Nonsuicidal self-injury: what we know, and what we need to know

Why Are Individuals Who Have Not Disclosed Self-Injury Comfortable Discussing Their Experiences in Research?

ABSTRACT

Not everyone who shares their lived experience of nonsuicidal self-injury (NSSI) in research has disclosed this previously outside of a research context. Our objective was to identify reasons people who have not previously disclosed their NSSI felt comfortable discussing their self-injury in research contexts. The sample consisted of 70 individuals with lived experience of self-injury who had not previously disclosed this experience outside of research (Mage = 23.04 years, SD = 5.90; 75.70% women). Using content analysis of open-ended responses, we identified three reasons participants felt comfortable discussing their NSSI in research. Most commonly, participants did not anticipate negative consequences discussing their NSSI due to the way the research was conducted (e.g., confidentiality). Second, participants valued NSSI research and wanted to contribute to such work. Third, participants referenced feeling mentally and emotionally prepared to discuss their NSSI. The findings indicate that individuals who have not previously disclosed their NSSI may wish to discuss their experience in research for a variety of reasons. Such findings highlight implications for how we foster safe spaces in research for people with lived experience of NSSI.

Psychometric properties of the Alexian Brother Urge to Self-Injure (ABUSI) Spanish version for adolescents

Objective

This study aimed to evaluate the psychometric properties of the Alexian Brother Urge to Self-Injure (ABUSI) in its Spanish version for Colombian adolescents. This instrument was created to measure cognitive and emotional aspects of the urge to self-injure by assessing the frequency, the urge, thoughts associated with time and place, the capacity for resistance, and thoughts associated with the urge to self-injure.

Method

A total of 752 preadolescents and adolescents between 10 and 18 years of age, with a mean of 15.3 years (SD = 1.97), participated. The instruments used were The Alexian Brother Urge to Self-Injure ABUSI, ERS Suicide Risk Scale, Plutchik Suicide Risk Scale, and the Zimet The MSPSS Perceived Social Support Scale. Confirmatory factor analysis, inter-test correlations, to estimate cut-off point discriminant validity Receiver Operating Characteristics (ROC) and to determine convergent validity, a Pearson's coincidence analysis was performed between the ABUSI total score and the ERS Suicide Risk Scale, the Plutchik's Suicide Risk Scale and Zimet's Perceived Social Support Scale assessments.

Results

The presence of a unidimensional model of the instrument is confirmed with adequate fit, reliability, and concurrent validity indices. The high score classification was determined from six (6) points for the total of the scale. These results show that ABUSI is a valid and reliable tool for the clinical assessment of self-injurious behavior in adolescents and preadolescents.

Definitions and incidence rates of self-harm and suicide attempts in Europe: A scoping review

INTRODUCTION

European countries use various terminologies for self-harm and attempted suicide, which are sometimes used interchangeably. This complicates cross-country comparisons of incidence rates. This scoping review aimed to examine the definitions used and the possibilities to identify and compare incidence rates of self-harm and attempted suicide in Europe.

METHODS

A literature search was conducted in Embase, Medline and PsycINFO for studies published from 1990 to 2021, followed by grey literature searches. Data were collected for total populations originating from health care institutions or registries. Results were presented in tabular form supplemented by a qualitative summary by area.

RESULTS

A total of 3160 articles were screened, resulting in 43 studies included from databases and further 29 studies from other sources. Most studies used the term 'suicide attempt' rather than 'self-harm' and reported person-based rates with annual incidence rates from age 15+. None of the rates were considered comparable due to different reporting traditions related to classification codes and statistical approaches.

CONCLUSION

The present extensive literature on self-harm and attempted suicide cannot be used to compare findings between countries because of the high degree of heterogeneity among studies. International agreement on definitions and registration practices is needed to improve knowledge and understanding of suicidal behaviour.

Efficacy of psychotherapeutic interventions for non-suicidal self-injury in adolescent population: Systematic review and meta-analysis

Non-suicidal self-injury (NSSI) is the deliberate and self-inflicted damage to body tissue in the absence of fatal intent, and has become a serious health problem among adolescents. The aim of this study was to evaluate the efficacy of treatment for NSSI in this population through a systematic revision and meta-analysis (PROSPERO ID: 252355). Studies with therapies that reduced NSSI were included. The search was performed in the Medline, APA PsycINFO and PubPsych databases. The synthesis of measures for the main outcome (NSSI reduction) and for secondary outcomes (global functioning change and depressive symptomatology reduction) was performed using a random effects model. The search identified a total of 1881 studies. The systematic review included five studies and the meta-analysis four studies. The summary effect estimate for the standardized mean difference in NSSI was -0.53 (95% CI: -0.82, -0.25), in global functioning it was 0.62 (95% CI: 0.34, 0.91), and in depressive symptomatology it was -0.59 (95% CI: -0.82, -0.36). The certainty of the evidence using the GRADE method is low. We conclude that therapies specifically aimed at reducing NSSI are effective in reducing both NSSI and depressive symptoms while increasing global functioning.

Body modifications in borderline personality disorder patients: prevalence rates, link with non-suicidal self-injury, and related psychopathology

BACKGROUND

Borderline Personality Disorder (BPD) is a potentially severe personality disorder, characterized by difficulties in emotion regulation and control of behaviors. It is often associated with non-suicidal self-injury (NSSI). Borderline personality features have also been linked to body modifications (BMs). However, the prevalence of BMs, the link between BMs and NSSI, and between BMs and several psychopathology dimensions (e.g. borderline severity, emotion regulation, impulsivity …) remains understudied in patients with BPD. This study aims to fill this gap, and to provide further evidence on the link between NSSI and BMs.

METHODS

We used data from a psychiatric outpatient center located in Switzerland (n = 116), specialized in the assessment and treatment of BPD patients. Patients underwent several semi-structured interviews and self-report psychometric scales at the arrival, and the data were retrospectively analyzed.

RESULTS

We found that 70.69% of the patients had one piercing or more, and 69.83% were tattooed. The total score of body modifications and the total number of piercings score of piercings were significantly positively associated with NSSI and the SCID BPD total score. The association with the SCID score was mainly driven by the "suicide and self-damaging behaviors" item and the "chronic feeling of emptiness" item. A significant association was found between total number of piercings and emotion dysregulation. On the other hand, the self-reported percentage of body covered by tattoos score was specifically associated with the sensation seeking subscale of the UPPS-P.

CONCLUSION

This study provides evidence on the prevalence of BMs in BPD patients, and on the link between BMs and NSSI in this population, suggesting a role of emotion regulation in the link between both constructs. These results also suggests that tattoos and piercings may be differentially linked to specific underlying psychological mechanisms. This calls for further considerations of body modifications in the assessment and care of BPD patients.

Self-Harm Among Forensic Psychiatric Inpatients With Schizophrenia Spectrum Disorders: An Explorative Analysis

The burden of self-injury among offenders undergoing inpatient treatment in forensic psychiatry is substantial. This exploratory study aims to add to the previously sparse literature on the correlates of self-injury in inpatient forensic patients with schizophrenia spectrum disorders (SSD). Employing a sample of 356 inpatients with SSD treated in a Swiss forensic psychiatry hospital, patient data on 512 potential predictor variables were retrospectively collected via file analysis. The dataset was examined using supervised machine learning to distinguish between patients who had engaged in self-injurious behavior during forensic hospitalization and those who had not. Based on a combination of ten variables, including psychiatric history, criminal history, psychopathology, and pharmacotherapy, the final machine learning model was able to discriminate between self-injury and no self-injury with a balanced accuracy of 68% and a predictive power of AUC = 71%. Results suggest that forensic psychiatric patients with SSD who self-injured were younger both at the time of onset and at the time of first entry into the federal criminal record. They exhibited more severe psychopathological symptoms at the time of admission, including higher levels of depression and anxiety and greater difficulty with abstract reasoning. Of all the predictors identified, symptoms of depression and anxiety may be the most promising treatment targets for the prevention of self-injury in inpatient forensic patients with SSD due to their modifiability and should be further substantiated in future studies.

Do Cortisol and Dehydroepiandrosterone Influence Motivational Factors for Non-Suicidal Self-Injury in Female Adolescents?

Non-suicidal self-injury (NSSI) is a significant public health issue that particularly affects female adolescents usually emerging during puberty, with a subsequent reduction and even remission in the phenomenon later in life. The dysregulation of the hormonal stress response, particularly cortisol and dehydroepiandrosterone sulfate (DHEA-S), whose levels increase markedly during pubertal adrenarche, has been associated with the development and maintenance of a wide range of emotional disorders. Our study aims to investigate whether different cortisol-DHEA-S response patterns could be associated with the main motivational moderators to engage NSSI as well as with urgency and motivation to stop NSSI in a sample of female adolescents. We found significant correlations between stress hormones and several factors that support and sustain NSSI, specifically: cortisol levels and distressing/upsetting urge (r = 0.39 and a p = 8.94 × 10^-3) and sensation seeking (r = -0.32 and a p = 0.04), as well as cortisol/DHEA-s ratio and external emotion regulation (r = 0.40 and a p = 0.01) and desire to stop NSSI (r = 0.40 and a p = 0.01). Cortisol and DHEA-S may play a role in NSSI through the regulation of stress responses and affective states. Such results could have implications for the development of new and improved treatment and prevention plans for NSSI.

Evaluation of the Conversations about Non-Suicidal Self-Injury Mental Health First Aid Course: Effects on Knowledge, Stigmatising Attitudes, Confidence and Helping Behaviour

BACKGROUND

Non-suicidal self-injury (NSSI) is a common mental health problem, with a 19% lifetime prevalence in Australian adolescents and 12% in adults. Though rates of professional help-seeking for NSSI are low, disclosure to family and friends is more common, providing opportunities for them to encourage professional support. Mental Health First Aid® Australia's Conversations about Non-Suicidal Self-Injury course provides evidence-based training for the general public to support a person engaging in NSSI.

METHODS

This uncontrolled trial evaluated the effects of the Conversations about Non-Suicidal Self-Injury course on participants' knowledge, confidence, stigmatising attitudes, and intended and actual helping behaviours. Surveys were administered pre- and post-course, and at a six-month follow-up. A linear mixed-model analysis determined mean change over time, and effect sizes were estimated using Cohen's d. Course satisfaction was assessed using descriptive statistics and summative content analysis of qualitative data.

RESULTS

The pre-course survey was completed by 147 Australian participants (77.5% female, mean age 45.8 years), 137 (93.2%) at post-course and 72 (49%) at follow-up. Knowledge, confidence, quality of intended helping behaviours, and quality of actual helping behaviours increased significantly at both time points. Social distance decreased significantly at all time points and stigma decreased significantly at post-course. The course was perceived to be highly acceptable by participants.

CONCLUSIONS

There is initial evidence that the Conversations about Non-Suicidal Self-Injury course is effective and acceptable for members of the public who may support a person engaging in NSSI.

An investigation of self-injury in female adolescents: a qualitative study

This study aimed to investigate the phenomenon of self-injury among female adolescents. The research was qualitative, and the sampling method was purposive non-random; the sample size was 20 Iranian girl adolescents aged 13-15 years who had experienced non-suicidal self-injury. Data were collected through semi-structured interviews. The data analysis process was performed during three coding steps (open, axial, selective), through which the basic codes and categories were identified. Study results indicate that the main factors in adolescents' self-injury were individual or psychological (thoughts, emotions, and behaviors) and social (peers, family, communication with different gender, communication with others, media/cyberspace, school, and economic). In the former, the role of emotions was remarkable, while in the latter, the family played a key role. Further, results revealed that communication within the family was an important motivating and sustentative factor in adolescents' self-injury. The results can help counselors in working with adolescents who self-injure; results can also be used in the development and implementation of treatment plans.

For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt

Nonsuicidal self-injury (NSSI) has been repeatedly associated with increased suicide risk. However, the transition from NSSI to suicidal thoughts and behaviors still remains as an enigma. One possible construct that may influence this relationship is cognitive flexibility, which refers to the ability to adapt responses/strategies based on environmental feedback. It may be that greater cognitive flexibility increases one's cognitive accessibility to suicide, making it a more viable option upon distress especially for those with a prior history of NSSI. Conversely, it may be that less cognitive flexibility creates a negative bias that exacerbates the effects of NSSI on suicide. Thus, in this study, we examined how NSSI characteristics (i.e., frequency and methods) interact with cognitive flexibility to predict lifetime suicide attempt (SA) history. Participants were 505 individuals with a lifetime history of NSSI who completed a survey assessing for their NSSI experiences, cognitive flexibility, and SA history. Moderation analyses were conducted while controlling for sexual orientation, which significantly predicted SA history. Results indicated a significant interaction between number of NSSI methods endorsed and cognitive flexibility. In particular, individuals were more likely to have had a history of SA if they scored higher on the alternative subscale of cognitive flexibility. The results suggest that the adaptive value of cognitive flexibility may be context dependent, and highlight the importance of personalized care among those who engage in self-harm.

Correlations between childhood maltreatment, anxiety and depressive symptoms, and risk behaviors in adolescent schoolchildren

OBJECTIVE

Childhood maltreatment is extremely harmful to health, especially in relation to development of the psychiatric disorders throughout life. The objective of this study was to describe the prevalence and types of maltreatment in a sample of adolescent schoolchildren and to investigate associations between maltreatment types and anxiety and depressive symptoms, sociodemographic variables, and risk behaviors. The study also identified which variables were the greatest predictors of anxiety and depressive symptoms.

METHODS

We conducted a cross-sectional study with a sample of 654 school students aged 11 to 17 years. We collected sociodemographic data and administered the Revised Child Anxiety and Depression Scale (RCADS-47) to measure anxiety and depressive symptoms as well as the Childhood Trauma Questionnaire (CTQ) to evaluate maltreatment and adverse experiences such as abuse and negligence during childhood and adolescence. Statistical analyses were conducted to estimate correlations between sociodemographic data, anxiety, depression, and types of maltreatment. A regression analysis was also conducted to identify maltreatment types that predict psychological symptoms.

RESULTS

Emotional abuse and emotional neglect were the most prevalent types of maltreatment. Statistically, emotional abuse was the maltreatment type most strongly correlated with depression and anxiety and tended to co-occur with other types of maltreatment. Additionally, emotional and sexual abuse were the greatest predictors of anxiety and depression in adolescents.

CONCLUSION

The above results reinforce the findings of previous studies in terms of understanding the effects of maltreatment. They identify emotional abuse as the main predictor of depressive and anxiety symptoms.

Resilience to Self-Harm

Background: Although a wide range of studies discuss prevalence and risk factors associated with self-harm, protective factors that are equally important are rarely explored. Moreover, much of our understanding of young individuals who engage in self-harm come from studies conducted in Western countries with very little emphasis on marginalized groups. Aim: This scoping review identifies research on resilience among marginalized youth and youth living in low- and middle-income countries (LMICs) who show evidence of self-harm. Method: A scoping review following Arksey and O'Malley's (2005) framework was conducted. This effort included drawing upon peer-reviewed research published between January 2000 and September 2020 to identify protective factors and coping strategies that are employed by individuals 10-29 years old with self-harming tendencies. Results: A total of 15 original papers met the inclusion criteria. The majority of the LMIC publications were from China. Social support, positive youth development, and religiosity were the most frequently reported protective factors. Conclusion: Despite widespread concern about self-harm, there are few peer-reviewed articles that look at resilience or recovery among youth in LMICs and among marginalized young people. In addition to various internal and external protective factors, this scoping review identifies gaps in our understanding of resilience to self-harm among youth belonging to these groups.

NSSI questionnaires revisited: A data mining approach to shorten the NSSI questionnaires

BACKGROUND AND OBJECTIVE

Non-suicidal self-injury (NSSI) is a psychological disorder that the sufferer consciously damages their body tissues, often too severe that requires intensive care medicine. As some individuals hide their NSSI behaviors, other people can only identify them if they catch them while injuring, or via dedicated questionnaires. However, questionnaires are long and tedious to answer, thus the answers might be inconsistent. Hence, in this study for the first time, we abstracted a larger questionnaire (of 662 items in total) to own only 22 items (questions) via data mining techniques. Then, we trained several machine learning algorithms to classify individuals based on their answers into two classes.

METHODS

Data from 277 previously-questioned participants is used in several data mining methods to select features (questions) that highly represent NSSI, then 245 different people were asked to participate in an online test to validate those features via machine learning methods.

RESULTS

The highest accuracy and F1 score of the selected features-via the Genetics algorithm-are 80.0% and 74.8% respectively for a Random Forest algorithm. Cronbach's alpha of the online test (validation on the selected features) is 0.82. Moreover, results suggest that an MLP can classify participants into two classes of NSSI Positive and NSSI Negative with 83.6% accuracy and 83.7% F1-score based on the answers to only 22 questions.

CONCLUSION

While previously psychologists used many combined questionnaires to see whether someone is involved in NSSI, via various data mining methods, the present study showed that only 22 questions are enough to predict if someone is involved or not. Then different machine learning algorithms were utilized to classify participants based on their NSSI behaviors, among which, an MLP with 10 hidden layers had the best performance.

["Razors always speak louder": the topic of self-harm in online communities]

This study aims to understand how Brazilian online communities portray the topic of self-harm, discussing its particularities, the narratives produced, the interactions established, and the purpose of the digital space. It was based on qualitative research in the digital environment from the silent observation of Facebook online communities, which were selected considering the number of participants and their interaction. The observation followed a previous script and posts were recorded by screenshots. Publications were organized in the following categories: characterization and functioning of the community; self-directed violence (self-harm and suicide); motivations for the act; strategies to prevent the act; and loving experience. Results showed that the communities were positively guided and defended self-harm without any regulation, which guaranteed the free expression of their participants and detailed reports describing the methods and objects used, the level of efficiency, and how to hide the wounds. Although participants shared the fear of being discovered, they published images of their own scars and wounds, materializing discourses of suffering on the Internet and glamorizing the cuts, the feeling of pleasure, and the sense of belonging, since they are also identity marks. Our findings show that young people who harm themselves share their suffering experiences with other young people without the mediation of a professional, therefore, considering its possible effects on mental health is necessary.

Frequency of, Confidence in, and Educational Satisfaction With Mental Illness Recognition and Referral Among Certified Athletic Trainers

CONTEXT

Mental illness recognition and referral are required components of professional athletic training education. However, athletic trainers (ATs) often report feeling underprepared to assist patients with mental health emergencies.

OBJECTIVE

To determine ATs' frequency of and confidence in psychosocial skill use and their satisfaction with education related to mental illness recognition and referral.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 226 ATs (86 men, 140 women; age = 35.5 ± 9.9 years, years of practice = 11.9 ± 9.0).

MAIN OUTCOME MEASURE(S)

The independent variables were professional athletic training program, professional psychosocial courses, highest education level, psychosocial continuing education units, clinical practice setting, and years of experience. For each skill, individuals identified the average frequency with which the skill was performed each year, rated their confidence in performing the skill, and rated their satisfaction with professional education related to the skill.

RESULTS

Anxiety was reported as the symptom most frequently recognized and referred. Most respondents felt moderately or extremely confident in managing patients with anxiety, panic attacks, depression, suicidal ideation, or eating disorders but less confident or unconfident in managing those with psychosis or substance use disorder. The majority of respondents felt dissatisfied or only slightly satisfied with their education related to mental health recognition and referral. Years of clinical practice and self-reported frequency of referral were significantly associated for managing patients with anxiety disorder (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({\rm{\chi }}_{87}^2\) = 117.774, P = .016) and suicidal thoughts or actions (\({\rm{\chi }}_{87}^2\) = 179.436, P < .001). For confidence, significant positive associations were present between years of practice and self-reported recognition of patients with anxiety disorders (\({\rm{\chi }}_{145}^2\) = 195.201, P = .003) and referral for those with anxiety disorders (\({\rm{\chi }}_{145}^2\) = 15.655, P = .048) or panic attacks (\({\rm{\chi }}_{145}^2\) = 19.790, P = .011). Significant associations were also noted between the number of continuing education units and self-reported confidence in recognizing suicide (\({\rm{\chi }}_{15}^2\) = 26.650, P = .032), referring for suicidal concerns (\({\rm{\chi }}_{18}^2\) = 40.456, P = .002), recognizing substance use (\({\rm{\chi }}_{18}^2\) = 33.649, P = .014), and referring for substance use (\({\rm{\chi }}_{18}^2\) = 30.918, P = .029). No significant associations were related to satisfaction.

CONCLUSIONS

The ATs with fewer years of clinical practice (ie, who had completed professional programs more recently) expressed higher confidence in mental health recognition and referral than those who had completed professional programs longer ago. We recommend that real-time interactions with individuals who have mental health concerns or emergencies be incorporated into professional education programs and that increased emphasis be placed on continuing education related to these topics.

Relationships between Outcome Expectancies and Non-Suicidal Self-Injury: Moderating Roles of Emotion Regulation Difficulties and Self-Efficacy to Resist Self-Injury

BACKGROUND

Non-suicidal self-injury (NSSI) is the deliberate damage of one's own body tissue in the absence of suicidal intent. Research suggests that individuals engage in NSSI as a means of regulating their emotions and that NSSI is associated with emotion regulation difficulties. There is also evidence supporting the role of outcome expectancies and self-efficacy to resist NSSI. However, it is unclear how these factors work together to explain NSSI.

OBJECTIVE

To explore whether the relationships between five NSSI-specific outcome expectancies and NSSI history are moderated by emotion regulation difficulties and self-efficacy to resist NSSI.

METHOD

1002 participants (Mage = 20.51, 72.5% female, 39.7% lifetime history of NSSI) completed an online survey including measures of NSSI history, outcome expectancies, self-efficacy to resist NSSI, and emotion regulation difficulties.

RESULTS

Emotion regulation difficulties were associated with NSSI, as was expecting NSSI to regulate affect. Conversely, expectations of communication and/or pain, as well as self-efficacy to resist NSSI were negatively associated with NSSI. Expectancies also interacted with both difficulties in emotion regulation and self-efficacy to resist NSSI in predicting self-injury. For example, the association between expectations of affect regulation and self-injury was weaker when associated with greater self-efficacy to resist NSSI.

CONCLUSION

These findings provide support for considering NSSI-specific cognitions in concert with emotion regulation when understanding NSSI.HighlightsOutcome expectancies can differentiate people based on NSSI history.Emotion regulation difficulties and self-efficacy to resist NSSI moderate the relationships between outcome expectancies and NSSI history.Emotion regulation difficulties and low self-efficacy to resist NSSI work together to predict NSSI history.

Revisiting Social Stigma in Non-suicidal Self-injury: A Narrative Review

Non-suicidal self-injury (NSSI) is highly prevalent in our community. Yet, there is a significant discrepancy between the number of individuals engaging in NSSI and those who seek treatment for NSSI. This discrepancy can be due to the high social stigma associated with the behavior. The impact of NSSI stigma is significant and can impair the quality of life in the individuals engaging in NSSI, delay help-seeking, reduce access to mental health care and further fuel misinformation. Even though the symptomatology, risks, and demographics of NSSI have received attention in terms of research, there is limited literature on NSSI stigma and its consequences. With that background set, this review provides a bird's-eye view of the different levels of stigma in NSSI (public, self, and health care), associated discrimination, the various aspects of such stigmatization (NSSI-related language, physical scarring, misinformation, the media), and, finally, the collaborative clinical-outreach interventions for mitigating NSSI-associated social stigma. If NSSI is indeed recognized as a clinical disorder, future research would need to focus on these constructs of stigma and treat them with the same importance as the one given to clinical studies of intervention and symptomatology in NSSI.

A systematic review of the relationship between momentary emotional states and nonsuicidal self-injurious thoughts and behaviours

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with high levels of distress, co-morbid mental health issues, and elevated risk of suicide. Previous literature indicates that emotion regulation is the most endorsed function of NSSI. Experience Sampling Methodology (ESM) provides a powerful tool for investigating the moment-to-moment associations between emotional states and NSSI thoughts and behaviours. The aim of the current study was to systematically review and evaluate ESM research concerning the relationship between momentary emotional states and NSSI.

METHODS

A systematic search of electronic databases from date of inception to 16th April 2021 was conducted. This was supplemented through backwards citation tracking. A risk of bias assessment was completed prior to data synthesis.

RESULTS

Nineteen eligible studies were identified for inclusion in the review. Heightened negative affect was found to typically precede instances of NSSIT thoughts and behaviour. Results were less consistent for positive affect.

LIMITATIONS

Sample sizes across studies were often small, meaningful effect sizes were not always reported, and non-validated measures of NSSI thoughts and behaviour were used during ESM assessments.

CONCLUSIONS

The results support affect regulation models of NSSI, and demonstrate the value of ESM studies, specifically those sampling more than once per day, in plotting the temporal, "in-the-moment" characteristics of these processes.

Parental Psychological Control, Parent-Related Loneliness, Depressive Symptoms, and Regulatory Emotional Self-Efficacy: A Moderated Serial Mediation Model of Nonsuicidal Self-Injury

OBJECTIVE

Adolescent nonsuicidal self-injury (NSSI) has become an alarming public health concern. Parental psychological control has been identified as a risk factor for NSSI in some western samples. However, the relationship between parental psychological control and NSSI remains unclear among Chinese adolescents. Furthermore, little is known about how parental psychological control affects NSSI. This study aims to examine a moderated serial mediation model of NSSI, revealing the mediating and moderating mechanisms underlying the relationship between parental psychological control and NSSI.

METHOD

A total of 953 Chinese secondary school students (47.7% females, mean age = 12.53 years, SD = 0.63) completed questionnaires of NSSI, parental psychological control, parent-related loneliness, depressive symptoms, and regulatory emotional self-efficacy.

RESULTS

Parental psychological control was positively associated with NSSI. This association was mediated by parent-related loneliness and depressive symptoms independently. Also, it was serially mediated by parent-related loneliness and depressive symptoms. In addition, regulatory emotional self-efficacy moderated the indirect relationships between parental psychological control and NSSI.

CONCLUSIONS

Findings of this study shed light on how NSSI is affected by parental psychological control, parent-related loneliness, depressive symptoms, and regulatory emotional self-efficacy, and provide insights into the prevention and intervention measures targeting adolescent NSSI.HIGHLIGHTSParental psychological control was positively associated with NSSI.Parent-related loneliness and depressive symptoms independently and serially mediated the association between parental psychological control and NSSI.Regulatory emotional self-efficacy moderated the indirect relationships between parental psychological control and NSSI.

The UPPS Model of Impulsivity and Suicide: A Systematic Literature Review

INTRODUCTION

Suicide is a leading cause of death worldwide. Although inconsistent, impulsivity has been identified as a risk factor for suicidal thoughts and behaviors, and these inconsistent findings can largely be attributed to varying operationalizations of impulsivity. As such, the UPPS model of impulsivity provides a clear definition of impulsivity and its associated features that may provide utility in clarifying unreliable findings between impulsivity and suicide. This review aimed to summarize relevant information pertaining to the UPPS model of impulsivity and suicide.

METHODS

This systematic review followed the a priori guide outlined by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Articles were gathered from PsycINFO, PsycArticles, Scopus, and PubMed.

RESULTS

Twenty-eight articles were reviewed and analyzed. Most articles reviewed reported on indirect (i.e., through mediators and moderators) associations between the UPPS dimensions and suicidal behaviors. Additionally, results noted limited between-group differences in UPPS facets among individuals with a history of suicide attempts and those without a history of suicide attempts, those with a history of suicide attempts and individuals with suicide ideation, and those with suicide ideation and those without suicide ideation, with the exception of lack of premeditation.

DISCUSSION

The results of this review indicate support for the UPPS model of impulsivity as a theoretical starting point when examining the relation between impulsivity and suicide. Further, findings are helpful for clinicians and case conceptualization. Particularly, suicide risk assessment and treatment would be impacted based on impulsivity traits and suicide history.

A Person-Centered Approach to Adolescent Nonsuicidal Self-Injury: Predictors and Correlates in a Community Sample

Growing incidence of nonsuicidal self-injury (NSSI) and a lack of intensive examination of NSSI variability among adolescents justify identification of latent classes based on the endorsement of different NSSI behaviors. Latent class analysis was used to detect the heterogeneity of past month NSSI among 322 high school students (73.2% female). Two interpretable latent classes emerged. The Severe/Multimethod NSSI class (39%) engaged in almost all forms of NSSI with high intensity and motivated mainly for intrapersonal reasons. The results imply that compared to Mild/Moderate NSSI group (61%), the Severe class is at greater risk for poor mental health, which can exacerbate further NSSI acts. In school settings, identifying adolescents who are vulnerable for more severe NSSI can help to interrupt NSSI trajectories to emerging adulthood.

Emotional Reactivity and Inhibitory Control in Nonsuicidal Self-Injury Adolescence: Divergence Between Positive and Negative Emotions

Nonsuicidal self-injury (NSSI) is prevalent in adolescents and is often linked to emotion dysregulation. However, it remains unknown which specific processes of emotion regulation and under what emotional context these processes are related to the risk for NSSI in samples of community-based adolescents. This study used two laboratory tasks to examine whether adolescents with a history of NSSI displayed difficulties in emotional reactivity and inhibitory control in response to negative and positive emotions. In Study 1, adolescents with/without a history of NSSI (N = 64; M_Age = 13.45 ± 0.50; 53% female) completed a picture perception task in which they were asked to judge the valence and arousal of images. In Study 2, adolescents with/without a history of NSSI (N = 74; M_Age = 13.49 ± 0.80; 50% female) were given a two-choice emotional oddball task that required them to differentially respond to frequent stimuli (images of an object) and infrequent stimuli (affective images). The results showed that adolescents with a history of NSSI showed decreased emotional sensitivity and lower levels of inhibitory control in response to images depicting negative emotional content but not to those depicting positive emotional content. Furthermore, affective inhibitory control problems were significantly positively related to the severity of NSSI, especially in the context of negative emotions. These findings suggest that there is a divergence between positive and negative emotions in both emotional reactivity and affective inhibitory control processes on NSSI. Specifically, relative to adolescents with no history of NSSI, adolescents with a history of NSSI showed lower emotional awareness and behavioral inhibitory control when processing negative emotions, but these distinctions were not found in contexts involving positive emotions. Additionally, the results suggest that affective inhibitory control deficits specific for negative emotions may result in vulnerability to increased NSSI severity.

Peripheral and neural correlates of self-harm in children and adolescents: a scoping review

BACKGROUND

Self-harm in children and adolescents is difficult to treat. Peripheral and neural correlates of self-harm could lead to biomarkers to guide precision care. We therefore conducted a scoping review of research on peripheral and neural correlates of self-harm in this age group.

METHODS

PubMed and Embase databases were searched from January 1980-May 2020, seeking English language peer-reviewed studies about peripheral and neural correlates of self-harm, defined as completed suicide, suicide attempts, suicidal ideation, or non-suicidal self-injury (NSSI) in subjects, birth to 19 years of age. Studies were excluded if only investigating self-harm in persons with intellectual or developmental disability syndromes. A blinded multi-stage assessment process by pairs of co-authors selected final studies for review. Risk of bias estimates were done on final studies.

RESULTS

We screened 5537 unduplicated abstracts, leading to the identification of 79 eligible studies in 76 papers. Of these, 48 investigated peripheral correlates and 31 examined neural correlates. Suicidality was the focus in 2/3 of the studies, with NSSI and any type of self-harm (subjects recruited with suicidality, NSSI, or both) investigated in the remaining studies. All studies used observational designs (primarily case-control), most used convenience samples of adolescent patients which were predominately female and half of which were recruited based on a disorder. Over a quarter of the specific correlates were investigated with only one study. Inter-study agreement on findings from specific correlates with more than one study was often low. Estimates of Good for risk of bias were assigned to 37% of the studies and the majority were rated as Fair.

CONCLUSIONS

Research on peripheral and neural correlates of self-harm is not sufficiently mature to identify potential biomarkers. Conflicting findings were reported for many of the correlates studied. Methodological problems may have produced biased findings and results are mainly generalizable to patients and girls. We provide recommendations to improve future peripheral and neural correlate research in children and adolescents, ages 3-19 years, with self-harm.

The Psychosocial Correlates of Non-suicidal Self-Injury Within a Sample of Adolescents With Mood Disorder

Background

According to the integrated theoretical model, adolescents' behaviors were the outcome of the complex interplay between multiple levels. Non-suicidal self-injury (NSSI) is a serious and high prevalent problem among adolescents with mood disorders. However, a systematic perspective on psychosocial correlates among Chinese clinical adolescents is still rare.

Method

The impact of several factors at the individual (i.e., sex, age, self-esteem, and psychological distress), family (i.e., family structure, family income, and family support), and social level (i.e., living environment, peer support, and teacher support) on the frequency of NSSI behaviors were investigated in the current study. This research included 621 Chinese adolescents with mood disorders from 20 hospitals.

Results

Three-steps hierarchical regression analyses indicated that lower levels of psychological distress and higher levels of self-esteem were most associated with less frequency of NSSI behaviors. In addition, family support was negatively associated with the frequency of NSSI behaviors. After controlling the factors at individual and family levels, no significant association was found between the factors at the social level and the frequency of NSSI behaviors.

Conclusion

These findings provide preliminary support for the notion that adolescent self-esteem and family support may effectively shield them from problematic behavior; nevertheless, adolescents suffering from more emotional pain can be even riskier. Thus, further intervention strategies should consider the non-independence of individual capacities, co-combinatory effects of mood disorder, and family environment in treating those vulnerable Chinese adolescents.

Self-injury in young bisexual people: A microlongitudinal investigation (SIBL) of thwarted belongingness and self-esteem on non-suicidal self-injury

BACKGROUND

Bisexual people are at an elevated risk for non-suicidal self-injury (NSSI). Psychological factors including self-esteem and thwarted belongingness may help explain this risk. The aim of the current study was to investigate associations between self-esteem, thwarted belongingness and NSSI urges and behavior in young bisexual people.

METHODS

Participants aged 16-25 from 25 countries took part in this microlongitudinal online survey study (N = 207). Mixed-effects linear and logistic regression were used for analysis, given the nested structure of data. Analysis examined the relationship between self-esteem and thwarted belongingness on NSSI urges and behavior at the same point in time, and lagged by one week.

RESULTS

At the same timepoint, self-esteem and thwarted belongingness both had significant between- and within-person associations with NSSI urges and behavior. For lagged models, self-esteem had significant between-person effects on urges, and thwarted belongingness had significant within-person effects. For NSSI behavior, both variables were only associated with between-person effects.

CONCLUSION

Findings support previous research suggesting the importance of self-esteem in explaining NSSI among sexual minorities. Preventative and intervention strategies to improve self-esteem may help reduce NSSI risk. Future studies should focus upon the experiences of bisexual people with intersecting identities and ensure that studies are statistically powered from inception to detect effects.

Brief Admission for Patients with Self-Harm from the Perspective of Outpatient Healthcare Professionals

The aim of the study was to describe the role of brief-admission (BA) in treating high-risk patients with self-harm from the perspective of outpatient healthcare staff in Sweden. Ten outpatient healthcare professionals from three psychiatric clinics were interviewed. Data were analyzed using a conventional content analysis. The findings of this study help support the role of BA as an acute crisis management intervention, and describe how BA serves as a useful adjunct to outpatient treatment, especially for patients with complementarily psychotherapeutic interventions. The findings also suggest that implementing BA may increase treatment opportunities for outpatient staff and strengthen the concept of person-centered care.

Identifying Specific Emotion Regulation Deficits that Associate with Nonsuicidal Self-injury and Suicide Ideation in Adolescents

It is not known how emotion regulation deficits and strategies may differentially relate to nonsuicidal self-injury (NSSI) and suicide ideation in samples of community-based adolescents. The current study examined emotion regulation using comprehensive multi-method assessment to identify which specific deficits are uniquely related to NSSI and suicide ideation in a sample of high school students. Regarding specific deficits, it was expected that lack of emotional awareness, lack of access to emotion regulation strategies, poor cognitive reappraisal, and poorer automatic emotion processing would uniquely associate with past-year NSSI engagement. It was also predicted that lack of access to strategies, lack of impulse control, lack of awareness, and nonacceptance of emotion would uniquely associate with past-year presence of suicide ideation and suicide ideation severity. The sample included 696 adolescents (54.8% female; ages 14-17; mean age = 15.5) recruited from public high schools. Self-report measures were administered assessing suicide ideation, NSSI engagement, dimensions of emotion regulation, and automatic emotion processing (Emotion Stroop). Emotion suppression was the only unique and significant predictor of past-year NSSI engagement, and lack of access to emotion regulation strategies was the strongest predictor of both past-year presence of suicide ideation and recent suicide ideation severity when accounting for all deficits in the same model. Acquiring emotion regulation skills during the period of adolescence has great potential to buffer from occurrence of NSSI and severity of suicide ideation.

Non suicidal self injury and suicidal behavior among adolescents: co-occurrence and associated risk factors

BACKGROUND

Non-suicidal self-injury (NSSI) and suicidal behavior (SB) are the major public health problems in adolescents. Despite the increased focus on these phenomena, there exist no reliable data in Nepal. This study aimed to determine the prevalence of NSSI and SB among adolescents. Furthermore the study identified the relationship between these two behaviors and assessed demographic, behavioral, and psychological risk factors of NSSI and SB in Nepalese adolescents in a representative sample of the general population.

METHODS

The study was conducted among 730 adolescents studying in grade 9 to 12 of public and private schools of Pokhara Metropolitan city, Nepal. Data were collected through self administered standard tools- Functional Assessment of Self Mutilation (FASM) tool, Suicidal Behaviors Questionnaire-Revised (SBQ-R), Rosenberg self-esteem scale (RSES) and Beck Depression Inventory (BDI). Descriptive statistical measures such as frequency, percentage, mean, standard deviation, range were used to assess demographic characteristics and adolescent's behavior regarding NSSI and suicide. For inferential analysis chi-square and one way ANOVA test was used. Furthermore, to determine the predictors of NSSI and SB, multiple logistic regression analysis was used.

RESULTS

Regarding behavioral characteristics, nearly half of the sample 327 (44.8%) reported a history of NSSI in past 1 year. Furthermore, 25.8% (n = 188) of the overall sample engaged in minor NSSI only and 3.42% (n = 25) engaged in at least one act of moderate/severe NSSI. The mean number of type of NSSI performed was 2.63 ± 1.71. The most common type of NSSI method used were picking at wound (27.3%), biting self (20.3%), pulling hair out (11.8%), cutting self (11.1%). Boys (52.6%) were more likely to be engaged in NSSI than girls (47.4%) (χ²  =  10.298, p  =  0.002). Furthermore, among 730 adolescents who completed the SBQ-R questionnaire, 131 (17.9%) had suicidal behaviors (SB) (as defined by SBQ-R a total score ≥ 7). Regarding sex differences female were significantly higher in life time prevalence of suicidal behavior than male (χ² = 30.26, p = 0.001). Simple Chi-square tests indicated that NSSI was significantly associated with SB (χ² = 58.16, P < .001). Logistic regressions identified the four significant predictors of NSSI behavior: male, low-level of self-esteem (SE), moderate to severe form of depression and SB. Similarly, significant predictors of SB were: female, low-level of SE, moderate to severe form of depression and NSSI behavior.

CONCLUSION

The prevalence of both NSSI and SB is high in adolescents. Despite the differences between NSSI and SB a significant number of adolescents reported a history of both behaviors. Lower level of SE and moderate to severe depression were the significant predictors of both NSSI and SB. Furthermore, male and adolescents with the history of SB were at risk of NSSI behavior whereas female sex and adolescents with the history of NSSI were at risk of SB.

Correlates of disclosure of non-suicidal self-injury amongst Australian university students

Purpose

Non-suicidal self-injury (NSSI) is associated with psychological disorders and suicidal thoughts and behaviours; disclosure of NSSI can serve as a catalyst for help-seeking and self-advocacy amongst people who have self-injured. This study aims to identify the socio-demographic, NSSI-related, socio-cognitive and socio-emotional correlates of NSSI disclosure. Given elevated rates of NSSI amongst university students, this study aimed to investigate these factors amongst this population.

Design/methodology/approach

Australian university students (n = 573) completed online surveys; 80.2% had previously disclosed self-injury.

Findings

NSSI disclosure was associated with having a mental illness diagnosis, intrapersonal NSSI functions, specifically marking distress and anti-dissociation, having physical scars from NSSI, greater perceived impact of NSSI, less expectation that NSSI would result in communication and greater social support from friends and significant others.

Originality/value

Expanding on previous works in the area, this study incorporated cognitions about NSSI. The ways in which individuals think about the noticeability and impact of their NSSI, and the potential to gain support, are associated with the decision to disclose self-injury. Addressing the way individuals with lived experience consolidate these considerations could facilitate their agency in whether to disclose their NSSI and highlight considerations for health-care professionals working with clients who have lived experience of NSSI.

Hypothalamic-pituitary-thyroid axis function in female adolescent nonsuicidal self-injury and its association with comorbid borderline personality disorder and depression

OBJECTIVES

Behavioral disturbances in adolescence are potentially linked to aberrant functioning of the thyroid gland. Accordingly, alterations of the hypothalamic-pituitary-thyroid (HPT) axis might impact psychopathological development. Yet corresponding research in adolescents with nonsuicidal self-injury (NSSI) and comorbid mental disorders is scarce.

METHODS

The present study examined HPT axis functioning in adolescents with NSSI compared to healthy controls (HC) using blood-based assays of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), and the ratio of these hormones (fT3/fT4 ratio). Cortisol was additionally examined to contrast HPT axis functioning with a well-established biomarker of stress responsivity. Moreover, associations between clinical characteristics, HPT axis and HPA axis functioning were investigated. Female adolescents meeting NSSI criteria according to DSM-5 criteria (n = 117) were compared to adolescent HC (n = 41). Standardized serum-based endocrinological assays and interview- and questionnaire-based psychiatric assessments were used. Smoking status was included as covariate for all analyses.

RESULTS

NSSI patients displayed altered HPT axis functioning as fT3/fT4 ratio values were blunted in comparison to HC. Negative correlations were further present between fT3, fT3/fT4 ratio and severity of BPD symptoms, depression scores and symptomatic distress. TSH correlated negatively with severity of BPD symptoms and symptomatic distress exclusively. Cortisol values differed neither significantly between experimental groups nor correlated significantly with clinical characteristics.

CONCLUSIONS

Longitudinal examinations, assessing links between psychopathology and endocrinological alterations, are warranted to address potential clinical implications of thyroid markers in child and adolescent psychiatry.

Understanding Perceptions of Nonsuicidal Self-Injury: Descriptive and Injunctive Norms

Nonsuicidal self-injury (NSSI) is a major public health concern. Web-based personalized feedback interventions (PFIs) may be a cost-effective and efficient way to treat NSSI. In order to develop a PFI, it is imperative to assess descriptive and injunctive norms. The current study examines descriptive and injunctive norms of NSSI within college students and adults in the community, comparing how perceived norms may differ for those who do or do not engage in NSSI. Study 1 calculated percentages of NSSI behavior within the student sample. Study 2 then examined perceived descriptive and injunctive norms between those with and without history of NSSI in both samples. Study 1 indicated that 19% of undergraduate students had histories of NSSI. Additionally, there was a general tendency to overestimate the percentage of people who engage in NSSI and the number of times a typical person engages in NSSI. Finally, those who engaged in NSSI believed that most people do not understand why individuals engage in NSSI; comparatively, the majority of people without history of NSSI still indicated that they understand why others would engage in NSSI. These research findings may be utilized in a PFI to reduce shame and NSSI behavior.

Beating Adolescent Self-Harm (BASH): a randomised controlled trial comparing usual care versus usual care plus a smartphone self-harm prevention app (BlueIce) in young adolescents aged 12-17 who self-harm: study protocol

INTRODUCTION

A mobile app, BlueIce, was codesigned with young people with a history of self-harm to provide them with more accessible and available evidence-based support at times of distress. A preliminary evaluation found that BlueIce was acceptable, safe and used by young people and helped to reduce self-harm. The present study is designed to assess the effectiveness and cost-effectiveness of adding BlueIce to usual Child and Adolescent Mental Health Service (CAMHS).

METHODS AND ANALYSIS

This study is a single-blind, randomised controlled trial comparing usual CAMHS care with usual care plus BlueIce. A total of 138 adolescents aged 12-17 with current or a history of self-harm will be recruited through the Oxford Health National Health Service (NHS) Foundation Trust via their CAMHS clinician. The primary outcome is self-harm at 12 weeks assessed using the Risk Taking and Self-Harm Inventory for Adolescents. Secondary outcomes include mood, anxiety, hopelessness, general behaviour, sleep and impact on everyday life at 12 weeks and 6 months. Health-related quality of life and healthcare resource utilisation data will be collected at baseline, 12 weeks and 6 months. Postuse interviews at 12 weeks will determine the acceptability, safety and usability of BlueIce.

ETHICS AND DISSEMINATION

The study was approved by the NHS South Central-Oxford B NHS Research Ethics Committee (19/SC/0212) and by the Health Research Authority (HRA) and Health and Care Research Wales. Findings will be disseminated in peer review open-access journals and at academic conferences.

TRIAL REGISTRATION NUMBER

ISRCTN10541045.

The relationship between rumination and NSSI: A systematic review and meta-analysis

BACKGROUND

Rumination is a cognitive process that has been implicated in the onset and maintenance of a variety of psychological difficulties. The purpose of this review and meta-analysis was to examine the nature and strength of the relationship between rumination and non-suicidal self-injury (NSSI).

METHODS

The protocol for this review was pre-registered (CRD42019148186). A literature search of electronic databases PsycINFO, CINAHL, MEDLINE, and Web of Science was performed from the earliest date available to March 2020. Thirty-nine eligible papers were identified. An additional seven papers were identified from a search conducted in September 2021, resulting in a total of 46 papers. Separate meta-analyses were undertaken for NSSI frequency and NSSI history, with studies grouped by rumination type (depressive, transdiagnostic, anger, brooding, reflection, catastrophising, overall). Moderator analyses were also conducted along with a narrative synthesis of adjusted associations and longitudinal studies.

RESULTS

Rumination had a positive small association with NSSI frequency and a positive moderate association with NSSI history. The adjusted associations yielded mixed findings and most longitudinal research found rumination to be associated with prospective NSSI.

LIMITATIONS

Most included studies had a moderate risk of bias and used a student sample. A limitation of this review was that only English language papers were included.

CONCLUSIONS

Findings indicate that rumination is associated with NSSI, but more so the likelihood of engaging in NSSI overall than the frequency. Rumination-focused techniques for NSSI may therefore be of benefit. Further research is needed to understand this association, particularly with longitudinal studies that focus on state rumination rather than stable trait rumination.

PRACTITIONER POINTS

Rumination was found to have a small to moderate association with NSSI. Some individuals who engage in NSSI may benefit from psychological techniques that target rumination. Most of the studies included had a moderate risk of bias.

Risk of Suicidal Behavior in Children and Adolescents Exposed to Maltreatment: The Mediating Role of Borderline Personality Traits and Recent Stressful Life Events

Childhood maltreatment (CM) is associated with increased non-suicidal self-injury (NSSI) and suicidal behavior (SB), independently of demographic and mental health conditions. Self-Trauma Theory and Linehan's Biopsychosocial Model might explain the emergence of Borderline Personality Disorder (BPD) symptoms as mediators of the association between CM and the risk of SB. However, little is known regarding such relationships when the exposure is recent for young persons. Here, we study 187 youths aged 7-17, with or without mental disorders. We explore CM experiences (considering the severity and frequency of different forms of neglect and abuse), recent stressful life events (SLEs), some BPD traits (emotion dysregulation, intense anger and impulsivity), and the risk of SB (including NSSI, suicide threat, suicide ideation, suicide plan and suicide attempt). We study the direct and mediating relationships between these variables via a structural equation analysis using the statistical software package EQS. Our findings suggest that youths exposed to more severe/frequent CM have more prominent BPD traits, and are more likely to have experienced recent SLEs. In turn, BPD traits increase the risk of SLEs. However, only emotion dysregulation and recent SLEs were found to be correlated with SB. Therefore, targeted interventions on emotion dysregulation are necessary to prevent NSSI or SB in children and adolescents exposed to CM, as is the minimization of further SLEs.

Psychotherapeutic interventions for the prevention of suicide re-attempts: a systematic review

A history of suicide attempt (SA) is a strong predictor of future suicide re-attempts or suicide. The aim of this systematic review is to evaluate the efficacy of psychotherapeutic interventions specifically designed for the prevention of suicide re-attempts. A systematic search from 1980 to June 2020 was performed via the databases PubMed and Google Scholar. Only randomized controlled trials were included which clearly differentiated suicidal self-harm from non-suicidal self-injury in terms of intent to die. Moreover, psychotherapeutic interventions had to be focused on suicidal behaviour and the numbers of suicide re-attempts had to be used as outcome variables. By this procedure, 18 studies were identified. Statistical comparison of all studies revealed that psychotherapeutic interventions in general were significantly more efficacious than control conditions in reducing the risk of future suicidal behaviour nearly by a third. Separate analyses revealed that cognitive-behavioural therapy as well as two different psychodynamic approaches were significantly more efficacious than control conditions. Dialectical behaviour therapy and elementary problem-solving therapy were not superior to control conditions in reducing the number of SAs. However, methodological reasons may explain to some extent these negative results. Considering the great significance of suicidal behaviour, there is unquestionably an urgent need for further development of psychotherapeutic techniques for the prevention of suicide re-attempts. Based on the encouraging results of this systematic review, it can be assumed that laying the focus on suicidal episodes might be the key intervention for preventing suicide re-attempts and suicides.

Targeting self-criticism in the treatment of nonsuicidal self-injury in dialectical behavior therapy for adolescents: a randomized clinical trial

BACKGROUND

The Benefits and Barriers Model proposes both benefits and barriers associated with nonsuicidal self-injury (NSSI) and that a negative association with the self plays a key role in the initial selection of and acute motivation for NSSI. The current investigation builds upon previous findings by assessing the added benefit of targeting self-criticism in the treatment of NSSI.

METHODS

Sample included 40 participants (30 females; M_age  = 14.92) enrolled in dialectical behavior therapy for adolescents within a partial hospitalization program. All study participants received dialectical behavior therapy for adolescents, and those randomized to the experimental condition received an additional brief cognitive intervention developed to decrease self-criticism.

RESULTS

There was no evidence of an indirect effect of targeting self-criticism upon NSSI at post-treatment via post-treatment self-criticism (b = -0.98, p = .543); however, there was evidence of a significant interaction between treatment condition and self-criticism at pretreatment in the prediction of NSSI at post-treatment (b = 0.33, p = .030). Analyses of simple slopes indicated the conditional direct effect of targeting self-criticism varied as a function of patient's level of self-criticism at the onset of treatment, such that individuals -1 SD below the mean (b = -5.76, p = .037) and at average pretreatment levels of self-criticism (b = -4.09, p = .042), but not + 1 SD above the mean (b = -2.42, p = .056), experienced fewer incidents of NSSI at post-treatment.

CONCLUSIONS

The results of this investigation support the added benefit of targeting self-criticism in the treatment of NSSI for adolescents.

The association between alcohol use and suicide attempt in employees

Purpose: This study aimed to analyze the alcohol use patterns that may influence suicide attempt in employees who have suicidal ideation.Methods: The 15,199 participants were classified into three groups according to suicide risk severity. Participant scores on the Alcohol Use Disorders Identification Test-Korea (AUDIT-K), subscale for drinking amount/frequency (AUDIT-C, items 1–3), subscale for dependence/related problems (AUDIT-D/P, items 4–10), and other sociodemographic and psychiatric scales were analyzed between the groups using one-way analysis of variance (ANOVA) and the chi-square test, followed by post hoc analysis using the Bonferroni correction.Results: A statistically significant difference between all three groups was observed for AUDIT-D/P scores after post hoc analysis (P < 0.001), indicating an increasing trend for greater suicide risk. This trend was present in both sexes and across all age groups above 30 years old.Conclusion: Alcohol dependence/related problems are significantly associated with suicide attempt among employees. Assessing and preventing suicide risk according to these issues may minimize socioeconomic losses due to suicide.

Self-Injury Is My Drug: The Functions of Describing Nonsuicidal Self-Injury as an Addiction

ABSTRACT

Adolescents and emerging adults who engage in nonsuicidal self-injury (NSSI) often participate in online activity regarding their self-injury. Of particular importance are the potential benefits and risks associated with online NSSI activity, including how individuals describe their NSSI experiences. One way that individuals describe these experiences is by discussing NSSI as an addiction. Accordingly, we used thematic analysis to explore why individuals may use addiction references to describe their NSSI experiences. To do this, we examined 71 posts from a popular NSSI social network. Four themes emerged: difficulty inherent in stopping, authentication, warn others, and communicate the plight of the behavior. Findings highlight a number of avenues for research as well as implications for clinicians working with clients who self-injure perceive NSSI as an addiction. Mental health professionals can leverage their understanding of clients' perceptions of NSSI to better serve this population.

The role of personality dimensions and trait anxiety in increasing the likelihood of suicide ideation in women during the perinatal period

INTRODUCTION

Increasing amount of data reveal that suicide risk is a real phenomenon among perinatal women, determined by several other psychopathological conditions with depression being just one of them. This study aimed to investigate the role of personality dimensions on the occurrence of suicide ideation during the perinatal period.

METHODS

A longitudinal prospective study was performed in pregnant women who were monitored at university-based obstetrical care units in our county. Recruited women were reassessed between 6 and 8 weeks into their postnatal period. Trait and state anxiety, five-factor based dimensions of personality, and depressive symptoms were assessed using established psychometric measures. Appropriate statistical analyses were conducted, depending on the distribution of variables.

RESULTS

Significant levels of state anxiety (33.7% vs. 15.5%), depressive symptoms (19.8% vs. 8.5%), and suicide risk (13.9% vs. 6.3%) have halved in the postnatal period compared to the antenatal assessment. A lower level of education was associated with the presence of postnatal suicide ideation (p = .041), while an unemployed professional status was more frequent in pregnant women presenting antenatal suicide ideation (p = .021). Trait anxiety was predictive for the appearance of suicide ideation within the entire perinatal period assessed (p < .001 and p = .007, respectively). Agreeableness and conscientiousness predicted antenatal suicide ideation (p = .033 and p = .032, respectively).

DISCUSSIONS

Different dimensions of personality may play a contributing role in the development of suicide ideation in perinatal women. Consequently, personality dimensions and trait anxiety, not only depressive symptoms, should be investigated when attempting to identify perinatal women at risk of suicide.

Early maladaptive schemas in young people who self-injure

BACKGROUND

There is emerging evidence that early maladaptive schemas (EMS) may be a cognitive vulnerability factor in nonsuicidal self-injury (NSSI). The current study sought to examine the relationship between EMS and NSSI history, and whether this is moderated by gender, in a community youth sample.

METHOD

Participants were 403 Australian secondary and university students aged between 16 and 25 years, who completed a survey of NSSI history, EMS, and general emotional distress.

RESULTS

Logistic regression analysis indicated that being female, depression, and EMS scores were useful for differentiating between youth reporting NSSI history and those who did not. High levels of Defectiveness/Shame and Abandonment/Instability schema scores, and low levels of Emotional Inhibition schema scores, were associated with NSSI history. Gender did not moderate the relationships between these EMS scores and NSSI history.

CONCLUSIONS

Present results suggest that aspects of the schema domain of Disconnection and Rejection are important for identifying NSSI history beyond young people's emotional distress. This provides researchers and clinicians with an opportunity to better target key EMS, especially beliefs about self-defectiveness and feelings of shame, that may be driving the regulatory function of self-injury among youth.

Perceptions of knowledge, attitude and skills about non-suicidal self-injury: A survey of emergency and mental health nurses

Non-suicidal self-injury (NSSI) is a major public health concern and is also associated with increased risk of suicide. The type of care people with NSSI receive at the hospital impacts their health outcomes. This study explored emergency department (ED) and mental health nurses' (MHNs) understanding, attitudes, empathy and confidence to work with people presenting with NSSI. ED and MHNs who belonged to either the College of Emergency Nursing Australasia (CENA) or the Australian College of Mental Health Nurses (ACMHN) were invited to complete an online survey through a group email from their college. One hundred and one nurses (56 ED and 45 MHNs) completed the survey. The results revealed that nurses from both groups had an accurate understanding of NSSI and had positive attitudes about patients who self-injure. However, confidence was higher among MHNs. Greater knowledge of NSSI was correlated with increased confidence, positive attitudes and empathy. For mental health nurses, but not ED nurses, years of clinical practice was associated with nurses' confidence. In contrast, ED nurses with more than 10 years' experience were less confident in addressing NSSI than ED nurses with less experience. Issues that affect both ED and MHNs' knowledge, attitude, empathy and confidence to care for patients who self-injure are multifactorial. Future education and training should focus on therapeutic interactions with people at risk of repeat NSSI. Further, more research is recommended to explore patients' perspectives of nurses' attitudes in care for people who self-injure.

Risk factors for self-harm repetition in adolescents: A systematic review

Self-harm behavior can begin in early adolescence, with the highest rates of self-harm, between 1990 and 2000 in England, being among adolescents aged 16 to 24 years and there being considerable risk of fatal and non-fatal repetition. Previous systematic reviews have identified risk factors for self-harm in adolescents, but not for the repetition of this behavior. The aim of this review was to synthesise the psychological, psychosocial and sociodemographic risk factors for self-harm repetition in adolescents. By searching four databases, 27 studies were identified and included in the review. Several psychological (e.g., psychiatric morbidity, features of previous self-harm, psychological distress), psychosocial (e.g., alcohol misuse, poor family and peer relationships) and sociodemographic (e.g., age, gender and ethnicity) risk factors were identified for self-harm repetition in adolescents. Several risk factors across all categories for self-harm overlapped with that of self-harm repetition, such as depression, alcohol misuse and female gender. The clinical implications of these findings for practitioners were discussed. As was the case with prior reviews in this area, comparability between studies was limited and a meta-analysis was not possible due to considerable heterogeneity in outcome definitions, measures and methodologies.