Covariation of self- and other-directed aggression among inpatient youth: continuity in the transition to treatment and shared risk factors

Dual harm: Violent behaviour to others and self-harm behaviour in adults compulsorily admitted to a Dutch psychiatric hospital

BACKGROUND

Verbal and physical violence in psychiatric hospitals can have harmful consequences for staff members, such as physical injury, traumatisation, and sick leave, and they often accompany involuntary admission. Harm to others may co-occur with self-harm, i.e., dual harm. However, little is known about the association between dual-harm and violent behaviour towards staff members and its clinical outcomes, such as seclusion and rapid tranquilisation after involuntary admission to a psychiatric inpatient unit.

METHOD

A convenience sample of patients admitted involuntarily (N = 384; mean age = 48.03, SD = 19.92) between January 2016 and December 2019 in Western Brabant, the Netherlands, was used to design a retrospective file audit. Distinct harm groups, marked by the presence/absence of self- and/or other-harm, were investigated using multivariate linear regression modelling on the seriousness of violent acts and the total length of admission. Logistic regression analyses were used to study the association between harm groups and the administration of rapid tranquilisation, seclusion, and extended involuntary admissions.

RESULTS

Several harm groups were identified, including self-harm only, other-harm only, and dual-harm groups. Psychiatric patients admitted to the hospital because of (the risk of) violence towards others had a higher risk of violent incidents during admission and some restrictive measures. In a subgroup of patients with psychotic disorders, patients with dual harm committed the most serious violent incidents compared to those in the other harm groups.

CONCLUSION

Distinct harm groups were identified in a sample of involuntarily admitted patients. In a general adult psychiatric setting, patients at risk for violent behaviour, especially dual-harm patients, should be identified and monitored as part of the risk assessment. Future research is needed to explore more clinical correlates in the proposed distinction between harmful groups and to assess long-term prognosis.

Adolescents' Emotion Regulation Strategies Questionnaire-Extended: Further Development and Associations With Mental Health Problems in Adolescence

Emotion regulation (ER) is implicated in a range of psychopathologies and behavioral problems that are prevalent or have their initial onset in adolescence. In this study, we aim to evaluate the psychometric properties (factor structure, internal consistency, and construct validity) of the Adolescents' Emotion Regulation Strategies Questionnaire-Extended (AERSQ-E), a modified and extended version of an ER instrument developed by Zhou et al. Across six sub-studies using data from different Swedish adolescent community samples (1,104 students in total), we generated and validated a 23-item version containing six subscales: rumination/negative thinking, positive reorientation, creative expression, aggressive outlet, social support, and distraction. Assessing test-retest reliability, internal consistency, measurement invariance as well as convergent and discriminant validity, we could establish, with some limitations, the general reliability and validity of the AERSQ-E as a valid measure of ER strategies for use in adolescence.

Dual harm among patients attending a mental health unit in Uganda: a hospital based retrospective study

BACKGROUND

Dual harm encompasses the complex interplay of the co-occurrence of self-harm and aggression. Individuals with dual harm may display a more hazardous pattern of harmful behaviors like homicide-suicide compared to people with sole harm. This study aimed to examine the presence of dual harm among general psychiatry inpatients in a mental health unit in Uganda.

METHODS

A retrospective chart review of 3098 inpatients from January 2018 to December 2021. Dual harm reported experience at admission was based on experiences of self-harm with harm to people or property or both. Logistic regression assessed the association between dual harm and sociodemographics and clinical characteristics.

RESULTS

A total of 29 (1%) patients experienced dual harm, with five having experienced self-harm with both harm to others and property, 23 with harm to people, and one with harm to property. Dual harm was statistically significantly associated with the male gender at bivariate analysis. However, there were no statistically significant factors associated with dual harm at multivariate analysis or sensitivity analysis with the specific types of dual harm.

CONCLUSION

General psychiatry inpatients in Uganda experience dual harm before admission at lower prevalence than in previous literature. However, no investigated sociodemographic and clinical factors could explain these experiences. Further studies looking at dual harm are warranted to understand these unfortunate experiences with serious consequences among patients in Uganda.

Relationship among Aggression, Non-Suicidal Self-Injury, and Depression in Youths

Background

Competition among countries becomes fiercer with progress in globalization. As the future and hope of national development, the youth are undertaking intensifying competitive pressures. More youths suffer psychological health issues, such as non-suicidal self-injury (NSSI), depression, and aggressive behaviors. What are the relationships among suicidal self-injury, aggression, and depression? There's few systematic study on these two aspects yet. Thus, we examined the relationship between aggression and NSSI in youths, as well as the mediating effects of depression in such a relationship.

Methods

A total of 770 youths (comprising university students, community youths and rural migrant workers) in Zhejiang, Anhui and Henan in China were investigated from August to December 2022 by using the aggression scale, NSSI scale, and depression scale. The relationship among aggression, NSSI and depression in youths was discussed through a t-test, correlation analysis, and multivariate regression analysis.

Results

With respect to abuse experiences during childhood, parental emotional status and family conditions, the total scores in aggression, NSSI, and depression of youths differed significantly (P<0.05). A significantly positive correlation existed between aggression and NSSI of youths (r=0.41, P<0.01), a significantly positive correlation existed between aggression and depression (r=0.42, P<0.01), and a significantly positive correlation exists between NSSI and depression (r=0.42, P<0.01). Aggression of youths had not only direct and positive prediction effects on NSSI (B=0.41, P<0.001) but also indirect effects on NSSI through depression.

Conclusion

Aggression, NSSI and depression of youths were influenced significantly by abuse experiences during childhood, parental emotional status and family conditions. Depression has partial mediating effects between aggression and NSSI in youths.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature.

Methods

The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted.

Results

The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression.

Discussion

The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

Reseach progress in dual harm

Growing evidence supports an association between self-harm and aggression, and the two behaviors frequently co-occur. The co-occurrence of self-harm and aggression is termed as dual harm. Existing evidence reveals that rather than a simple co-occurrence of self-harm and aggression, dual-harm may be an independent behavior different from a sole harm behavior. Identification of characteristics and influencing factors for dual harm may help develop effective prevention strategies for the affected population. A review of the literature yields a high incidence of dual harm among the clinical and forensic populations. Individuals with dual harm engage in an earlier, more frequent, and a wider range of harmful behaviors, with the increased use of lethal methods. Common factors that affect dual harm include childhood adversities, emotional dysregulation, personality traits, mental disorders, and biological factors. A comprehensive theory to explain dual harm is still not available. Currently, two main theories for explaining mechanism of dual harm are the two-stage model of countervailing forces and the cognitive-emotional model. An in-depth exploration of characteristics, influencing factors, and theories for dual harm is of great importance for the prevention of dual harm.

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

Assessment of the association between non-suicidal self-injury disorder and suicidal behaviour disorder in females with conduct disorder

BACKGROUND

Non-suicidal self-injury (NSSI) and aggression have been demonstrated to serve as risk factors of suicidal behaviours (SB). Non-suicidal self-injury disorder (NSSID) and Suicidal Behaviour Disorder (SBD) are among new diagnostic categories for further studies in the DSM-5 classification.

METHODS

We recruited 196 girls (aged 15.5 ± 1.2 years) diagnosed with conduct disorder (CD). All of them were assessed with respect of non-suicidal self-injury acts, suicidal attempts, psychopathology, self-esteem and general functioning.

RESULTS

Age of NSSI onset was significantly lower compared to age of first suicidal attempt. SBD was present in 50.0% of patients with NSSID and the prevalence of NSSID in individuals with SBD was estimated at 52.2%. A diagnosis of NSSID, with at least 8 days of engagement in self-injuries during the preceding year, significantly predicted the risk of SBD. This effect appeared to be independent of depressive symptomatology.

LIMITATIONS

Our results cannot be generalized over the whole population of individuals diagnosed with CD because of a lack of male patients, as well as individuals with the most severe and mildest forms of CD. Causal inferences cannot be established due to a cross-sectional study design.

CONCLUSIONS

The NSSID with at least 8 days of engagement in self-injuries during the preceding year serves as a predictor of SBD independently of the effects of depressive symptoms. Longitudinal studies are required to confirm our findings.

The Co-occurrence of Self-Harm and Aggression: A Cognitive-Emotional Model of Dual-Harm

There is growing evidence that some individuals engage in both self-harm and aggression during the course of their lifetime. The co-occurrence of self-harm and aggression is termed dual-harm. Individuals who engage in dual-harm may represent a high-risk group with unique characteristics and pattern of harmful behaviours. Nevertheless, there is an absence of clinical guidelines for the treatment and prevention of dual-harm and a lack of agreed theoretical framework that accounts for why people may engage in this behaviour. The present work aimed to address this gap in the literature by providing a narrative review of previous research of self-harm, aggression and dual-harm, and through doing so, presenting an evidence-based theory of dual-harm – the cognitive-emotional model of dual-harm. This model draws from previous studies and theories, including the General Aggression Model, diathesis-stress models and emotional dysregulation theories. The cognitive-emotional model highlights the potential distal, proximal and feedback processes of dual-harm, the role of personality style and the possible emotional regulation and interpersonal functions of this behaviour. In line with our theory, various clinical and research implications for dual-harm are suggested, including hypotheses to be tested by future studies.

Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder

Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.

Toward a re-interpretation of self-harm: A cross-contextual approach

A common view is that self-harmers are individuals who are exposed to or have been exposed to stressors and hostility in everyday settings. A strand of research has also found that self-harmers expose other people to their hostility. Extending these findings, this study examined whether adolescent self-harmers are simultaneously exposed and expose others to hostility in their everyday interpersonal contexts-at home, at school, and during leisure-time. The participants were 1,482 adolescents, ranging from 13 to 16 years of age, who attended different schools in a medium-sized city in central Sweden. The results show that the adolescents involved in mutually hostile relationships in their different interpersonal contexts exhibited higher self-harm than the adolescents who were exposed to others' hostility or exposed other people to their hostility. Also, the more mutually hostile settings the adolescents were involved in, the more self-harm they reported. Overall, our findings suggest not only that self-harmers are exposed to hostility in their different interpersonal contexts, as has been typically assumed, but also that they simultaneously expose others to hostility in these contexts. This has implications for our understanding of young people who harm themselves and also for intervention. Aggr. Behav. 42:522-532, 2016. © 2016 Wiley Periodicals, Inc.

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.

Co-Occurring Non-Suicidal Self-Injury and Firesetting Among At-Risk Adolescents: Experiences of Negative Life Events, Mental Health Problems, Substance Use, and Suicidality

Co-occurring internalizing and externalizing problem behaviors in adolescence typically marks more severe psychopathology and poorer psychosocial functioning than engagement in a single problem behavior. We examined the negative life events, emotional and behavioral problems, substance use, and suicidality of school-based adolescents reporting both non-suicidal self-injury (NSSI) and repetitive firesetting, compared to those engaging in either behavior alone. Differences in NSSI characteristics among self-injurers who set fires, compared to those who did not, were also assessed. A total of 384 at-risk adolescents aged 12-18 years (58.8% female) completed self-report questionnaires measuring NSSI, firesetting, and key variables of interest. Results suggest that adolescents who both self-injure and deliberately set fires represent a low-prevalence but distinct high-risk subgroup, characterized by increased rates of interpersonal difficulties, mental health problems and substance use, more severe self-injury, and suicidal behavior. Implications for prevention and early intervention initiatives are discussed.

Suicidality among adolescents engaging in nonsuicidal self-injury (NSSI) and firesetting: the role of psychosocial characteristics and reasons for living

BACKGROUND

Co-occurrence of problem behaviors, particularly across internalizing and externalizing spectra, increases the risk of suicidality (i.e., suicidal ideation and attempt) among youth.

METHODS

We examined differences in psychosocial risk factors across levels of suicidality in a sample of 77 school-based adolescents engaging in both nonsuicidal self-injury (NSSI) and repeated firesetting. Participants completed questionnaires assessing engagement in problem behaviors, mental health difficulties, negative life events, poor coping, impulsivity, and suicidality.

RESULTS

Adolescents endorsing suicidal ideation reported greater psychological distress, physical and sexual abuse, and less problem solving/goal pursuit than those with no history of suicidality; adolescents who had attempted suicide reported more severe NSSI, higher rates of victimization and exposure to suicide, relative to those with suicidal ideation but no history of attempt. Additional analyses suggested the importance of coping beliefs in protecting against suicidality.

CONCLUSIONS

Clinical implications and suggestions for future research relating to suicide prevention are discussed.

An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services

Background

Inpatient child and adolescent mental health services are one part of a complex system, and exist to meet the needs of young people with the greatest mental health difficulties.

Objectives

The research question was ‘What is known about the identification, assessment and management of risk (where “risk” is broadly conceived) in young people (aged 11–18 years) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’

Data sources

The two-phase Evidence for Policy and Practice Information and Co-ordinating Centre approach was used. In phase 1, scoping searches were made using two databases with an end date of March 2013. Phase 2 centred on the search for citations relating to the risks to young people of ‘dislocation’ and ‘contagion’. Searches were made using 17 databases, with time limits from 1995 to September 2013. Websites were searched, a call for evidence circulated and references of included citations reviewed.

Review methods

Priority risk areas for phase 2 were decided in collaboration with stakeholders including through consultations with young people and the mother of a child who had been in hospital. All types of evidence relating to outcomes, views and experiences, costs and cost-effectiveness, policies, and service and practice responses in the areas of ‘dislocation’ and ‘contagion’ for young people (11–18 years) using inpatient mental health services were considered. A staged approach to screening was used. Data were extracted into tables following guidance from the Centre for Reviews and Dissemination or tables developed for the review. Quality was assessed using appraisal checklists from the Effective Public Health Practice Project or the Critical Skills Appraisal Programme or devised by previous reviewers. No papers were excluded on the grounds of quality, and all materials identified were narratively synthesised.

Results

In phase 1, 4539 citations were found and 124 included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found and 40 addressing the less obvious risks of ‘dislocation’ and ‘contagion’ were included, supplemented by 20 policy and guidance documents. These were synthesised using these categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis or economic evaluation. The importance to stakeholders of these less obvious risks contrasted with the limited quantity and quality of research capable of informing policy, services and practice in these areas.

Limitations

Included studies were of variable quality. Data derived could not be used to inform an economic modelling of NHS costs or to analyse cost-effectiveness. Other limitations were the search for only English-language materials and the use of umbrella concepts (‘dislocation’ and ‘contagion’).

Conclusions

The less obvious risks are important, but little evidence exists to support their identification, assessment and management. This has implications for services, and a programme of research is recommended to generate new knowledge.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Registration of aggressive incidents in an adolescent forensic psychiatric unit and implications for further practice

Although aggression is part of daily life in psychiatric units for adolescents, empirical data on its prevalence are sparse. Only few studies have described prevalence of aggressive incidents in adolescent psychiatric wards, and data in forensic psychiatric care are even more limited. Available studies reported high prevalence rates of aggression, ranging from 0.4 to 2.4 incidents of aggression per day across (forensic) child and adolescent psychiatric units. Between 27 and 78 % of all admitted youth committed an aggressive act. In this study, we collected systematically registered data of all aggressive incidents from the first 2 years (2010-2012) on a newly established forensic adolescent psychiatric unit, which used a formal aggression management program embedded in the social competence model, which is based on early intervention in the 'chain of behavior' to prevent any further escalation. The inclusion of also minor aggressive incidents is unique in the literature and the clinical relevance is highlighted. A mean of one incident a day took place, with each adolescent involved in at least one incident. Notably, 1.7 aggressive incidents per month made seclusion of restraint use necessary. Based on the social competence theory, the aggression management model suggests intervening early in the cascade of aggression, in order to prevent further escalation and reduce the need for intrusive interventions. Evidence supported that aggression is a contextual event, as external factors clearly influence the incidence of aggression. Aggression management should be built on both relational and structural security.

Negative cognitive style and perceived social support mediate the relationship between aggression and NSSI in hospitalized adolescents

Despite the well-documented association between aggression and NSSI among adolescents, relatively little research has been conducted on the mechanisms underlying this relationship. The purpose of this study was to investigate potential socio-cognitive mechanisms through which aggression and NSSI are related. Participants were 186 adolescents (ages 13-18) recruited from a psychiatric inpatient facility in the northeastern United States. According to teen report, 57.5% of the sample endorsed NSSI in the previous year. Mediation was tested using the modern bootstrapping technique described by Hayes, using 5000 resamples with replacement, including sex and depression diagnosis as covariates. Results demonstrated that greater negative self-talk, a more negative cognitive style, and lower perceived family support were all significant mediators of the relationship between aggression and greater frequency of NSSI, whereas perceived social support from friends was not a significant mediator. Limitations, clinical implications, and future research directions of the current research are discussed.