Correlates of suicide attempts among self-injurers: A meta-analysis

Differentiating Suicide Attempters from Suicide Ideators: The Role of Capability for Suicide

This study examined whether different components of capability for suicide (i.e., fearlessness about death, pain tolerance, pain insensitivity, preparation for suicide, suicide plan, and courage), as well as painful and provocative events, nonsuicidal self-injury, depressive symptoms, and hopelessness, could distinguish between suicide attempters, suicide ideators, and non-suicidal controls. A total of 930 Chinese adolescents completed questionnaires, and a multinomial logistic regression was conducted to identify factors that could distinguish among the 3 groups. We found that higher levels of pain tolerance, more detailed suicide plans, more positive attitudes towards suicide, as well as more painful and provocative experiences and more severe depressive symptoms were positively associated with increased likelihood of the engagement in both suicide ideation and suicide attempts. Only nonsuicidal self-injury increased the likelihood of falling in the suicide attempt group as compared to the suicide ideation group. Findings of this study emphasize the role of nonsuicidal self-injury in intervening suicidality.

White Matter Microstructure in Adolescents and Young Adults With Non-Suicidal Self-Injury

BACKGROUND

Non-suicidal self-injury (NSSI) is a growing public health concern that commonly begins in adolescence, and can persist into young adulthood. A promising approach for advancing our understanding of NSSI in youth is to examine white matter microstructure using diffusion magnetic resonance imaging (dMRI).

METHOD

The present study examined whole-brain group differences in structural connectivity (as measured by generalized fractional anisotropy [GFA]) between 28 female adolescents and young adults ages 13-21 years with NSSI and 22 age-matched healthy controls (HC). We also explored the association between clinical characteristics including NSSI severity and duration, impulsivity, emotion regulation and personality traits within the NSSI group and GFA of the uncinate fasciculus and cingulum.

RESULTS

Compared to the HC group, participants with NSSI had lower GFA in several white matter tracts, including the uncinate fasciculus, cingulum, bilateral superior and inferior longitudinal fasciculi, anterior thalamic radiation, callosal body, and corticospinal tract. When controlling for depressive symptoms, the NSSI group showed an association between NSSI duration (time since initiating NSSI behavior) and lower GFA in the left cingulum. Higher levels of attentional impulsivity were related to lower GFA in the left uncinate fasciculus within the NSSI group.

CONCLUSIONS

We found evidence suggesting widespread white matter microstructure deficits in adolescents and young adults with NSSI versus HC. We also report inverse associations between white matter integrity and clinical characteristics (duration of NSSI and attentional impulsivity). These white matter microstructural deficits may represent a possible neurobiologically-based vulnerability to developing maladaptive coping mechanisms, such as NSSI. Additionally, results suggest that this white matter disorganization may either worsen with prolonged engagement in NSSI or predict persistent NSSI; thereby highlighting the importance of early intervention targeting this behavior.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.¹ This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.

The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors

BACKGROUND

Theoretical and empirical literature suggests that non-suicidal self-injury (NSSI) is an important correlate of suicide risk. The present study was designed to evaluate: (a) whether NSSI is associated with increased odds of subsequent onsets of suicidal thoughts and behaviors (STB) independent of common mental disorders, (b) whether NSSI is associated with increased risk of transitioning from suicide ideation to attempt, and (c) which NSSI characteristics are associated with STB after NSSI.

METHOD

Using discrete-time survival models, based on retrospective age of onset reports from college students (n = 6,393, 56.8% female), we examined associations of temporally prior NSSI with subsequent STB (i.e., suicide ideation, plan, and attempt) controlling mental disorders (i.e., MDD, Broad Mania, GAD, Panic Disorder, and risk for Alcohol Dependence). NSSI characteristics associated with subsequent STB were examined using logistic regressions.

RESULTS

NSSI was associated with increased odds of subsequent suicide ideation (OR = 2.8), plan (OR = 3.0), and attempt (OR = 5.5) in models that controlled for the distribution of mental disorders. Further analyses revealed that NSSI was associated with increased risk of transitioning to a plan among those with ideation, as well as attempt among those with a plan (ORs = 1.7-2.1). Several NSSI characteristics (e.g., automatic positive reinforcement, earlier onset NSSI) were associated with increased odds of experiencing STB.

LIMITATIONS

Surveys relied on self-report, and thus, there is the potential for recall bias.

CONCLUSIONS

This study provides support for the conceptualization of NSSI as a risk factor for STB. Investigation of the underlying pathways accounting for these time-ordered associations is an important avenue for future research.

Exploratory analysis of mediators of the relationship between childhood maltreatment and suicidal behavior

INTRODUCTION

Suicide is a major public health concern. One consistently cited risk factor for suicide is childhood maltreatment, which also may play a role in the transition from suicidal ideation to suicidal behavior.

METHOD

The current study aimed to examine the relationship between childhood maltreatment and suicide attempts during adolescence (N = 4834; 52.1% female; 67.5% Caucasian). Data from the U.S. National Longitudinal Study of Adolescent Health were utilized. Forty-six theoretically-relevant risk factors were explored as potential mediators of this relationship using an exploratory mediation data analytic method.

RESULTS

Results demonstrated a significant childhood maltreatment - suicide attempt relationship only among females. After considering demographics and suicidal ideation, having received counseling in the previous 12 months was the most influential mediator, followed by having a friend attempt suicide in the previous 12 months.

CONCLUSIONS

These findings highlight potential gender differences in the relationship between childhood maltreatment and later suicide attempts, and, moreover, the importance of assessing for recent exposure to peer suicidal behavior in suicide risk assessments.

Prefrontal cortex activation during cognitive interference in nonsuicidal self-injury

Nonsuicidal self-injury (NSSI), deliberate behavior resulting in self-inflicted damage to oneself, is common, particularly among female adolescents, and may be a form of maladaptive emotion regulation. Cognitive interference, a specific type of processing associated with inhibiting prepotent responses in favor of less automatic ones, is utilized in treatment strategies to shift patients' thoughts and behaviors away from maladaptive responses and replace them with more adaptive ones. We examined cognitive interference processing using the Multi-Source Interference Task (MSIT) in females with NSSI behavior (n=15) and healthy control females (n=15). Functional magnetic resonance imaging (fMRI) data were collected concurrently. Results revealed similar between-group performance on the MSIT; however, women with NSSI behavior exhibited altered patterns of neural activation during the MSIT. Specifically, the NSSI group demonstrated increased cingulate cortex (CC) and decreased dorsolateral prefrontal cortex (DLPFC) activation compared to the control group. Further, within the NSSI group, DLPFC activation inversely correlated with emotional reactivity and self-reported impulsivity, suggesting that decreased DLPFC activation is associated with poorer emotional control and increased impulsivity. Taken together, these results indicate that women with NSSI behavior utilize different cortical areas during cognitive interference processing, which may have broader implications regarding the treatment efficacy of cognitive-based therapies.

Perceived effectiveness of NSSI in achieving functions on severity and suicide risk

Nonsuicidal self-injury (NSSI) continues to be a psychiatric problem for youth and young adults, and is a robust risk factor for suicidal thoughts and behaviors. Research has established that NSSI is motivated by intrapersonal and interpersonal functions; however, research on the perceived effectiveness of NSSI for achieving the desired functions is lacking. In the current study, it was expected that using NSSI to achieve intrapersonal functions would be rated as more effective than interpersonal functions, and that perceived effectiveness of NSSI would be differentially related to NSSI severity and suicide risk outcomes. In a sample of 264 adults with lifetime NSSI history (over 70% past year), intrapersonal functions were endorsed more than interpersonal functions, and were rated as significantly more effective. Overall, perceived effectiveness of NSSI for intrapersonal functions was significantly and positively predictive of NSSI severity, while interpersonal functions were significantly and negatively related. Perceived effectiveness of NSSI for intrapersonal functions, but not interpersonal functions, were significantly predictive of more frequent and intense suicide ideation and greater likelihood of suicide plans and attempts. Results highlight the importance of assessing the perceived effectiveness of NSSI for specific functions in identifying individuals at risk for more severe NSSI and suicide.

Non-suicidal self-injury in patients with eating disorders: prevalence, forms, functions, and body image correlates

INTRODUCTION

More than one third of patients with eating disorders report NSSI. Moreover, negative attitudes and feelings toward the body, body dissatisfaction, and body image disturbances have been linked to NSSI in community and clinical samples. However, there is a lack of studies exploring NSSI frequency and functions and the specific relationship between multidimensional body image dimensions and NSSI in eating disorder patients.

OBJECTIVES

First, we explored the frequency, types, and functions of NSSI in a sample of 226 Spanish female participants with eating disorders (ED). Second, we explored differences in NSSI and body image depending on the ED restrictive-purgative subtype; and third, we explored differences in body dissatisfaction, body image orientation, and body investment in eating disorder patients without NSSI (n = 144), with NSSI in their lifetime (n = 19), and (b) with NSSI in the previous year (n = 63).

RESULTS

Of the overall sample, 37.1% (n = 89) had a history of self-injury during their lifetime, and 27.1% (n = 65) had self-injured in the previous year. Among the types of ongoing NSSI, the most frequent were banging (64.6%) and cutting (56.9%). Restrictive vs purgative patients differed on NSSI lifetime, Appearance Evaluation, Body Areas Satisfaction, Body Protection and Feelings and Attitudes toward the Body. Moreover, significant differences were found on Appearance Evaluation, Body Areas Satisfaction, Positive Feelings and Attitudes towards the Body, Body Protection, and Comfort with physical contact, between participants without a history of self-injury and both NSSI groups.

DISCUSSION

Body dissatisfaction and body investment have been found to be variables related to NSSI. Thus, the present study highlights the importance of working on body image in ED patients to reduce the frequency of NSSI.

Patterns of Non-Suicidal Self-Injury and Their Relationship with Suicide Attempts in Youth with Borderline Personality Disorder

The study aimed to identify the relationships between patterns of non-suicidal self-injury (NSSI), their severity, and suicide attempts among 107 youth (aged 15-25 years) with borderline personality disorder (BPD). Two principal patterns were identified via a graphical representation of retrospectively reported 12-month histories of NSSI. These were habitual (NSSI occurring at regular intervals) and random patterns (NSSI inconsistently spaced). Habitual patterns of NSSI were associated with lower severity and fewer suicide attempts than random patterns. Within-person comparisons revealed a reduction in NSSI engaged within a habitual pattern and an increase in NSSI engaged within a random pattern in the month prior to a suicide attempt. Findings suggest that the accuracy of risk assessments among youth with BPD might be improved by identifying an individual's historical pattern of NSSI, as well as any relative increase in NSSI engaged within a random pattern or relative reduction in NSSI engaged within a habitual pattern.

Understanding the social context of adolescent nonsuicidal self-injury

OBJECTIVE

Research investigating the social context of adolescent nonsuicidal self-injury (NSSI) has been limited. We therefore examined social characteristics of NSSI, such as knowledge of friends' NSSI and the role friends play in continuing NSSI, and their relationships to other known NSSI correlates, such as suicidality.

METHOD

We assessed NSSI characteristics, including social features, in a community sample of 89 self-injuring adolescents. We also assessed psychosocial correlates of NSSI, including impulsivity, self-concept, and psychiatric symptoms.

RESULTS

Knowledge of friends' NSSI was relatively common among self-injurers. In addition, knowledge of friends' NSSI was associated with use of more NSSI methods, cutting behaviors, and suicidal ideation, but not with other NSSI correlates. However, teaching or encouragement of NSSI by friends was rare.

CONCLUSIONS

Knowledge of friends' NSSI may serve as marker of increased severity among adolescent self-injurers. These findings have implications for identifying and intervening with high-risk self-injuring youth.

Impulsivity and Response Latency in Non-Suicidal Self-Injury: The Role of Negative Urgency in Emotion Regulation

Impulsivity is thought to be a contributing factor in non-suicidal self-injury (NSSI), yet the research is limited and inconsistent. In particular, little is known about how impulsivity is associated with response latency between initial urge and later self-injury, emotion regulation processes, or severity of NSSI. In this study, we tested group differences between participants with and without a history of NSSI on a questionnaire measure of impulsivity. In addition, we tested hypothesized correlations between impulsivity and relevant variables within the NSSI sample using questionnaires and self-reported response latency between urge and injury. Participants included 159 undergraduate students, 84 with an NSSI history and 75 without an NSSI history. Results indicated greater impulsivity on facets of Urgency and (lack of) Perseverance for the NSSI group. Within the NSSI sample, facets of impulsivity were associated with difficulties in emotion regulation and NSSI severity, but not response latency. In addition, response latency, a possible behavioral marker of impulsivity, was not associated with emotion regulation processes or NSSI frequency. These results suggest that higher scores on self-report measures of impulsivity, but not behavioral response latency measures, are associated with emotion regulation processes in individuals who self-injure.

[Links between self-harm and suicidal behaviour in adolescents]

Nonsuicidal self-injury (NSSI) and suicidal behaviour (SB) are both important issues in adolescent health care. The fact that they frequently coexist means that it is important to consider the nature of the link between them and the ways they are understood. Suicide and self-injury share the same risk factors. Integrated models envisage NSSI as a gateway enabling teenagers to acquire a capability for suicide. The act short-circuits the thought process and the intention to die underlying the act appears difficult to assess.

Pre-disaster PTSD as a moderator of the relationship between natural disaster and suicidal ideation over time

BACKGROUND

Natural disasters are associated with a variety of negative health consequences, including enhanced suicide risk. Factors that moderate the relationship between disaster exposure and enhanced suicide risk are unknown. The aim of the current study was to determine whether pre-disaster PTSD moderates the association between change over time in thoughts of death, suicidal ideation (SI), suicide plans, and suicide attempts (SA) from pre- to post-disaster.

METHODS

Participants (n = 2832) were recruited from Chile as part of the larger PREDICT study and completed a measure of lifetime PTSD and panic disorder at baseline and a lifetime death/suicide measure at baseline in 2003 and again 6, 12, and 24 months later (i.e. "pre-disaster"). One year following a major earthquake and tsunami in 2010 (i.e., "post-disaster"), participants completed another death/suicide measure.

RESULTS

Both those with and without pre-disaster PTSD experienced significant increases in SI from pre- to post-disaster. However, pre-disaster PTSD was associated with significantly accelerated increases in thoughts of death and SI from pre-to post-disaster. At nearly all time-points, pre-disaster PTSD was associated with higher thoughts of death and SI, suicide planning, and SA. In contrast, panic disorder did not moderate the association between time and changes in SI.

LIMITATIONS

There was a long time-gap between pre-disaster and post-disaster, with limited data about what occurred during this time.

CONCLUSION

Pre-disaster PTSD is an important predictor of increased SI following a natural disaster, and groups with pre-disaster PTSD should be prioritized for receipt of mental health resources following a natural disaster.

Characterizing gender differences in nonsuicidal self-injury: Evidence from a large clinical sample of adolescents and adults

While nonsuicidal self-injury (NSSI) is common in both men and women, research exploring the intersection of NSSI and gender has been limited by the use of small samples of males drawn primarily from non-clinical populations. To address these limitations, we analyzed data from a large sample of patients enrolled in an NSSI partial hospitalization program (PHP) to compare males and females across several variables, including NSSI characteristics, correlates, and pre-post treatment outcomes. Results indicated similar NSSI characteristics and treatment outcomes for males and females, with few exceptions. Males notably reported lower severity levels for most NSSI correlates (e.g., psychopathology, suicidality), highlighting the need to screen males for NSSI even when reporting comparatively less impairment. Finally, our results also suggest that PHP treatment for NSSI can be beneficial for both males and females. These findings have implications for the assessment, diagnosis, conceptualization, and treatment of NSSI in males and females.

Identifying the relative importance of non-suicidal self-injury features in classifying suicidal ideation, plans, and behavior using exploratory data mining

Individuals with a history of non-suicidal self-injury (NSSI) are at alarmingly high risk for suicidal ideation (SI), planning (SP), and attempts (SA). Given these findings, research has begun to evaluate the features of this multi-faceted behavior that may be most important to assess when quantifying risk for SI, SP, and SA. However, no studies have examined the wide range of NSSI characteristics simultaneously when determining which NSSI features are most salient to suicide risk. The current study utilized three exploratory data mining techniques (elastic net regression, decision trees, random forests) to address these gaps in the literature. Undergraduates with a history of NSSI (N = 359) were administered measures assessing demographic variables, depression, and 58 NSSI characteristics (e.g., methods, frequency, functions, locations, scarring) as well as current SI, current SP, and SA history. Results suggested that depressive symptoms and the anti-suicide function of NSSI were the most important features for predicting SI and SP. The most important features in predicting SA were the anti-suicide function of NSSI, NSSI-related medical treatment, and NSSI scarring. Overall, results suggest that NSSI functions, scarring, and medical lethality may be more important to assess than commonly regarded NSSI severity indices when ascertaining suicide risk.

Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6-12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.

Sporadic and recurrent non-suicidal self-injury before age 14 and incident onset of psychiatric disorders by 17 years: prospective cohort study

BACKGROUND

Non-suicidal self-injury (NSSI) is highly prevalent in adolescents and may be a behavioural marker for emergent mental illnesses. Aims To determine whether sporadic or recurrent NSSI up to the age of 14 years predicted increased risk of new onset of psychiatric disorder in the subsequent 3 years, independent of psychiatric symptoms and social risk factors.

METHOD

In total, 945 individuals aged 14 years with no past/present history of mental illness completed a clinical interview and completed a questionnaire about NSSI at the ages of 14 and 17 years.

RESULTS

Recurrent NSSI at baseline predicted total disorders, depression and eating disorders. Sporadic baseline NSSI predicted new onset of anxiety disorders only.

CONCLUSIONS

NSSI (especially recurrent NSSI) in the early-adolescent years is a behavioural marker of newly emerging mental illnesses. Professionals should treat both recurrent and sporadic NSSI as important risk factors, and prevention strategies could be targeted at this vulnerable group. Declaration of interest None.

N-Acetylcysteine for Nonsuicidal Self-Injurious Behavior in Adolescents: An Open-Label Pilot Study

BACKGROUND

Nonsuicidal self-injury (NSSI) is common in adolescents and young adults, and few evidence-based treatments are available for this significant problem. N-acetylcysteine (NAC) is a widely available nutritional supplement that has been studied in some psychiatric disorders relevant to NSSI including mood and addictive disorders. This pilot study tested the use of NAC as a potential treatment for NSSI in youth.

METHODS

Thirty-five female adolescents and young adults with NSSI aged 13-21 years were enrolled in this study that had an open-label, single-arm study design. All participants were given oral NAC as follows: 600 mg twice daily (weeks 1-2), 1200 mg twice daily (weeks 3-4), and 1800 mg twice daily (weeks 5-8). Patients were seen every 2 weeks throughout the trial, at which time youth reported the frequency of NSSI episodes. Levels of depression, impulsivity, and global psychopathology were measured at baseline and at the end of the trial using the Beck Depression Inventory-II (BDI-II), Barratt Impulsivity Scale, and Symptoms Checklist-90 (SCL-90).

RESULTS

About two-thirds of the enrolled female youth completed the trial (24/35). NAC was generally well tolerated in this sample. NAC treatment was associated with a significant decrease in NSSI frequency at visit 6 and visit 8 compared to baseline. We also found that depression scores and global psychopathology scores (but not impulsivity scores) decreased after NAC treatment. Decrease in NSSI was not correlated with decrease in BDI-II or SCL-90 scores, suggesting these might be independent effects.

CONCLUSION

We provide preliminary evidence that NAC may have promise as a potential treatment option for adolescents with NSSI. The current results require follow-up with a randomized, placebo-controlled trial to confirm efficacy.

Association between Non-Suicidal Self-Injury, Parents and Peers Related Loneliness, and Attitude Towards Aloneness in Flemish Adolescents: An Empirical Note

Loneliness and attitude towards aloneness have been shown to be associated to depression, anxiety, and other psychiatric disorders in adolescents and they may also increase the vulnerability to Non-Suicidal Self-Injury (NSSI). Therefore, the present study investigated the association between lifetime prevalence and functions of NSSI, parent- and peer-related loneliness, and attitude towards aloneness (positive and negative). Data regarding NSSI, loneliness, and attitude towards aloneness were collected from a sample of 401 high school students from three different high schools located in the Dutch-speaking part of Belgium. Lifetime prevalence of NSSI was found to be 16.5%. Females reported a higher lifetime prevalence of NSSI than males. Higher mean scores for parent-, peer-related loneliness, and positive attitude (i.e., affinity) towards aloneness was observed in adolescents with lifetime NSSI as compared to adolescents without a history of NSSI. Finally, a positive correlation between self-related (i.e., automatic) functions of NSSI and parent- and peer-related loneliness and a positive attitude towards aloneness was also observed.

The Relationship Between Nonsuicidal Self-Injury Age of Onset and Severity of Self-Harm

This study examined how age of nonsuicidal self-injury (NSSI) onset relates to NSSI severity and suicidality using decision tree analyses (nonparametric regression models that recursively partition predictor variables to create groupings). Those with an earlier age of NSSI onset reported greater NSSI frequency, NSSI methods, and NSSI-related hospital visits. No significant splits were found for suicide ideation or attempts, although those with an earlier onset were more likely to have a suicide plan. Overall, findings suggest that onset of NSSI before age 12 is associated with more severe NSSI and may be a crucial age for prevention efforts.

Affect toward the self and self-injury stimuli as potential risk factors for nonsuicidal self-injury

Few risk factors for nonsuicidal self-injury (NSSI) have been identified. This study investigated diminished aversion toward self-injury (i.e., NSSI, suicide/death stimuli) and self-criticism as unique NSSI risk factors. After terminating a treatment study, 154 adults with a recent and frequent NSSI history completed self-report and computer-based measures of psychopathology, implicit and explicit self-criticism, and implicit aversion to NSSI and suicide/death. Participants were then contacted 4 weeks later to test factors predicting NSSI frequency over this follow-up period. Diminished aversion toward NSSI stimuli and self-criticism significantly predicted NSSI 4 weeks later. These effects were unique from other theoretically important predictors, such as past week NSSI frequency and total number of NSSI methods used. Findings provide support that erosion of barriers to NSSI (e.g., aversion to self-injurious stimuli, decreased self-worth) may facilitate continued engagement in these dangerous behaviors. Results shed light on potential treatment targets for NSSI.

Psychological and behavioral characteristics of suicide attempts and non-suicidal self-injury in Chinese adolescents

BACKGROUND

Suicide attempts (SA) and non-suicidal self-injury (NSSI) are prevalent in adolescents and important risk factors of suicide death. Both SA and NSSI are associated with multiple psychosocial, behavioral, biological and genetic factors. This study examined similarities and differences in psychological vulnerability and internalizing and externalizing problems between adolescents with SA and NSSI.

METHODS

Participants consisted of 11,831 students and had a mean age of 14.97 (SD = 1.46) years. Students completed a structured questionnaire to report their demographic information, psychological characteristics, internalizing and externalizing problems, SA and NSSI. Based on the history of NSSI and SA in the last year, the sample was divided into four groups: non-self-harm (NSH), NSSI only, SA only, and NSSI+SA. Multivariate analyses of covariance and post-hoc pairwise comparisons were performed for multiple comparisons.

RESULTS

Compared with NSH group, adolescents with either NSSI or SA scored significantly higher on trait anger, impulsiveness, hopelessness, internalizing and externalizing problems. NSSI+SA group and SA only group scored significantly higher than NSSI only group but both did not score significantly different on most psychological and behavioral variables.

LIMITATIONS

Limitations include reliance on self-reported measures and cross-sectional survey.

CONCLUSIONS

Psychological and behavioral profiles between adolescents with SA and NSSI are similar but are more severe in suicide attempters. The findings highlight the necessity of assessing psychological and behavioral problems for prevention and early intervention of adolescent self-harm.

Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a serious health risk behavior that forms the basis of a tentative diagnosis in DSM-5, NSSI Disorder (NSSID). To date, established treatments specific to NSSI or NSSID are scarce. As a first step in evaluating the feasibility, acceptability, and utility of a novel treatment for adolescents with NSSID, we conducted an open trial of emotion regulation individual therapy for adolescents (ERITA): a 12-week, behavioral treatment aimed at directly targeting both NSSI and its proposed underlying mechanism of emotion regulation difficulties.

METHODS

Seventeen girls (aged 13-17; mean = 15.31) with NSSID were enrolled in a study adopting an uncontrolled open trial design with self-report and clinician-rated assessments of NSSI and other self-destructive behaviors, emotion regulation difficulties, borderline personality features, and global functioning administered at pre-treatment, post-treatment, and 6-month follow-up. Measures of NSSI and emotion regulation difficulties were also administered weekly during treatment.

RESULTS

Ratings of treatment credibility and expectancy and the treatment completion rate (88%) were satisfactory, and both therapeutic alliance and treatment attendance were strong. Intent-to-treat analyses revealed significant improvements associated with large effect sizes in past-month NSSI frequency, emotion regulation difficulties, self-destructive behaviors, and global functioning, as well as a medium effect size in past-month NSSI versatility, from pre- to post-treatment. Further, all of these improvements were either maintained or further improved upon at 6-month follow-up. Finally, change in emotion regulation difficulties mediated improvements in NSSI over the course of treatment.

CONCLUSIONS

Results suggest the acceptability, feasibility, and utility of this treatment for adolescents with NSSID.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02326012, December 22, 2014, retrospectively registered).

Multi-modal neuroimaging of adolescents with non-suicidal self-injury: Amygdala functional connectivity

BACKGROUND

Non-suicidal self-injury (NSSI) is a significant mental health problem among adolescents. Research is needed to clarify the neurobiology of NSSI and identify candidate neurobiological targets for interventions. Based on prior research implicating heightened negative affect and amygdala hyperactivity in NSSI, we pursued a systems approach to characterize amygdala functional connectivity networks during rest (resting-state functional connectivity [RSFC)]) and a task (task functional connectivity [TFC]) in adolescents with NSSI.

METHOD

We examined amygdala networks in female adolescents with NSSI and healthy controls (n = 45) using resting-state fMRI and a negative emotion face-matching fMRI task designed to activate the amygdala. Connectivity analyses included amygdala RSFC, amygdala TFC, and psychophysiological interactions (PPI) between amygdala connectivity and task conditions.

RESULTS

Compared to healthy controls, adolescents with NSSI showed atypical amygdala-frontal connectivity during rest and task; greater amygdala RSFC in supplementary motor area (SMA) and dorsal anterior cingulate; and differential amygdala-occipital connectivity between rest and task. After correcting for depression symptoms, amygdala-SMA RSFC abnormalities, among others, remained significant.

LIMITATIONS

This study's limitations include its cross-sectional design and its absence of a psychiatric control group.

CONCLUSIONS

Using a multi-modal approach, we identified widespread amygdala circuitry anomalies in adolescents with NSSI. While deficits in amygdala-frontal connectivity (driven by depression symptoms) replicates prior work in depression, hyperconnectivity between amygdala and SMA (independent of depression symptoms) has not been previously reported. This circuit may represent an important mechanism underlying the link between negative affect and habitual behaviors. These abnormalities may represent intervention targets for adolescents with NSSI.

Non-suicidal self-injury and suicide attempts in a New Zealand birth cohort

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide attempts are related, but distinct behaviors. The primary aim of the current study was to identify factors that distinguish those with different lifetime histories of self-injury. A secondary aim was to test whether lifetime history of self-injury at age 26 predicted current suicide ideation at age 32.

METHODS

Participants were 26 year olds from a large birth cohort with a lifetime history of no self-injury (n = 466), a lifetime history of NSSI (n = 191), or a lifetime history of NSSI and a suicide attempt (NSSI+SA; n = 52). They were compared on a history of psychiatric disorders, 12-month suicide ideation, lifetime history of childhood sexual abuse, and lifetime exposure to suicide.

RESULTS

An anxiety disorder, a substance dependence disorder, suicide ideation, and a history of childhood sexual abuse distinguished the NSSI+SA and NSSI only groups. Longitudinal results demonstrated that a history of NSSI predicted future suicide ideation after adjusting for other selected risk factors.

LIMITATIONS

The majority of analyses are cross-sectional which limits inferences about causality. The retrospective self-report for lifetime behavior could be subject to reporting biases.

CONCLUSIONS

Adults with a history of NSSI and adults with a history of NSSI and a suicide attempt are clinically distinct groups that are both at risk of future suicide ideation. Identifying and treating NSSI could be a key preventive factor in reducing subsequent suicide risk.

Emotion regulation group therapy for deliberate self-harm: a multi-site evaluation in routine care using an uncontrolled open trial design

OBJECTIVE

Emotion regulation group therapy (ERGT) has shown promising results in several efficacy trials. However, it has not been evaluated outside a research setting. In order to increase the availability of empirically supported treatments for individuals with borderline personality disorder and deliberate self-harm, an evaluation of ERGT in routine clinical care was conducted with therapists of different professional backgrounds who had received brief intensive training in ERGT prior to trial onset.

DESIGN

Multi-site evaluation, using an uncontrolled open trial design with assessments at pretreatment, post-treatment and 6-month follow-up.

SETTING

14 adult outpatient psychiatric clinics across Sweden.

PARTICIPANTS

Ninety-five women (mean age=25.1 years) with borderline personality disorder (both threshold and subthreshold) and repeated self-harm were enrolled in the study. Ninety-three per cent of participants completed the post-treatment assessment and 88% completed the follow-up assessment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was self-harm frequency as measured with the Deliberate Self-Harm Inventory. Secondary outcomes included self-harm versatility, emotion dysregulation, other self-destructive behaviours, depression, anxiety, stress symptoms and interpersonal and vocational difficulties.

INTERVENTION

ERGT is an adjunctive, 14-week, acceptance-based behavioural group treatment that directly targets both self-harm and its proposed underlying mechanism of emotion dysregulation.

RESULTS

At post-treatment, intent-to-treat analyses revealed a significant improvement associated with a moderate effect size on the primary outcome of self-harm frequency (51%, reduction; Cohen's d=0.52, p<0.001) as well as significant improvements in the secondary outcomes of self-harm versatility, emotion dysregulation, other self-destructive behaviours and general psychiatric symptomatology. These results were either maintained or further improved on at 6-month follow-up.

CONCLUSIONS

ERGT appears to be a feasible, transportable and useful treatment for deliberate self-harm and other self-destructive behaviours, emotion dysregulation and psychiatric symptoms when delivered by clinicians in the community.

TRIAL REGISTRATION NUMBER

NCT01986257; results.

Exploring the relationship between non suicidal self-injury and borderline personality traits in young adults

Non-suicidal self-injury (NSSI) is highly prevalent during late adolescence and young adulthood. There is some evidence of a link between NSSI and Borderline Personality Disorder (BPD), but little is known about the association between BPD traits and the various functions that maintain NSSI. The main purpose of this study was to explore the association between borderline personality traits and NSSI functions in a sample of college students. We also compared NSSI functions in college students who engaged in NSSI to those in an age-matched sample of BPD patients. This study included a total of 238 college students and 36 BPD patients. Participants were asked to complete a number of clinical measures. In the non-clinical sample, BPD features were more pronounced in the presence of NSSI, and we observed a differential relationship between NSSI functions and psychopathological BPD-traits. The NSSI clinical variables most strongly associated with BPD were frequency, variety of methods and severity, but not age of onset. Our results provide new information on the relationship between BPD and NSSI in young adults, and could be used to improve the early detection of vulnerable BPD-individuals and in planning NSSI treatment.

The continuity and duration of depression and its relationship to non-suicidal self-harm and suicidal ideation and behavior in adolescents 12-17

BACKGROUND

There is a significant overlap between non-suicidal self-harm and suicidal ideation and behavior in young people with both symptom continuity and symptom duration implicated in this association.

METHODS

A population sample of Australian 12-17 year olds. Interviewers collected measures for DSM disorders, symptom duration and continuity, and background information from their parents, while young people self-reported symptoms of depression, non-suicidal self-harm and suicidal ideation and behaviors. This report focusses on the 265 young people who met the DSM criteria for Major Depressive Disorder based on their own self-reports.

RESULTS

Relative to young people who had at least one period 2 months or longer without symptoms since first onset, young people who had the continuous presence of depressive symptoms since their first onset had significantly higher odds for life-time self-harm, 12-month self-harm, multiple self-harm, suicidal ideation and suicide attempt within the past 12 months. The duration of depressive symptoms and the continuity of these symptoms each independently contribute to elevating the risks of non-suicidal self-harming and suicidal ideation and behaviors.

LIMITATIONS

Reliance on self-report from the young people and time constraints prohibiting administering diagnostic modules other than the Major Depressive Disorder and estimating self-reported co-morbidity.

CONCLUSIONS

Among young people with a Major Depressive Disorder, self-reports about duration of depressive symptoms as well as the continuity of symptoms, each independently contributes to elevated risks of non-suicidal self-harming and suicidal ideation and behaviors. As well, un-remitting as opposed to episodic symptoms in this group of young people are common and are a powerful indicator of suffering associated with both self-harm and suicidal behavior.

Nonsuicidal Self-Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders

Nonsuicidal self-injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood-disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood-disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16-3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.

Predictors of non-suicidal and suicidal self-injurious behaviours, among adolescents and young adults in urban India

BACKGROUND

The complex intersections between non-suicidal self-injurious (NSSI) behaviours; like cutting, burning or self-hitting, and suicide attempts, are an important domain of enquiry among vulnerable adolescents and young adults. A cross-sectional survey in urban schools and colleges assessed the rates of self-injurious behaviour among Indian adolescents and young adults. Predictors of NSSI and of self-injurious behaviours with associated suicidal intent, were also examined.

PARTICIPANTS AND METHODS

The sample comprised 1571 male and female students, from 19 private and government aided high schools, pre-university colleges and undergraduate colleges in an urban city in South India. Participants completed the Functional Assessment of Self-Mutilation which assesses the methods, characteristics and functions of self-injurious acts in the past 12 months. The measures of psychopathology included the Youth Self-Report and the Young-Adult Self-Report.

RESULTS AND CONCLUSION

The results indicated that rate of NSSI was 33.8%, with minor forms of self-injury reported more often (19.4%) than the moderate/severe forms (14.6%). A smaller proportion (6.8%) reported self-injurious acts with associated suicidal intent. Certain self-injury characteristics and levels of internalizing and externalizing problems differentiated self-injuring youth with and without suicidal intent. Logistic regression analyses identified predictors of any self-injurious behaviour and of self-injury associated with suicidal intent. The implications for assessment and intervention frameworks for self-injuring youth are discussed.

Nonsuicidal Self-Injury and Suicidality Among Sexual Minority Youth: Risk Factors and Protective Connectedness Factors

OBJECTIVE

We investigated differences in prevalence of repetitive nonsuicidal self-injury (NSSI), suicidal ideation, and a suicide attempt among youth who identified as bisexual, gay/lesbian, and questioning. In addition, we examined which types of social connections were associated with reduced risk of repetitive NSSI and suicidality among youth who identified with a specific sexual minority group.

METHODS

Data came from the 2013 Minnesota Student Survey. The analytic sample included 77,758 students in grades 9 and 11. Connectedness factors included parent connectedness, teacher caring, connectedness to other nonparental adults, school safety, and friend caring. Logistic regression analyses, stratified according to sexual minority group, determined social connectedness factors associated with repetitive NSSI, suicidal ideation, and a suicide attempt, as well as moderating effects of significant connectedness factors on different risk factors (depression, anxiety, bullying, and violence victimization).

RESULTS

Approximately 3% identified as bisexual or questioning their sexual orientation, and <1% identified as gay/lesbian. Sexual minority youth, particularly bisexual youth, were significantly more likely than heterosexual youth to report repetitive NSSI and suicidality. Effects of connectedness varied across sexual minority groups and outcomes on the basis of types of connections. Parent connectedness emerged as a robust protective factor for all self-harm behaviors among bisexual and questioning youth. Feeling connected to nonparental adults and safe at school represented additional factors that reduced risk of repetitive NSSI and suicidality among certain groups.

CONCLUSIONS

In addition to facilitating connections between youth and parents, clinicians might consider encouraging sexual minority youth to remain connected to trusted nonparental adults who could offer support and care. Schools might consider implementing sociocultural norms of acceptance, tolerance, and positive identity development to reduce risk of self-harm.

Functions of Nonsuicidal Self-Injury Are Differentially Associated with Suicide Ideation and Past Attempts among Childhood Trauma Survivors

Research into factors for suicide has revealed relations between trauma exposure and suicidality (e.g., Bridge, Goldstein, & Brent, ; Joiner, Sachs-Ericson, Wingate, Brown, Anestis, & Selby, ) wherein painful and provocative experiences (e.g., nonsuicidal self-injury [NSSI]) are an important link (e.g., Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, ; Smith, ). No prior research has assessed the relationship between functions of NSSI and suicidality among childhood trauma survivors. Participants who endorsed childhood trauma exposure (N = 121; M_age  = 18.69, range 18-22) completed measures of posttraumatic stress disorder (PTSD) symptoms, NSSI, and suicidality. Multiple regressions assessing whether the four functions of NSSI predicted suicide ideation and past attempts after controlling for PTSD symptom severity found that only social negative reinforcement was associated with SI (β = .304, SE = .243, t = 2.23, p = .028), while only automatic negative reinforcement was associated with past attempts (β = .470, SE = .066, t = 2.25, p = .028). Findings highlight the importance of assessing NSSI functions when assessing suicidality among trauma survivors.

Effect of alcohol dose on deliberate self-harm in men and women

OBJECTIVE

Nonexperimental survey and field research support the notion that alcohol use may be associated with deliberate self-harm (DSH) across the spectrum of lethality, from nonsuicidal self-injury (NSSI) through suicide. Nonexperimental studies, however, provide limited information about potential causal relationships between alcohol consumption and DSH. Two previous experiments showed that a relatively high-dose of alcohol increases the likelihood of engaging in DSH in men, with DSH defined by the self-administration of a "painful" shock (the self-aggression paradigm [SAP]; Berman & Walley, 2003; McCloskey & Berman, 2003). In this study, we examined whether (a) lower doses of alcohol also elicit DSH, (b) this effect occurs for women as well as men, and (c) individual differences in past nonsuicidal self-injury (NSSI) moderate alcohol's effects on DSH.

METHOD

Nonalcohol dependent men and women (N = 210) were assigned either to .00%, .05%, .075%, or .100% blood alcohol concentration (BAC) drink conditions and completed a self-rating scale of NSSI (the Deliberate Self-Harm Inventory [DSHI]; Gratz, 2001). As in previous SAP studies, DSH was operationalized by shock setting behavior during a competitive reaction time (RT) game.

RESULTS

Overall, a greater proportion of participants in the .075% and .100% (but not .050%) alcohol conditions self-selected a "painful" shock to administer compared to participants in the placebo condition. NSSI predicted self-administration of painful shocks, but did not moderate the alcohol effect.

CONCLUSIONS

Results provide experimental evidence to support the notion that interventions for self-harm should include processes to monitor and limit alcohol intake. (PsycINFO Database Record

Functional Coping Dynamics and Experiential Avoidance in a Community Sample with No Self-Injury vs. Non-Suicidal Self-Injury Only vs. Those with Both Non-Suicidal Self-Injury and Suicidal Behaviour

Although emotional avoidance may be a critical factor in the pathway from psychological distress to self-injury and/or suicidality, little is known about the relative importance of differing functional coping dynamics and experiential avoidance between people with self-injury histories of differing intent (e.g., Non-Suicidal Self-Injury only vs. Non-Suicidal Self-Injury plus Suicidal Behaviour; NSSI vs. NSSI + SB). A community-based survey (N = 313; female, 81%; ages 16-49 years, M = 19.78, SD = 3.48) explored self-reported experiential avoidance and functional coping dynamics in individuals with (i) no self-injury history (controls); (ii) a history of NSSI only; and (iii) a history of NSSI + SB. Jonckheere-Terpstra trend tests indicated that avoidance coping was higher in the NSSI and NSSI + SB groups than in controls. Emotion regulation was higher in controls than those with a history of self-injury (NSSI and NSSI + SB). Approach and reappraisal coping demonstrated significant ordered effects such that control participants were higher in these coping dynamics than those with a history of NSSI only, who, in turn, were higher than those with a history of NSSI + SB (Control > NSSI > NSSI + SB). Endorsement of the reappraisal/denial facet of experiential avoidance was most pronounced in those with a history of NSSI + SB (Control < NSSI < NSSI + SB). No significant ordered effects were observed for other dimensions of experiential avoidance. Understanding how the endorsement of functional coping dynamics and which components of experiential avoidance vary between groups with differing self-injury intent histories has important implications for treatment planning.

Perceived Parental Monitoring and Sexual Orientation Moderate Lifetime Acts of Non-Suicidal Self-Injury

Being non-heterosexual, particularly bisexual, is associated with high rates of engagement in NSSI amongst young adults. The goal of the present study was to determine if parenting practices, specifically parental monitoring, and sexual orientation moderate engagement with NSSI. Undergraduates (N = 1,353) completed a survey on sexual orientation, non-suicidal self-injury (NSSI) acts, and multiple aspects of perceived parental monitoring during high school. Moderation analyses revealed that most facets of parental monitoring were similarly negatively correlated with NSSI for both individuals whose sexual orientation where nearly, or entirely, gay and heterosexual youth. Youth who were neither exclusively heterosexual nor exclusively gay (mixed sexual orientation) reported the most NSSI acts, and no facet of parental monitoring predicted reduced NSSI acts for this group. While previous literature shows that many aspects of parental monitoring may be protective against engagement in health risk behaviors, the present study adds to these findings that similar aspects are negatively associated with self-injurious behavior for some, but not all, individuals. More research is needed to better understand the causes of increased NSSI for individuals with a mixed sexual orientation.

Non-suicidal self-injury and frequency of suicide attempts: The role of pain persistence

BACKGROUND

Non-suicidal self-injury (NSSI) and suicidal behavior exhibit a robust association with one another. Research on the contexts within which this relationship is stronger or weaker, however, is limited. The interpersonal theory of suicidal behavior (ITS) posits that NSSI influences suicidal behavior through a habituation to physical pain and, as such, pain tolerance has been theorized to play an important role. We tested whether pain persistence, the difference between pain threshold and pain tolerance, would moderate the relationship between frequency of NSSI and suicidal behavior in both an undergraduate and community sample.

METHOD

Study 1 assessed healthy undergraduates, whereas Study 2 was comprised of community members recruited largely based upon a history of suicidal behavior. Across both samples, participants completed self-report measures of NSSI and a structured interview on suicidal behavior. In both studies, pain was measured using a pressure algometer and, in Study 2, persistence was also assessed using the Enhanced Distress Tolerance Test (DTT-E).

RESULTS

Consistent with the notion that suicidal behavior requires persistence amidst pain and distress, results indicated that the willingness to remain engaged with pain and distress may significantly influence the degree to which NSSI is related to suicidal behavior.

LIMITATIONS

Both studies were limited by a cross-sectional design, which precluded assessments of causality and directionally of effects.

CONCLUSIONS

These results call attention to the potential importance of persistence through pain and/or distress in the association between NSSI and suicidal behavior.

Adolescent Admissions to Emergency Departments for Self-Injurious Thoughts and Behaviors

The objective of the present study was to describe the incidence and the characteristics of Self-Injurious Thoughts and Behaviors (SITBs), among adolescents aged 11–18 admitted, over a two year period, to all the Emergency Departments of a Region of North-eastern Italy through a comprehensive analysis of medical records. A two-step search was performed in the regional ED electronic database. First, we identified the cases that had been clearly diagnosed as SITBs by an Emergency Department physician. Secondly, suspect cases were detected through a keyword search of the database, and the medical records of these cases were hand screened to identify SITBs. The mean annual incidence rate of SITBs was 90 per 100,000 adolescents aged 11–18 years. Events were more frequent in females. Drug poisoning was the most frequently adopted method (54%). In 42% of cases a diagnosis of SITB was not explicitly reported by the physician. In 65% of cases adolescents were discharged within hours of admission. Only 9% of patients started a psychiatric assessment and treatment program during hospital stay. This research confirms the high incidence of SITBs among adolescents and highlights the difficulty in their proper diagnosis and management. Such difficulty is confirmed by the fact that only a few patients, even among those with a clear diagnosis, were sent for psychiatric assessment. Correct identification and management of SITB patients needs to be improved, since SITBs are an important public health problem in adolescence and one of the main risk factors for suicide.

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

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

Childhood Abuse, Nonsuicidal Self-Injury, and Suicide Attempts: An Exploration of Gender Differences in Incarcerated Adults

The relationship between types of childhood abuse, suicide attempts, and nonsuicidal self-injury (NSSI) was examined in a sample of 415 incarcerated adults (268 men, 147 women). Men and women were equally likely to experience childhood abuse, although women were more likely to report sexual abuse and men were more likely to report emotional neglect. Sexual abuse was the only type of abuse found to predict NSSI and suicide attempts in women. For men, physical abuse and physical neglect were significant predictors of NSSI and suicide attempts, respectively. Gender differences exist and should be examined in future research in this area.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

No association between current depression and latent toxoplasmosis in adults

Changes in behaviour and cognition have been associated with latent infection from the apicomplexan protozoan Toxoplasma gondii (Nicolle et Manceaux, 1908) in both animal and human studies. Further, neuropsychiatric disorders such as schizophrenia have also been associated with latent toxoplasmosis. Previously, we found no association between T. gondii immunoglobulin G antibody (IgG) seropositivity and depression in human adults between the ages of 20 and 39 years (n = 1 846) in a sample representative of the United States collected by the Centers for Disease Control as part of a National Health and Nutrition Examination Survey (NHANES) from three datasets collected between 1999-2004. In the present study, we used NHANES data collected between 2009 and 2012 that included subjects aged 20 to 80 years (n = 5 487) and used the Patient Health Questionnaire 9 (PHQ-9) to assess depression with the overall aim of testing the stability of the results of the prior study. In the current study, the seroprevalence of T. gondii was 13%. The percentage of subjects reporting clinical levels of depression assessed with the PHQ-9 was 8%. As before, we found no association between T. gondii IgG seroprevalence and depression (OR = 1.01, 95% CI = 0.81-1.25; p = 0.944) while controlling for sex, educational attainment, race-ethnicity, age, poverty-to-income ratio and cigarette smoking. We also found no positive associations between anti-T. gondii antibody titre and depression (OR = 1.00, 95% CI = 0.96-1.06; p = 0.868). Moreover, we found no association between T. gondii seroprevalence or antibody titre and suicidal ideation (seroprevalence: OR = 1.22, 95% CI = .85-1.75; p = 0.277, titre: OR = 1.05, 95% CI = 0.98-1.14; p = 0.177). Defining depression to also include subjects currently taking antidepressant medication even with non-elevated questionnaires did not find evidence of a positive association between latent toxoplasmosis and depression. In the present study, neither T. gondii seroprevalence nor anti-T. gondii antibody titre was positively associated with depression or suicidal ideation among subjects aged 20 to 80 years.

Impact of Non-Suicidal Self-Injury Scale: Initial Psychometric Validation

The current study examined the psychometric properties of the Impact of Non-Suicidal Self-Injury Scale (INS), a scale developed to assess the social, behavioral, and emotional consequences of engaging in non-suicidal self-injury (NSSI). University students (N=128) who endorsed a history of NSSI were administered the INS, as well as measures of hypothesized convergent and divergent validity. Results suggested that the INS is best conceptualized as a one-factor scale, and internal consistency analyses indicated excellent reliability. The INS was significantly correlated with well-known measures of NSSI severity (i.e., NSSI frequency, NSSI recency), and measures of suicide attempt history and emotional reactivity. Logistic regression analyses indicated that the INS contributed unique variance to the prediction of physical disfigurement (i.e., NSSI scarring) and clinically significant social anxiety, even after taking into account NSSI frequency. Furthermore, the INS demonstrated divergent validity. Implications for research on NSSI disorder and clinical practice are discussed.

Is psychotherapy effective for reducing suicide attempt and non-suicidal self-injury rates? Meta-analysis and meta-regression of literature data

OBJECTIVE

To determine the efficacy of psychotherapy interventions for reducing suicidal attempts (SA) and non-suicidal self-injury (NSSI).

METHODS

Meta-analysis of randomized controlled trials (RCTs) comparing psychotherapy interventions and treatment as usual (TAU; including also enhanced usual care, psychotropic treatment alone, cognitive remediation, short-term problem-oriented approach, supportive relationship treatment, community treatment by non-behavioral psychotherapy experts, emergency care enhanced by provider education, no treatment) for SA/NSSI. RCTs were extracted from MEDLINE, EMBASE, PsycINFO and Cochrane Library and analyzed using the Cochrane Collaboration Review Manager Software and Comprehensive Meta-analysis.

RESULTS

In the 32 included RCTs, 4114 patients were randomly assigned to receive psychotherapy (n = 2106) or TAU (n = 2008). Patients who received psychotherapy were less likely to attempt suicide during the follow-up. The pooled risk difference for SA was -0.08 (95% confidence intervals = -0.04 to -0.11). The absolute risk reduction was 6.59% (psychotherapy: 9.12%; TAU: 15.71%), yielding an estimated number needed to treat of 15. Sensitivity analyses showed that psychotherapy was effective for SA mainly in adults, outpatients, patients with borderline personality disorder, previously and non-previously suicidal patients (heterogeneous variable that included past history of SA, NSSI, deliberate self-harm, imminent suicidal risk or suicidal ideation), long- and short-term therapies, TAU only as a control condition, and mentalization-based treatment (MBT). No evidence of efficacy was found for NSSI, with the exception of MBT. Between-study heterogeneity and publication bias were detected. In the presence of publication bias, the Duval and Tweedie's "trim and fill" method was applied.

CONCLUSION

Psychotherapy seems to be effective for SA treatment. However, trials with lower risk of bias, more homogeneous outcome measures and longer follow-up are needed.

What bridges the gap between self-harm and suicidality? The role of forgiveness, resilience and attachment

Self-harm is the most robust risk for completed suicide. There is a lack of understanding of why some people who self-harm escalate to suicidal behaviour when others do not. Psychological factors such as attachment, self-forgiveness and self-appraisal may be important. To determine whether factors from the Interpersonal Theory and Schematic Appraisals models are useful to identify suicidal behaviour in populations that self-harm. Specifically we investigate whether resilience factors of secure attachment, self-forgiveness and positive self-appraisals significantly influence suicidality in people who self-harm. A cross-sectional online study of 323 participants recruited from self-harm support forum. Validated self-report measures were used to assess appraisals, relationships, self-forgiveness, attachment style, suicidality and self-harm. Emotion coping and support seeking self-appraisals and self-forgiveness were negatively associated with suicidality in participants with a history of self-harm. Dismissing attachment was positively associated with suicidality. The perceived ability to cope with emotions, the perceived ability to gain support and self-forgiveness may protect against suicide in people who self-harm. Conversely the presence of dismissing attachment may increase the risk of suicidality. Findings provide therapeutic targets to reduce risk of suicidality in this high risk group.