Self-mutilative behavior in adolescents who attempt suicide by overdose

Pain perception in female adolescents with borderline personality disorder

Borderline personality disorder (BPD) is a severe and often debilitating psychiatric disorder that begins during adolescence. Core features of BPD are affective dysregulation, dysfunctional self-concepts, and difficulties in social interactive domains. A widely accepted marker for severe emotion dysregulation in adult BPD is decreased pain sensitivity. Until now it is unclear whether this characteristic feature of BPD is already present during adolescence. Thus, this study aims to investigate pain sensitivity in adolescent patients meeting DSM-IV criteria for BPD. 20 female adolescent patients with BPD (mean age 16.4 years) and 20 healthy age-matched control participants were investigated. Detection and pain thresholds for thermal stimuli were assessed on both hands. Furthermore, self-rating instruments were used to assess overall psychopathology, dissociation, and depression. We found significantly higher pain thresholds in patients with BPD than in healthy controls. Patients with BPD had higher intensities of depression, overall psychopathology, and dissociative symptoms, but there was no correlation between pain sensitivity and any of these measures of psychopathology. These findings are in line with previous findings in adult BPD patients concerning lower pain sensitivity as compared to healthy controls. This provides support for the idea that disturbed pain processing is not only a consequence of chronic BPD but is already present in early stages of BPD.

Psychiatric and self-injury profiles of adolescent suicide attempters versus adolescents engaged in nonsuicidal self-injury

To better delineate the unique correlates of self-injurious behaviors (SIB), psychiatric profiles of mutually exclusive groups of adolescents who made a suicide attempt (SA) versus those engaged in nonsuicidal self-injury (NSSI) were examined. Contrary to hypotheses, the NSSI group endorsed earlier onsets of SIB and suicidal ideation (SI), as well as higher rates of depression and anxiety compared with their SA counterparts. Future work is warranted to understand the role of SI, including duration of SI and anxiety in the development of NSSI, and to identify risk and resiliency factors useful in predicting an adolescent's SIB status.

Patterns of non-suicidal self-injurious behaviours among college students in India

BACKGROUND

Non-suicidal self-injurious behaviour (NSSI) is a growing concern among youth and rarely reaches the attention of mental health and medical services.

AIMS

The study explored the occurrence, methods, characteristics and reported reasons for NSSI among a sample of college students in India.

METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the Functional Assessment of Self Mutilation (FASM) questionnaire.

RESULTS

Results indicated that 31.2% of the participants reported NSSI in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of NSSI were reported by 19.8% of the sample. The most common method was self-hitting (15.2%) followed by cutting or carving skin (13.2%). A majority of self-injurers endorsed multiple methods of NSSI, and there were no significant gender differences in NSSI rates. The NSSI was performed both to regulate internal emotional states (automatic reinforcement) and to influence others in the environment (social reinforcement).The most commonly endorsed reasons for NSSI were 'to feel relaxed' and 'to get control of the situation', while the least frequently endorsed reasons were 'to make others angry' and 'to avoid college, work, or other activities'.

CONCLUSION

The findings underscore the need to increase the awareness and understanding of NSSIs and to plan targeted interventions among college youth.

Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters

The current study compared characteristics of suicidal behavior and interpersonal violence in suicide attempters with and without a history of non-suicidal self-injury (NSSI). A total of 100 suicide attempters were assessed with Karolinska Interpersonal Violence Scale (KIVS) and Karolinska Suicide History Interview concerning interpersonal violence and NSSI. There was a high degree of comorbid NSSI in suicide attempters (44%). Suicide attempters with NSSI-history reported more interpersonal violence as adults and more severe suicidal behavior compared to suicide attempters without NSSI. Comorbid NSSI was related to severity of suicidal behavior in a gender specific manner. Comorbid NSSI in suicide attempters may increase suicide and violence risk.

Non-suicidal self-injury disorder in a community sample of adults

Non-suicidal self-injury (NSSI) Disorder has been included in DSM-5 for the first time as a disorder requiring further research. The present study investigated DSM-5 criteria for NSSI Disorder in a community sample of adults and provided an initial investigation of differences between those with and without a diagnosis of NSSI Disorder and NSSI history. Participants over the age of 18 (N=548) completed an online survey using Amazon׳s MTurk. A lifetime history of NSSI was reported by 23% of the sample. Nearly 3% of the total sample and 11.2% of those with an NSSI history met criteria for NSSI Disorder. Those with NSSI Disorder were similar to participants with an NSSI history who did not meet criteria for the disorder on NSSI frequency and methods, and age of NSSI onset, use of coping strategies, and borderline symptoms, but they differed on automatic reinforcement of the behavior and reported interference with functioning. Endorsement of specific NSSI Disorder criteria, potential implications for the diagnosis, and avenues for future research are discussed.

Psychiatric and psycho-social characteristics of suicide completers: a comprehensive evaluation of psychiatric case records and postmortem findings

Objectives

To explore the demographic, psychosocial and clinical characteristics of individuals known to the mental health services, who died by probable suicide in the West of Ireland.

Methods

Postmortem reports between January 2006 and May 2012 detailed 153 individuals who died by probable suicide, 58 of whom attended the mental health services. Relevant socio-demographic and clinical data was extracted from individuals’ lifetime case notes.

Results

Recurrent depressive disorder (44%) was the most common diagnosis and hanging the most common method of death (58%). Of individuals who died by hanging, 79% previously attempted suicide by the same method. For individuals with a documented history of depression, only 32% had antidepressants detected in their toxicology reports. Similarly, only one individual (20%) with schizophrenia had antipsychotics detected in their toxicology report.

Conclusions

Individuals who died by probable suicide, most commonly died by hanging and drowning; with previous attempts of hanging particularly prevalent in the group who subsequently died by hanging. At the time of death, less than one-third of individuals according to toxicology reports were taking the medication that was last prescribed to them by the mental health services suggesting a high rate of treatment non-concordance in individuals who died by probable suicide.

Personality organization in borderline patients with a history of suicide attempts

Suicide attempts (SA) are common in patients with Borderline Personality Disorder (BPD). Recent studies focus on aspects of personality associated with risk for SA such as deficits in affect regulation including impulse control and aggression. The current study examines associations of dysfunctional personality organization, psychiatric comorbidities as well as non-suicidal self-injury (NSSI) with SA in a sample of 68 BPD outpatients. Patients with a history of SA yielded higher scores in personality domains of aggression, especially self-directed aggression. Further, a history of SA was associated with a worse general level of personality organization and a higher prevalence rate of NSSI and substance abuse disorder. The results demonstrate that SA in BPD patients might be regarded as a manifestation of impaired personality functioning rather than mere state variables and symptoms. Moreover, these findings might have implications for indication, treatment, and prognosis of Borderline Personality Disorder.

A cross-sectional study of adolescent non-suicidal self-injury: support for a specific distress-function relationship

BACKGROUND

This study has investigated the specific relationship between childhood adversities, individual trauma symptoms and the functions of non-suicidal self-injury (NSSI). The aim was to examine whether different self-reported adverse experiences and trauma symptoms predict the need to engage in NSSI, either to regulate emotions or to communicate with and influence others.

METHOD

The participants were a community sample of 816 adolescents aged 15-17 years with NSSI. Hierarchical multiple regression was used, controlling for NSSI frequency and gender. The dependent variables were the automatic and social functions of NSSI, respectively. The predictors entered in the model were several different maltreatment and adversity experiences as well as individual trauma symptoms. Mediation analyses were also performed using the bootstrapping method with bias-corrected confidence estimates.

RESULTS

Frequency of NSSI, gender (female), emotional abuse, prolonged illness or handicap during upbringing and symptoms of depression uniquely predicted the automatic functions of NSSI in the final regression model, but not the social functions. Symptoms of anxiety uniquely predicted social but not automatic functions. Having experienced physical abuse, having made a suicide attempt and symptoms of dissociation were significant predictors in both final models. The model for automatic functions explained more of the variance (62%) than the social model (28%). The relationship between childhood emotional, physical and sexual abuse and performing NSSI for automatic reasons was mediated by symptoms of depression and dissociation. The relationship between physical abuse and the social functions of NSSI was mediated by symptoms of anxiety and dissociation.

CONCLUSIONS

It is important to understand the specific context in which NSSI has developed and is maintained. Experiences of emotional abuse and symptoms of depression could guide clinical work in the direction of emotion regulation skills since in this study these variables were uniquely associated with the need to engage in NSSI to regulate emotions, to self-punish or to generate feelings. The presence of physical abuse, a suicide attempt and symptoms of dissociation could alert clinicians to a broad treatment approach since they were associated with performing NSSI to regulate both social and automatic experiences.

Why alternative teenagers self-harm: exploring the link between non-suicidal self-injury, attempted suicide and adolescent identity

BACKGROUND

The term 'self-harm' encompasses both attempted suicide and non-suicidal self-injury (NSSI). Specific adolescent subpopulations such as ethnic or sexual minorities, and more controversially, those who identify as 'Alternative' (Goth, Emo) have been proposed as being more likely to self-harm, while other groups such as 'Jocks' are linked with protective coping behaviours (for example exercise). NSSI has autonomic (it reduces negative emotions) and social (it communicates distress or facilitates group 'bonding') functions. This study explores the links between such aspects of self-harm, primarily NSSI, and youth subculture.

METHODS

An anonymous survey was carried out of 452 15 year old German school students. Measures included: identification with different youth cultures, i.e. Alternative (Goth, Emo, Punk), Nerd (academic) or Jock (athletic); social background, e.g. socioeconomic status; and experience of victimisation. Self-harm (suicide and NSSI) was assessed using Self-harm Behavior Questionnaire and the Functional Assessment of Self-Mutilation (FASM).

RESULTS

An "Alternative" identity was directly (r ≈ 0.3) and a "Jock" identity inversely (r ≈ -0.1) correlated with self-harm. "Alternative" teenagers self-injured more frequently (NSSI 45.5% vs. 18.8%), repeatedly self-injured, and were 4-8 times more likely to attempt suicide (even after adjusting for social background) than their non-Alternative peers. They were also more likely to self-injure for autonomic, communicative and social reasons than other adolescents.

CONCLUSIONS

About half of 'Alternative' adolescents' self-injure, primarily to regulate emotions and communicate distress. However, a minority self-injure to reinforce their group identity, i.e. 'To feel more a part of a group'.

Family dynamics and self-injury behaviors: a correlation analysis

This study tested the relationship between family dynamics and self-injury. A total of 189 participants responded to a web-based survey collecting information related to previous self-injury behaviors and family dynamics. Participants were over 18 years old who had used self-injury (intentionally harming themselves physically to relieve painful emotions without suicidal intent), but who had not used self-injury for over a year. Results indicated that healthy family dynamics were negatively correlated and associated with higher scores of self-injury behaviors. This study offers some evidence that family dynamics influence self-injury behaviors. The implications for family therapy are discussed.

Nonsuicidal self-injury in an adolescent population in Singapore

This mixed methods study examined the phenomenon of nonsuicidal self-injury (NSSI) of adolescents in Singapore. The researchers analyzed quantitative data to understand the functions of NSSI, the relationship of parental invalidation to NSSI, and the association between academic stress and parental invalidation. In addition, the researchers employed semi-structured qualitative interviews to provide supportive qualitative data. The participants were outpatients at the Child Guidance Clinic, Singapore, between the ages of 13 to 19 years old. Researchers compared 30 participants who engage in NSSI with 30 participants who do not engage in NSSI. The emotional regulation function was the most commonly endorsed function for NSSI. Adolescents who engage in NSSI have statistically significant (p < .01) higher mean parental invalidation scores than those who do not engage in NSSI. There is also a moderate, positive correlation between the level of parental invalidation and the level of academic stress for Singaporean adolescents. The researchers discuss the implications of this study for mental health professionals.

Relationship between Personality Profiles and Suicide Attempt via Medicine Poisoning among Hospitalized Patients: A Case-Control Study

Objectives. Inflexible personality traits play an important role in the development of maladaptive behaviors among patients who attempt suicide. This study was conducted to investigate the relationship between personality profiles and suicide attempt via medicine poisoning among the patients hospitalized in a public hospital. Materials and Methods. Fifty-nine patients who attempted suicide for the first time and hospitalized in the poisoning ward were selected as the experimental group. Sixty-three patients hospitalized in the other wards for a variety of reasons were selected as the adjusted control group. Millon Clinical Multiaxial Personality Inventory, 3rd version (MCMI-III) was used to assess the personality profiles. Results. The majority of the suicide attempters were low-level graduates (67.8% versus 47.1%, OR = 2.36). 79.7% of the suicide attempters were suffering from at least one maladaptive personality profile. The most common maladaptive personality profiles among the suicide attempters were depressive personality disorder (40.7%) and histrionic personality disorder (32.2%). Among the syndromes the most common ones were anxiety clinical syndrome (23.7%) and major depression (23.7%). Conclusion. Major depression clinical syndrome, histrionic personality disorder, anxiety clinical syndrome, and depressive personality disorder are among the predicators of first suicide attempts for the patients hospitalized in the public hospital due to the medicine poisoning.

Measurement of perceived functions of non-suicidal self-injury for Chinese adolescents

Due to the lack of validated assessment tools for motives of non-suicidal self-injury behaviors in the Chinese contexts, this study aims to evaluate the psychometric properties of the Chinese version of the Functional Assessment of Self-Mutilation (C-FASM). A total of 345 secondary school students (mean age = 11.41 years), who reported non-suicidal self-injury in the past year, voluntarily participated in the questionnaire survey. Confirmatory factor analysis results supported a second-order model of 4 motivational factors. The overall scale scores had significant correlations with depression, anxiety, impulsiveness, self-esteem, social support, and suicidal ideation. The internal consistency of the scale was also satisfactory. The C-FASM is a valid and reliable instrument for assessing non-suicidal self-injury among nonclinical Chinese adolescents.

Phenomenology of borderline personality disorder: the role of race and socioeconomic status

Little is known about racial differences in borderline personality disorder (BPD) that may influence etiology, phenomenology, and treatment of women with BPD. A total of 83 women with BPD participated in this cross-sectional study: n = 41 white and n = 42 African-American women. Structured interviews were used to assess Axis I and II disorders, and a series of interviews and questionnaires captured internalizing and externalizing symptoms. The white women with BPD reported more severe internalizing symptoms, whereas the African-American women reported more severe externalizing symptoms. Except for the association between race and number of suicide attempts, the relationship between race and internalizing/externalizing symptoms was mediated by socioeconomic status. In conclusion, African-American women with BPD may present with more severe symptoms of lack of anger control and fewer suicidal behaviors than those of white women with BPD, raising the possibility that they are misdiagnosed and receive treatments that are not optimal for BPD.

Cognitive and social factors associated with NSSI and suicide attempts in psychiatrically hospitalized adolescents

Although non-suicidal self-injury (NSSI) and suicide attempts (SA) frequently co-occur among youth, there is increasing evidence that both the risk factors and the phenomenology of the behaviors are distinct. This study examined how individuals who engage in NSSI only, individuals who attempt suicide only, and those who have histories of both NSSI and at least one suicide attempt may differ in terms of cognitions and perceived social support. Participants were 185 adolescents (78.1 % female) between the ages of 13 and 18 recruited from a psychiatric inpatient facility in the northeastern United States. One hundred forty-eight teens were identified with a history of self-injurious behavior and divided into three groups: NSSI only (n = 45), SA only (n = 24) or both NSSI and SA (NSSI+SA; n = 79). Analyses showed that the NSSI+SA group exhibited more cognitive errors, negative self-statements, and negative views of self, world, and future, as well as less perceived familial support than either the NSSI or SA only groups. There were no differences between groups on perceived support from teachers or peers. No significant demographic or diagnostic differences were found between the NSSI and SA groups. Limitations and clinical implications of the current research are discussed.

Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm--a cross-sectional study

BACKGROUND

To investigate whether schizophrenia patients with both suicide attempts and non-suicidal self-harm have earlier age of onset of psychotic and depressive symptoms and higher levels of clinical symptoms compared to patients with only suicide attempts or without suicide attempt.

METHODS

Using a cross-sectional design, 251 patients (18-61 years old, 58% men) with schizophrenia treated at hospitals in Oslo and Innlandet Hospital Trust, Norway, were assessed with a comprehensive clinical research protocol and divided into three groups based on their history of suicide attempts and non-suicidal self-harm.

RESULTS

Suicide attempts were present in 88 patients (35%); 52 had suicide attempts only (29%) and 36 had both suicide attempts and non-suicidal self-harm (14%). When compared with nonattempters and those with suicide attempts without non-suicidal self-harm, patients with both suicide attempts and non-suicidal self-harm were more frequently women, younger at the onset of psychotic symptoms, had longer duration of untreated psychosis, and had higher levels of current impulsivity/aggression and depression. Patients with both suicide attempts and non-suicidal self-harm were more likely to repeat suicide attempts than patients with suicide attempts only.

CONCLUSIONS

Patients with both suicide attempts and non-suicidal self-harm had different illness history and clinical characteristics compared to patients with only suicide attempts or patients without suicidal behavior. Our study suggests that patients with both suicide attempts and non-suicidal self-harm represent a distinct subgroup among patients with schizophrenia and suicidal behavior with their early onset of psychotic symptoms, high rate of repeated suicidal behavior and significant treatment delay.

Nonsuicidal self-harm and suicide attempts in adolescents: differences in kind or in degree?

PURPOSE

The purpose of the present study was to measure the prevalence of self-harm (SH) behaviours and examine potential differences in characteristics among adolescents reporting on self-harm (SH), depending on whether they had attempted suicide (SA), performed nonsuicidal self-harm (NSSH), or both.

METHODS

Cross-sectional survey of 11,440 adolescents aged 14-17 years in the city of Oslo, Norway. Responses regarding measures of lifetime SH and risk factors were collected. The response rate was 92.7%. Data were analysed by segregating SH responses into the categories of NSSH, SA, and NSSH + SA.

RESULTS

Among all respondents, 4.3% reported NSSH, 4.5% reported SA, 5.0% reported both NSSH and SA, and 86.2% reported no SH. The group reporting to have engaged in both behaviours comprised more girls and reported more suicidal ideation, problematic lifestyles, poorer subjective health, and more psychological problems compared with the other groups. The four groups could be distinguished by one discriminant function that accounted for most of the explained variance.

CONCLUSIONS

Our findings suggest that NSSH and SA are parts of the same dimensional construct in which suicidal ideation carries much of the weight in adolescents from a school-based sample. They also indicate the group of adolescents who seems to alternate between NSSH and SA is more burdened with mental ill-health and behavioural problems compared with others. These adolescents should therefore be targeted by clinicians and school health personnel for identification and provision of adequate help and services.

Borderline personality disorder in suicidal adolescents

The diagnosis of borderline personality disorder (BPD) in adolescents has been controversial. Thus, few studies have examined BPD in suicidal adolescents, even though it is strongly associated with suicidal behaviours in adults. This study examines differences between suicidal adolescents with (n = 47) and without (n = 72) BPD on history and characteristics of suicidal behaviour, Axis I co-morbidity, affect regulation and aggression. Assessments were completed with both adolescents and parents, and consensus ratings based on best available data were analysed. BPD participants were more likely to have a history of suicide attempts and to have been admitted because of a suicide attempt (vs. suicidal ideation). There were no significant differences in self-injurious behaviours or degree of suicidal ideation. BPD participants also had more psychiatric co-morbidity and higher aggression scores but no significant differences in affective dysregulation compared with suicidal adolescents without BPD. Diagnostic stability over 6 months was modest. Our results demonstrate that, compared with other acutely suicidal adolescents, the clinical profile of BPD participants is unique and suggests an increased risk for suicidal behaviours. This extends upon other studies that support the construct validity of BPD during adolescence and suggests that BPD should be considered in suicide risk assessment for adolescents.

Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth

This study aimed to investigate a specific relationship between nonsuicidal self-injury (NSSI) and a variety of adverse childhood experiences (ACEs) over and above childhood abuse and their impact on frequency, severity, and functions of NSSI. A sample of 125 inpatients (aged 13 to 26) was consecutively recruited within a psychiatric university hospital. Frequency, methods and functions of NSSI were assessed by the Functional Assessment of Self-Mutilation (FASM), ACEs were assessed by the Childhood Experiences of Care and Abuse Questionnaire (CECA.Q). The 12 month prevalence of NSSI in this representative, clinical sample was 60.0%. Engagement in NSSI was significantly related to ACEs with highest associations for maternal antipathy and neglect. Whilst ACEs were not associated with frequency or severity of NSSI, some ACEs were significantly related to the automatic functions of NSSI (e.g., affect regulation, anti-dissociative function or self-punishment) as well as to a peer identification function. NSSI represents a frequent phenomenon among young clinical populations and seems to be specifically related to ACEs with maternal antipathy or neglect commonly featured over and above experiences of abuse. Since ACEs also influence the functions of NSSI such factors need to be examined as part of clinical care planning.

Suicidality and unhealthy weight control behaviors among female underaged psychiatric inpatients

OBJECTIVE

The aim of this study was to investigate whether unhealthy weight control behaviors, fear of becoming obese, binge eating, impulsivity, and body mass index are associated with suicide ideation, repetitive self-mutilative behavior (SMB), suicide attempts, or both suicide attempts and SMB among female adolescent psychiatric inpatients.

METHODS

Data were drawn from a clinical inpatient cohort of female adolescents (N = 300, aged 12-17 years) consecutively admitted for psychiatric hospitalization between April 2001 and March 2006. Information on adolescents' suicidal behavior, psychiatric Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnoses and weight control behaviors was obtained using the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL).

RESULTS

Even after adjustment with DSM-IV, affective, anxiety and eating disorders self-induced vomiting was significantly associated with SMB and suicide attempts with SMB. Impulsivity was related to suicide attempts with SMB. Excessive exercising was a significant finding only in those girls who had attempted suicide. Girls who had attempted suicide were more often overweight compared with girls without suicidal behavior.

CONCLUSION

Unhealthy weight control behaviors among adolescent girls were found to be strongly associated with suicidal behavior. Girls with a history of both suicide attempts and SMB seem to be the most disturbed group, with multiple weight loss methods and impulsivity. Girls who are overweight or exercise excessively may represent risk groups for attempted suicide.

The Relationship between the UPPS-P Impulsivity Dimensions and Nonsuicidal Self-Injury Characteristics in Male and Female High-School Students

The present study investigated the association between nonsuicidal self-injury characteristics, functions, and the UPPS-P impulsivity-related traits in high-school students using self-report questionnaires. More than 17% of the 613 students engaged in at least one type of NSSI behavior. Compared to male students, female students engaged more often in cutting and less in head banging. All NSSI behaviors were significantly related to Negative and Positive Urgency, that is, the tendency to act impulsive in the presence of negative/positive affect. Interactions between different UPPS-P impulsivity dimensions did not increase the percentage of explained variance in the different NSSI behaviors. Furthermore, severe cutting was negatively related to Lack of Premeditation. Different NSSI functions showed differential relationships with the five UPPS-P impulsivity dimensions.

Measuring engagement in deliberate self-harm behaviours: psychometric evaluation of six scales

BACKGROUND

Engagement in Deliberate Self-Harm (DSH) is commonly measured by behavioural scales comprised of specific methods of self-harm. However, there is a scarcity of information about the degree to which the methods relate to the same DSH construct although such scales are routinely used to provide a DSH total score. This study addresses the shortfall by evaluating the dimensionality of six commonly used behavioural measures of DSH.

METHODS

The DSH measures were Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviors Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). The behavioural scales contained in each measure were administered to 568 young Australians aged 18 to 30 years (62% university students, 21% mental health patients, and 17% community members). Scale quality was examined against the stringent standards for unidimensional measurement provided by the Rasch model.

RESULTS

According to the stringent post-hoc tests provided by the Rasch measurement model, there is support for the unidimensionality of the items contained within each of the scales. All six scales contained items with differential item functioning, four scales contained items with local response dependency, and one item was grossly misfitting (due to a lack of discrimination).

CONCLUSIONS

This study supports the use of behavioural scales to measure a DSH construct, justifies the summing of items to form a total DSH score, informs the hierarchy of DSH methods in each scale, and extends the previous evidence for reliability and external validity (as provided by test developers) to a more complete account of scale quality. Given the overall adequacy of all six scales, clinicians and researchers are recommended to select the scale that best matches their adopted definition of DSH.

A comparison of adolescents engaging in self-injurious behaviors with and without suicidal intent: self-reported experiences of adverse life events and trauma symptoms

Research comparing adolescents engaging in suicidal and non-suicidal self-injury (NSSI), both separately and in combination, is still at an early stage. The purpose of the present study was to examine overlapping and distinguishable features in groups with different types of self-injurious behaviors, using a large community sample of 2,964 (50.6% female) Swedish adolescents aged 15-17 years. Adolescents were grouped into six categories based on self-reported lifetime prevalence of self-injurious behaviors. Of the total sample, 1,651 (55.7%) adolescents reported no self-injurious behavior, 630 (21.2%) reported NSSI 1-4 times, 177 (6.0%) reported NSSI 5-10 times, 311 (10.5%) reported NSSI ≥ 11 times, 26 (0.9%) reported lifetime prevalence of suicide attempt and 169 (5.7%) adolescents reported both NSSI and suicide attempt. After controlling for gender, parental occupation and living conditions, there were significant differences between groups. Pairwise comparisons showed that adolescents with both NSSI and suicide attempt reported significantly more adverse life events and trauma symptoms than adolescents with only NSSI, regardless of NSSI frequency. The largest differences (effect sizes) were found for interpersonal negative events and for symptoms of depression and posttraumatic stress. Adolescents with frequent NSSI reported more adversities and trauma symptoms than those with less frequent NSSI. There were also significant differences between all the NSSI groups and adolescents without any self-injurious behavior. These findings draw attention to the importance of considering the cumulative exposure of different types of adversities and trauma symptoms when describing self-injurious behaviors, with and without suicidal intent.

Co-calibration of deliberate self harm (DSH) behaviours: towards a common measurement metric

The purpose of this study was to co-calibrate items from different deliberate self-harm (DSH) behavioural scales on the same measurement metric and compare cut points and item hierarchy across those scales. Participants included 568 young Australians aged 18-30 years (62% university students, 21% mental health patients, and 17% community volunteers). Six DSH scales (containing 82 items) were administered, namely, Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviours Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). Data were co-calibrated onto an underlying metric using the Rasch measurement model. The resulting calibration shows that the different scales occupy different ranges on the hierarchy of DSH methods with prevalence estimates ranging from 47.7 to 77.1%. A raw score conversion table is provided to adjust prevalence rates and to equate cut points on the six scales. A Rasch-validated hierarchy of DSH behaviours is also provided to inform the development of DSH nomenclatures and assist clinical practice.

Direct and indirect forms of non-suicidal self-injury: evidence for a distinction

Non-suicidal self-injury (NSSI) involves deliberate acts (such as cutting) that directly damage the body but occur without suicidal intent. However, other non-suicidal behaviors that involve people mistreating or abusing themselves but that do not deliberately and directly damage bodily tissue may have much in common with NSSI. Such 'indirect' methods of self-injury might include involvement in abusive relationships, substance abuse, risky or reckless behavior, or eating disordered behavior. Using a community sample (N=156) we compared individuals engaging in NSSI (n=50), indirect (non-suicidal) self-injurers (n=38), and healthy controls (n=68) on a range of clinical and personality characteristics. As predicted, non-suicidal self-injurers and indirect self-injurers showed more pathology than healthy controls on all measures. Comparisons of the NSSI and the Indirect self-injury groups revealed no significant differences on measures of dissociation, aggression, impulsivity, self-esteem, negative temperament, depressive symptoms, and borderline personality disorder. However, compared to people who engaged only in indirect forms of self-injury, those who engaged in NSSI were more self-critical, had higher scores on a measure of suicide proneness, and had a history of more suicide attempts. The findings suggest that NSSI and indirect self-injury are best viewed as separate and distinct clinical phenomena.

The co-occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates

Although attempted suicide and non-suicidal self-injury (NSSI) are distinct behaviors differing in intent, form, and function, the behaviors co-occur at a high rate in both adults and adolescents. Researchers have begun to investigate the association between attempted suicide and NSSI among adolescents. The purpose of this paper is to present current research on this association. First, we discuss definitional issues associated with self-injurious behaviors. Next, we present research on the co-occurrence of attempted suicide and NSSI, including prevalence and associations with self-injury characteristics. We then discuss psychosocial variables associated with engaging in both NSSI and attempted suicide or one type of self-injury alone. Finally, we present the research to date on risk factors uniquely associated with either attempted suicide or NSSI. Implications for mental health professionals and future avenues of research are discussed.

Alterations in the neuroendocrinological stress response to acute psychosocial stress in adolescents engaging in nonsuicidal self-injury

OBJECTIVE

To investigate the neuroendocrinological stress response to acute psychosocial stress in a clinical sample of female adolescents engaging in nonsuicidal self-injury (NSSI).

METHODS

The Trier Social Stress Test (TSST), a standardized psychosocial stress protocol, was performed in 14 female patients who engaged in NSSI and 14 healthy control subjects. NSSI was assessed by the Functional Assessment of Self-Mutilation (FASM). Salivary cortisol, heart rate, and affective states, assessed by the Positive and Negative Affect Schedule (PANAS), were measured during the TSST.

RESULTS

We found an attenuated cortisol response to acute psychosocial stress in female adolescents with NSSI, whereas no group differences were observed in heart rate and emotional response to the TSST.

CONCLUSIONS

These findings indicate that the HPA axis is hyporesponsive in adolescents with NSSI. Therefore, reduced secretion of cortisol could play a role in promoting vulnerability of these individuals to acute stress and maladaptive stress responses.

Cognitive-behavioral therapy for adolescent depression and suicidality

Cognitive-behavioral therapy (CBT) is a well-established treatment of depression in children and adolescents but treatment trials for adolescents with suicidality are few in number, and their efficacy to date is limited. This article reviews the rationale underlying the use of CBT for the treatment of depression and suicidality in adolescents, the literature supporting the efficacy of CBT for depressed adolescents, and whether CBT for depression reduces suicidal thoughts and behavior. A description of some of the core cognitive, affective, and behavioral techniques used in CBT treatments of suicidal ideation and behavior in depressed adolescents is included.

Executive functions are impaired in adolescents engaging in non-suicidal self-injury

BACKGROUND

The aim of this study was to investigate three main aspects of executive functions (EFs), i.e. shifting, updating and inhibition, in adolescents engaging in non-suicidal self-injury (NSSI) as compared with healthy controls.

METHOD

EFs were assessed using the Intra/Extradimensional Set Shift, the Spatial Working Memory (SWM) Test and the Stop Signal Test (SST) from the Cambridge Neuropsychological Test Automated Battery (CANTAB), in a high-severity NSSI group (n=33), a low-severity NSSI group (n=29) and a healthy control group (n=35). Diagnostic characteristics were examined using the Kiddie-Sads-Present and Lifetime Version.

RESULTS

There were group differences on the SWM Test. A trend towards an interaction effect of sex revealed that males in the high-severity NSSI group made significantly more errors than males and females in the control group. Both males and females in the high-severity NSSI group made poor use of an efficient strategy in completing the test. The low-severity NSSI group performed poorly on the SST, making more errors than the control group and showing an impaired ability to inhibit initiated responses, as compared with the high-severity NSSI group. There were group differences in frequencies of current and previous major depressive disorder. However, no effects of these diagnoses were found on any of the EF tests.

CONCLUSIONS

This study demonstrates that NSSI subgroups have distinct deficits in EFs. The high-severity NSSI group has working memory deficits, while the low-severity NSSI group has impaired inhibitory control. This supports the emotion regulation hypothesis.

Thresholds and tolerance of physical pain among young adults who self-injure

Prevalence rates of nonsuicidal self-injury among college students range from 17% to 38%. Research indicates that individuals with borderline personality disorder who self-injure sometimes report an absence of pain during self-injury. Furthermore, self-injury in the absence of pain has been associated with more frequent suicide attempts. The present study examined pain thresholds and tolerance among 44 college students (11 who engaged in self-injury and 33 who did not). Pain thresholds and tolerance were measured using an algometer pressure device that was used to produce pain in previous laboratory research. Participants who engaged in self-injury had a higher pain tolerance than those who did not. In addition, participants who engaged in self-injury rated the pain as less intense than participants who did not. ANCOVAs revealed that depression was associated with pain rating and pain tolerance.

Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients

Although attempted suicide and non-suicidal self-injury (NSSI) differ in several important ways, a significant number of individuals report histories of both behaviors. The current study further examined the relations between NSSI and attempted suicide among psychiatric inpatients. Self-report questionnaires were administered to 117 psychiatric inpatients at a general hospital (M=39.45 years old, S.D.=12.84 years, range=17-73 years). We found that presence and number of NSSI episodes were significantly related to presence and number of suicide attempts. Supporting the importance of NSSI assessment, patients' history of NSSI (presence and frequency) was more strongly associated with history of suicide attempts than were patients' depressive symptoms, hopelessness, and symptoms of borderline personality disorder, and as strongly associated with suicide attempt history as current levels of suicidal ideation. Finally, among patients with a history of suicide attempts, those with an NSSI history reported significantly greater lethal intent for their most severe attempt, and patients' number of prior NSSI episodes was positively correlated with the level of lethal intent associated with their most severe suicide attempt.

[Nonsuicidal self-injury in adolescence]

Nonsuicidal self-injury (NSSI) usually starts in adolescence. International studies report prevalence rates between 3 and 37% (for Germany between 15 and 26%) in adolescents. From a neurobiological perspective, there is evidence that primarily the serotonergic system is involved in the origin and maintenance of this behaviour. NSSI is often used by adolescents to influence aversive affective states, but sometimes serves other functions as well, such as self-punishment or anti-dissociation. To date there are many assessment instruments, some of which are available in a German translation. Regarding psychotherapeutic interventions there is evidence for a good efficacy of dialectical behavioral therapy for adolescents (DBT-A). There is little evidence for psychopharmacological interventions in childhood and adolescence; thus treatment should focus on psychotherapeutic interventions.

Variations in risk and treatment factors among adolescents engaging in different types of deliberate self-harm in an inpatient sample

This study employs a framework adopted in 2008 by Jacobson, Muehlenkamp, Miller, and Turner to explore differences in risk and treatment factors in a sample of 476 adolescent inpatients grouped with relation to their involvement in deliberately self-harmful (DSH) behavior. Participants were assigned to groups indicating no DSH, nonsuicidal self-injury (NSSI) only, suicide attempts (SA) only, and NSSI + SA. Groups were compared with respect to their status on a variety of background risk factors (e.g., maltreatment, presenting psychopathology, family history) and in-treatment behaviors (e.g., critical incidents resulting from self-injurious gestures) linked to DSH. Findings generally supported the conclusions drawn by Jacobson et al. in terms of the overall severity of youth exhibiting NSSI + SA, with some important similarities observed between the NSSI-only and NSSI + SA groups.

An examination of non-suicidal self-injury in men: Do men differ from women in basic NSSI characteristics?

Researchers have reported similar prevalence rates for non-suicidal self-injury (NSSI) among men and women, yet few studies have investigated gender differences in NSSI. This study describes and compares basic NSSI characteristics among a nonclinical sample by gender. Forty-eight individuals reporting a history of NSSI were interviewed (M = 18.52 years old, SD = 1.18 years). NSSI characteristics, including frequency, age of onset, method of NSSI, pain and control during NSSI, and degree of medical injury were compared between men (n = 19) and women (n = 29). Men and women differed significantly on age of onset, degree of medical injury, and NSSI methods. This study supports previous findings of gender differences in NSSI and suggests that further investigation of gender differences in NSSI is warranted.

Differences in non-suicidal self-injury and suicide attempts in adolescents

As suicide attempts and self-injury remain predominant health risks among adolescents, it is increasingly important to be able to distinguish features of self-harming adolescents from those who are at risk for suicidal behaviors. The current study examined differences between groups of adolescents with varying levels of self-harmful behavior in a sample of 373 high school students with a mean age of 15.04 (SD = 1.05). The sample was 48% female and the distribution of ethnicity was as follows: 35% Caucasian, 37.2% African-American, 16% Multi-ethnic, 9.2% Hispanic, and 2.3% Asian. The sample was divided into three groups: no history of self-harm, non-suicidal self-injury (NSSI) only, and NSSI in addition to a suicide attempt. Differences in depressive symptoms, suicidal ideation, social support, self-esteem, body satisfaction, and disordered eating were explored. Results indicated significant differences between the three groups on all variables, with the no self-harm group reporting the lowest levels of risk factors and highest levels of protective factors. Further analyses were conducted to examine specific differences between the two self-harm groups. Adolescents in the NSSI group were found to have fewer depressive symptoms, lower suicidal ideation, and greater self-esteem and parental support than the group that also had attempted suicide. The clinical implications of assessing these specific psychosocial correlates for at-risk adolescents are discussed.

Nonsuicidal self-injury and suicide risk among adolescents

PURPOSE OF REVIEW

Description of current research examining the association between adolescent nonsuicidal self-injury (NSSI) and suicidality. Research on this topic is important as emerging evidence suggests NSSI and suicidality are distinct yet related clinical phenomena and NSSI may increase later risk for suicide.

RECENT FINDINGS

Overall, a relatively strong relationship appears to exist between NSSI and suicidality. However, certain study limitations prevent documentation of the exact nature of this relationship.

SUMMARY

Results imply that whenever past or current NSSI or suicidality is identified, primary care clinicians conduct an assessment of the other behavior and make a timely and suitable referral. Future research requires longitudinal designs measuring the exact onset and duration of NSSI and suicidality.

Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide

This study examined clinical characteristics and laboratory-measured impulsive behavior of adolescents engaging in either non-suicidal self-injury with (NSSI+SA; n=25) or without (NSSI-Only; n=31) suicide attempts. We hypothesized that adolescent with NSSI+SI would exhibit more severe clinical symptoms and higher levels of behavioral impulsivity compared to adolescents with NSSI-Only. Adolescents were recruited from an inpatient psychiatric hospital unit and the two groups were compared on demographic characteristics, psychopathology, self-reported clinical ratings, methods of non-suicidal self-injury, and two laboratory impulsivity measures. Primary evaluations were conducted during psychiatric hospitalization, and a subset of those tested during hospitalization was retested 4-6 weeks after discharge. During hospitalization, NSSI+SA patients reported worse depression, hopelessness, and impulsivity on standard clinical measures, and demonstrated elevated impulsivity on a reward-directed laboratory measure compared to NSSI-Only patients. In the follow-up analyses, depression, hopelessness, suicidal ideation, and laboratory impulsivity were improved for both groups, but the NSSI+SA group still exhibited significantly more depressive symptoms, hopelessness, and impulsivity than the NSSI-Only group. Risk assessments for adolescents with NSSI+SA should include consideration not only of the severity of clinical symptoms but of the current level impulsivity as well.

Psychometric analysis of the self-harm inventory using Rasch modelling

BACKGROUND

Deliberate Self-Harm (DSH) is the intentional destruction of healthy body tissue without suicidal intent. DSH behaviours in non-clinical populations vary, and instruments containing a range of behaviours may be more informative than ones with restricted content. The Self-Harm Inventory (SHI) is a widely used measure of DSH in clinical populations (mental and physical health) and covers a broad range of behaviours (self-injury, risk taking and self-defeating acts). The test authors recommend the SHI to screen for Borderline Personality Disorder (BPD) using a cut-off score of five or more. The aim of this study was to investigate the psychometric characteristics of the SHI in non-clinical samples.

METHODS

The SHI was administered to a sample of 423 non-clinical participants (university students, age range 17 to 30). External validation was informed by the administration of the Depression Anxiety Stress Scales 21 (DASS-21) to a sub-sample (n = 221). Rasch analysis of the SHI was conducted to provide a stringent test of unidimensionality and to identify the DSH behaviours most likely to be endorsed at each total score.

RESULTS

The SHI showed adequate fit to the Rasch model and no modifications were required following checks of local response dependency, differential item functioning and unidimensionality. The scale identified gender and age differences in scores, with females and older participants reporting higher levels of DSH. SHI scores and DASS-21 scores were related.

CONCLUSION

The recommended cut-off point of five is likely to comprise mild forms of DSH and may not be indicative of psychopathology in a non-clinical population. Rather it may be more indicative of developmentally related risk taking behaviours while a higher cut-off point may be more suggestive of psychopathology as indicated by higher levels of depression, stress and anxiety.

Clinical diagnoses, characteristics of risk behaviour, differences between suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injury

OBJECTIVE

Self-injury (SI), self-injurious behaviour (SIB), including suicidal or non-suicidal self-injury (SSI, NSSI) represent an increasing problem among teenagers amounting to a 6-17% prevalence rate in adolescence, yet little data exists on detailed characteristics and associated factors of SI reaching clinical severity. There is also a scarcity of data distinguishing between suicidal and non-suicidal subsamples of self-injuring patients, i.e. showing which predictors contribute to develop self-injurious behaviour with a previous suicidal history (SSI).

METHOD

Clinical diagnoses and characteristics of risk behaviour were examined in a crosssectional design in suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injurious behaviour. From the total pool of 708 new patients consecutively referred with various psychiatric problems in five regional child psychiatric centres in Western-Hungary over an 18-month period, 105 adolescent outpatients suffering from self-injurious behaviour participated in the study (28 males and 77 females aged from 14 to 18 years, mean age 15.97, SD 1.05). The Ottawa/Queen's self-injury questionnaire (OSI) was used to measure the characteristics of risk behaviour, while the comorbid clinical diagnoses were confirmed by the M.I.N.I. Plus International Neuropsychiatric Interview. Descriptive statistics presented the frequencies of the characteristics of SI, bilateral comparisons were used to reveal relevant items to differentiate between sex, duration of practice and SSI versus NSSI and logistic regression was performed to identify significant predictors of suicidal subtype of self-injuring practice.

RESULTS

A total of 60% of the clinical SI population experienced a present or past episode of major depression. The motivation of patients to resist impulses and to discontinue malpractice was low. Cutting and scratching was the most common self-injuring methods. Two-thirds of the sample practised the impulsive type of SI, while 30% practised premeditated SI having an incubation time from 30 min to days and weeks before carrying out SI. Although duration of SI did not distinguish the sample in important aspects, girls and boys differed in several aspects of SI practice. SSI adolescents differed from their NSSI peers in a number of important characteristics including the frequency of actions, injured areas, methods, specific stresses and motivations. SSI adolescents were more likely to favour cutting of the lower leg and drug overdose as modes of SI. SSI adolescents were more likely to report addictive features than their peers with no suicidal motivation. From the aspect of self-injurious practice, logistic regression analysis found only two significant predictors for the combined pathology.

Psychiatric correlates of nonsuicidal cutting behaviors in an adolescent inpatient sample

This archival study of 288 adolescent psychiatric inpatients examined the psychiatric correlates of cutting behavior. Participants were categorized into Threshold cutters (n = 61), Subthreshold cutters (n = 43), and Noncutters (n = 184). Groups were compared on psychiatric diagnoses, suicidality, and self-reported impairment. Results demonstrated that females were more likely to cut relative to males; however, gender did not affect the correlates of cutting behavior. Adolescents in the Threshold group were more likely to be diagnosed with Major Depression and had higher self-reported suicidality, depression, and trauma-related symptoms of depression and dissociation relative to the Noncutting group. The Subthreshold group did not differ from the other groupings except for an elevated risk for Posttraumatic Stress Disorder compared to the Noncutting group.

Frequency of adolescent self-cutting as a predictor of HIV risk

OBJECTIVE

A wide range exists in the frequency of adolescent self-cutting behavior; however, the implications of this variability are relatively unexplored. Although evidence suggesting a relationship between self-harm and sexual risk behaviors has been identified, little is known regarding the relationship between frequency of self-cutting and sexual risk. The present study aimed to test the hypothesis that adolescents who repeatedly self-cut would report more HIV risk behaviors and riskier attitudes than those who had engaged in infrequent self-injury.

METHOD

Adolescents (11-18 years; mean age, 15 years) from intensive psychiatric treatment programs with a history of self-cutting (N = 105, 53% female) completed measures of self-cutting, sexual risk behaviors, and risk attitudes.

RESULTS

Frequent self-cutting (more than three times, lifetime) was associated with being sexually active, using condoms inconsistently, and sharing cutting instruments. Frequent self-cutters were significantly more likely to be female and nonwhite, and report low self-restraint. They also showed a trend toward being more likely to have a history of sexual abuse.

CONCLUSIONS

This study found important differences in self-cutters based on frequency of cutting. Adolescent self-cutting may be a spectrum of behavior that ranges from habitual, repeated behavior contrasted with infrequent, experimental, socially motivated cutting. The associations between frequent cutting, sexual risk, and low self-restraint suggest that common underlying mechanisms may determine these patterns.

Prevalence, course, incidence, and 1-year prediction of deliberate self-harm and suicide attempts in early Norwegian school adolescents

In this survey of early Norwegian school adolescents, the prevalence, course, and incidence of self-harm behavior with or without suicide intent were examined, in addition to predictors of self-harm for a 1-year follow-up period. Lifetime prevalence rates of self-harm without suicide intent and suicide attempts were 2.9% and 3.0%, respectively, while 1-year incidence rates were 3.6% and 1.7%, respectively. In multivariate analysis, five predictors significantly differentiated self-harmers from non-self-harming adolescents. Early school adolescents having frequent or intense suicidal ideation over an extended time period and attempting self-harm repeatedly with or without suicide intent should be identified and offered treatment.

Nonsuicidal self-injury among "privileged" youths: longitudinal and cross-sectional approaches to developmental process

This investigation examined process-level pathways to nonsuicidal self-injury (NSSI; e.g., self-cutting, -burning, -hitting) in 2 cohorts of suburban, upper-middle-class youths: a cross-sectional sample of 9th-12th graders (n = 1,036, 51.9% girls) on the West Coast and a longitudinal sample followed annually from the 6th through 12th grades (n = 245, 53.1% girls) on the East Coast. High rates of NSSI were found in both the cross-sectional (37.2%) and the longitudinal (26.1%) samples. Zero-inflated Poisson regression models estimated process-level pathways from perceived parental criticism to NSSI via youth-reported alienation toward parents. Pathways toward the initiation of NSSI were distinct from those accounting for its frequency. Parental criticism was associated with increased NSSI, and youth alienation toward parents emerged as a relevant process underlying this pathway, particularly for boys. The specificity of these pathways was explored by examining separate trajectories toward delinquent outcomes. The findings illustrate the prominence of NSSI among "privileged" youths, the salience of the caregiving environment in NSSI, the importance of parental alienation in explaining these relations, and the value of incorporating multiple systems in treatment approaches for adolescents who self-injure.