classifications of pain in understanding suicide risk, including the concepts of psychache and pain tolerance. Although psychache is defined as the experience of unbearable psychological pain, pain tolerance refers to the greatest duration or intensity of painful stimuli that one is able to bear. This review will focus on integrating current clinical and neurobiological findings by which psychache and pain tolerance confer suicide risk.

RECENT FINDINGS

Results indicate that psychache has been identified as a significant risk factor for suicide and that psychache may be associated with the neurocircuitry involved in the modulation of physical pain. Converging evidence has also been found linking pain tolerance to self-injurious behaviours and suicide risk. The experience of psychache and physical pain in relation to other predictors of suicide, including reward processing, hopelessness and depression, are further discussed.

SUMMARY

Future research examining the pain-suicide connection is required to understand the mechanism behind clinically relevant risk factors for suicide, which can ultimately inform the construction of empirically supported suicide risk assessment and intervention techniques.

Non-suicidal Self-Injury in Adolescence

PURPOSE OF REVIEW

Non-suicidal self-injury (NSSI) is a common mental health threat among adolescents. This review aims to present the current literature on epidemiology, etiology, and therapeutic approaches with a focus on the period of adolescence.

RECENT FINDINGS

NSSI is widespread among adolescents both in community as well as in clinical settings with lifetime prevalence rates between 17 and 60% in recent studies. It is influenced by multiple factors including social contagion, interpersonal stressors, neurobiological background, as well as emotional dysregulation and adverse experiences in childhood. There is still a lack of studies regarding the psychotherapeutic as well as the psychopharmacological treatment of NSSI in adolescence. Furthermore, sufficient evidence for prevention programs is missing.

Treating nonsuicidal self-injury (NSSI) in adolescents: consensus based German guidelines

BACKGROUND

Nonsuicidal self-injury (NSSI) is a frequent and clinically relevant phenomenon in adolescence. Within Europe, Germany has one of the highest prevalence rates in youth with lifetime prevalence ranging between 25 and 35%. However, treatment guidelines for NSSI are not yet available.

METHODS

Consensus based clinical guidelines were created by a working group consisting of members of eleven medical, psychological or psychotherapeutic professional national associations, and two members of patient self-help and prevention groups. The guidelines were developed in consecutive expert meetings and literature searches and agreed on in a final consensus conference.

RESULTS

Given that evidence on both the psychotherapeutic and psychopharmacological treatment of NSSI is limited, a consensus based approach was chosen. The consensus indicated that due to the accumulating evidence on the efficacy of psychotherapeutic approaches, core elements of psychotherapy should be provided in treatment of NSSI. A specific psychopharmacological therapy of NSSI cannot be recommended. In addition, the guidelines provide recommendations for surgical intervention of NSSI.

CONCLUSIONS

In accordance with the heterogeneous level of evidence, recommendations for the clinical management of NSSI in adolescence were made during a consensus conference after reviewing available literature. There is still a lack of knowledge on prevention as well as clinical interventions, which needs to be addressed by further clinically relevant studies.

The prevalence of Nonsuicidal Self-Injury (NSSI) in a representative sample of the German population

BACKGROUND

Non-suicidal self-injury (NSSI) is a proposed new "condition for further study" in the DSM-5. To date no prevalence data has been available on this diagnostic entity from a representative sample of the general population.

METHODS

A representative sample of the German population (N = 2509, mean age = 48.8 years, SD = 18.1, female 55.4 %) completed the NSSI section of the German version of the Self-Injurious Thoughts and Behaviors Interview (SITBI-G).

RESULTS

A history of NSSI at least once during lifetime was reported by 3.1 % of all participants, with higher lifetime prevalence rates in younger age groups. DSM-5 NSSI disorder criteria were met by 0.3 %. The most common function of NSSI was automatic negative reinforcement (e.g. to alleviate negative feelings).

CONCLUSIONS

To the best of our knowledge, this is the first study reporting rates for the proposed NSSI category in DSM-5 from a representative sample of the general population. In comparison to findings from community samples of adolescents, adults seem to have lower lifetime prevalence rates of NSSI, thus making it necessary to emphasize prevention and treatment efforts in younger age groups.

Reasons for Non-Suicidal Self-Harm in Adult Male Offenders With and Without Borderline Personality Traits

The presented study aimed to advance understanding of the reasons for non-suicidal self-harm (NSSH) in adult male offenders, with and without borderline personality traits. 179 offenders completed self-report measures of NSSH and other clinical constructs, with 42 being identified as having self-harmed. Results were consistent with past research and supported the relative importance of intrapersonal over interpersonal functions, but also highlight that self-harm is performed rarely for one type of reason. The results also show that the presence of borderline personality traits increases the likelihood of endorsing a range of interpersonal reasons. These findings highlight the importance of understanding the range of reasons for engaging in NSSH to help manage the behaviour within the prison.

Differential neural processing of social exclusion in adolescents with non-suicidal self-injury: An fMRI study

Non-suicidal self-injury (NSSI) is highly prevalent in adolescence and has been suggested as an autonomous diagnosis in the Diagnostic and Statistical Manual (DSM-5). Social rejection is as potential risk-factor for NSSI and depression in adolescence. Objectives of this study were to identify differences in neural processing of social rejection in depressed adolescents with and without co-morbid NSSI and healthy controls. Participants were 28 depressed adolescents (14 with co-morbid NSSI, 79% females) and 15 healthy controls, with an average age of 15.2 years (SD=1.8). Social exclusion was implemented using the Cyberball paradigm 'Cyberball' during functional magnetic resonance imaging (fMRI). All participants reported feelings of social exclusion after fMRI scanning. Investigating the effects of NSSI, we found that depressed adolescents with NSSI showed relatively enhanced activation of the medial prefrontal cortex (mPFC) and the ventrolateral prefrontal cortex (vlPFC) compared to depressed adolescents without NSSI and also compared to healthy controls. Results point towards divergent processing of social exclusion in depressed adolescents with NSSI as compared to adolescents with mere depression in brain regions previously related to the processing of social exclusion. This finding of distinct neurophysiological responses may stimulate further research on individual treatment approaches.

Direct and indirect forms of childhood maltreatment and nonsuicidal self-injury among clinically-referred children and youth

BACKGROUND

Although exposure to direct forms of childhood maltreatment is among the most widely studied risk factors for nonsuicidal self-injury (NSSI), research on NSSI has largely overlooked the role of exposure to indirect forms of child maltreatment (i.e., witnessing domestic violence). To address this gap in the literature, the present study examined associations among both direct and indirect forms of child maltreatment and NSSI among clinically-referred children and youth.

METHODS

Data was collected using the interRAI Child and Youth Mental Health Assessment (ChYMH) at ten mental health agencies. The ChYMH is a comprehensive standardized clinical assessment tool completed by trained assessors using multiple sources. The study included a convenience sample of 747 children and youth (68% male) between ages 8-18 with complex mental health histories referred for inpatient or outpatient care in Ontario, Canada.

RESULTS

Univariate chi-square analyses indicated positive associations with NSSI and both direct (i.e., physical, sexual) and indirect child maltreatment (i.e., witnessing domestic violence). In a binary multivariate logistic regression analysis controlling for participant age and sex, only exposure to indirect child maltreatment emerged as multivariate predictor of NSSI.

LIMITATIONS

The sample was limited to only 10 mental health agencies and only consenting parents/guardians referred to mental health services suggesting the study may not be generalizable to all clinical samples.

CONCLUSION

The present study provides evidence that witnessing domestic violence in childhood is an important risk factor for NSSI. Clinical relevance includes implications for clinicians to develop targeted intervention and prevention strategies for NSSI for children who have witnessed domestic violence.

Non-suicidal self-injury and suicidal ideation in relation to eating and general psychopathology among college-age women

Non-suicidal self-injury (NSSI) and suicidal ideation are potent risk factors for suicide and are associated with general and eating disorder-specific psychopathology. Limited research has examined the effects of combined NSSI+suicidal ideation thus concurrent examination is needed to understand potential differential effects on psychopathology. College-aged women (N=508) completed self-report measures of NSSI, suicidal ideation, general psychopathology, and Eating Disorder-specific psychopathology. MANOVAs determined whether the NSSI/SI status groups differed on general and eating disorder pathology measures as a set. Significant MANOVAs were followed up with univariate ANOVAs and posthoc tests. Thirteen women endorsed NSSI+Suicidal Ideation, 70 endorsed NSSI-only, 25 endorsed Suicidal Ideation-only, and 400 endorsed no NSSI/Suicidal Ideation. Both general and eating disorder-specific psychopathology differed across groups. NSSI+Suicidal Ideation and Suicidal Ideation-only groups typically endorsed higher general psychopathology than the no NSSI/Suicidal Ideation and NSSI-only groups. Regarding eating disorder pathology, the NSSI+Suicidal Ideation group was more pathological than no NSSI/Suicidal Ideation and NSSI-only, except on the weight concerns scale, where NSSI+Suicidal Ideation only differed from no NSSI/Suicidal Ideation. The NSSI+Suicidal Ideation group was only greater than Suicidal Ideation-only on measures of depression and eating concern. Results highlight the importance of screening for both NSSI and suicidal ideation, especially for individuals with eating disorder symptoms. Likewise, screening for eating disorder pathology may be beneficial for individuals presenting with NSSI and suicidal ideation.