Borderline Personality Disorder and Posttraumatic Stress Disorder at Psychiatric Discharge Predict General Hospital Admission for Self-Harm

Non-suicidal Self-injury and Quantified Electroencephalogram in Adolescents and Young Adults with Depression

Objective

: This study investigated the association between non-suicidal self-injury (NSSI) and quantified electroencephalogram (QEEG) in patients with depression. We aimed to identify clinical features of NSSI and differences in QEEG findings.

Methods

: This retrospective study used the medical records of 52 inpatients with major depressive episodes, aged from 15 to 30. The patients were categorized according to their history of NSSI. Their main diagnosis and sex were also considered. To evaluate clinical symptoms, self-reported scales were used. The absolute power and the Z-scores of various waves were included.

Results

: NSSI was associated with suicidal ideations (p = 0.001) and trauma history (p = 0.014). In the binary logistic regression analysis, the Z-score of absolute alpha power was higher on the FP2 node (p = 0.029), lower on the F4 node (p = 0.029) in the NSSI group. The absolute high beta power in the NSSI group was higher on the FP2 and the F3 node, but lower on the F7 and F8 node. Patients with NSSI showed higher Z-score of the absolute delta power at the FP2 node (p = 0.044). The absolute gamma power was higher on the FP2 (p = 0.012) and the F3 node (0.043), lower on the FP1 (p = 0.019) and the F7 node (0.018) in the NSSI group. The absolute high gamma power at the FP2 (p = 0.017) and F8 nodes (p = 0.045) were higher in the NSSI group.

Conclusion

: Patients with NSSI may have clinical features distinct from those of patients without NSSI. QEEG results have shown some differences, although it is less applicable due to some limitations.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project

Background

Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited.

Objectives

To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors.

Method

A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report.

Results

The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample.

Conclusion

The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Opioid use as a proximal risk factor for suicidal behavior in young adults

INTRODUCTION

There is a concomitant rise in suicide rates with the prevalence of opioids involved in overdose deaths, especially among adolescents and young adults. However, there are limited studies on whether opioid use prospectively predicts suicidal behavior in youth.

METHODS

Our sample included 183 psychiatric patients (18-30 years) admitted for a suicide attempt (SA), have current suicidal ideation (SI), and psychiatric controls without ideation or attempt (PC). Suicidal behavior was assessed using the Columbia Suicide Severity Rating Scale. We also recruited a healthy control group (HC; n = 40). Patients and controls were followed over a year. ANOVA, regression, and cox regression were used.

RESULTS

Suicide attempt (β = 0.87, CI [0.1-1.6], p = 0.02) and SI [(β = 0.75, CI [0.03-1.5], p = 0.04) were significantly more likely than HCs to have used opioids in the past year at baseline. Opioid use was associated with increased anxiety symptoms (β = 0.75, CI [0.001-1.5], p = 0.05), PTSD symptoms (β = 3.90, CI [1.1-6.7], p = 0.01), and aggression (β = 0.02, CI [0.01-0.04], p = 0.02). Opioid use in the month prior to hospitalization predicted SA at 6 months (OR = 1.87, CI [1.06-3.31], p = 0.032).

CONCLUSIONS

Opioid use is a proximal predictor for SA. These findings may help clinicians better identify patients at risk for suicidal behavior, allowing for more personalized treatment approaches.

Borderline Personality Disorder: What Predicts Acute Psychiatric Readmissions?

Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission.

Suicidal and violent ideation in acute psychiatric inpatients: prevalence, co-occurrence, and associated characteristics

OBJECTIVE

We studied the point prevalence of suicidal and violent ideation, as well as their co-occurrence and associated characteristics in inpatients with mental health disorders.

METHODS

Data on suicidal and violent ideation, and sociodemographic and clinical information, were gathered from 1,737 patients when admitted to the acute psychiatric ward.

RESULTS

The point prevalence was 51.9% for suicidal ideation and 19.8% for violent ideation. The point prevalence of co-occurring suicidal and violent ideation was 12.3%, which was significantly greater than expected by chance. Logistic regression analyses indicated that both suicidal and violent ideation were associated with young age and the absence of diagnoses of psychotic disorders; in addition, suicidal ideation was associated with female gender, violent ideation, and diagnoses of mood- neurotic and personality disorders, whereas violent ideation was associated with male gender, suicidal ideation, and diagnoses of mood and neurotic disorders.

CONCLUSIONS

Overall, the findings highlight the need for further research on suicidal and violent ideation in people with mental health problems including, but not limited to, their association with adverse behavioral outcomes, as well as the need to routinely assess both suicidal and violent ideation in clinical practice.

Previous suicide attempt and subsequent risk of re-attempt and suicide: Are there differences in immigrant subgroups compared to Swedish-born individuals?

BACKGROUND

Studies investigating how suicide attempting refugees and non-refugee migrants differ from Swedish-born individuals in terms of re-attempts and suicide are missing. It remains unknown how mental disorders and labour market marginalization (LMM) impact on these associations.

METHODS

This longitudinal cohort study included Swedish residents aged 20-64 with suicide attempt in 2004-2012. In total, 42,684 individuals including 2017 refugees, and 2544 non-refugee migrants were included and followed until December 31, 2016. Risks of re-attempt and suicide were calculated as hazard ratios (HR) with 95% confidence intervals (CI), and adjusted for important confounders. Stratified analyses were to assess if mental disorders or LMM modified these associations.

RESULTS

In the adjusted models, refugees had an adjusted HR (aHR) of suicide re-attempt of 0.74 (CI: 0.67-0.81), and an aHR of 0.67 (CI: 0.53-0.86) for suicide death. These estimates were very similar to those of non-refugee migrants. Refugees and non-refugee migrants with suicide attempt had a lower prevalence of specialised health care due to mental disorders compared to Swedish-born attempters (48%, 44% and 61%, respectively). Mental disorders and LMM in terms of long-term sickness absence and disability pension increased the risk of re-attempt and suicide in all three groups.

LIMITATIONS

Only suicide attempts and mental disorders resulting in specialized in-and outpatient care were registered.

CONCLUSION

Migrants show considerably lower risks of re-attempt and suicide than Swedish-born individuals, with no differences between migrant groups. Despite vast differences in the prevalence of specific mental disorders, the role of mental disorders in the pathways to re-attempt and suicide does not appear to differ considerably between these groups.

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT)

BACKGROUND

Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome.

METHOD

The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person's theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24).

RESULTS

The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity.

CONCLUSION

This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.

PTSD in prison settings: A systematic review and meta-analysis of comorbid mental disorders and problematic behaviours

Purpose

Prevalence rates of PTSD are higher in the prison population than in the community. We sought to systematically review the extent to which this disorder is associated with other mental health disorders and problematic suicidal or aggressive behaviours in the prison population.

Methods

Studies reporting a relationship between PTSD and comorbid mental disorders and/or problematic behaviours in imprisoned adolescent and adult populations were identified from four bibliographic indexes. Primary studies involving clinical interviews, validated instruments leading to DSM or ICD diagnoses, or validated self-report questionnaires such as the PTSD checklist were included. Random-effects meta-analysis was conducted where possible. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results

This review identified 36 studies, with a combined sample of 9594 participants, (6478 male and 2847 female prisoners) from 11 countries. Thirty-four of the identified studies employed a cross-sectional design. We identified significant associations between PTSD and comorbid mental disorders including depression (OR = 3.4, 95% confidence interval (CI): 2.3–4.9), anxiety (OR = 2.9, 95% confidence interval (CI): 1.8–4.7) and substance use (OR = 1.9, 95% confidence interval (CI): 1.5–2.4). We also identified significant associations between PTSD and suicidality (OR = 3, 95% confidence interval (CI): 2.4–3.8) and aggressive behaviours (this latter finding was not subject to meta-analysis). Significant methodological heterogeneity was identified between studies.

Conclusions

High rates of psychiatric comorbidity among prisoners with PTSD, and links to suicidal behaviour, self-harm and aggressive behaviour, provide further support for the need for trauma-informed treatment approaches in prisons. However, significant gaps in the current evidence were apparent. In particular, a lack of large, longitudinal studies meant that the temporal relationships between PTSD and relevant outcomes cannot currently be determined.

High-Gamma: A biological marker for suicide attempt in patients with depression

BACKGROUND

Quantitative EEG (qEEG) analysis can be used to evaluate brain correlates of human psychology in all aspects. As the gamma oscillations of qEEG rhythms are related to depression, and particularly to treatment resistance, they may also be related to suicidality.

AIM

The present study aimed to identify the neural correlates of suicidal ideation and suicide attempt in depression using qEEG, based on the hypothesis that gamma rhythm in patients with depression would be higher in patients with suicidal ideation and suicide attempt.

METHOD

qEEG were recorded in 533 participants (276 female). Groups were divided into the following: Non-suicidal (n = 218), Suicide Ideation (n = 211), Suicide Attempt (n = 74), and control (n = 30).

RESULTS

High-gamma power at the F4, Fz, C4, Cz, O2, F8, T5 and T6 regions was significantly higher in the Suicide Ideation than the other groups.

CONCLUSION

If confirmed by further studies, high-gamma rhythm has the potential to be used as a biomarker for screening suicidality.

Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation

BACKGROUND

Extreme self-harming behavior is a major challenge for patients and health services. Nevertheless, this patient population is poorly described in research literature.

AIMS

The aim of this study was to assess the volume of patients with extensive psychiatric hospitalization due to extreme self-harming behaviors, the extent of severe medical sequelae, and collaboration problems within health services.

METHODS

In a national screening investigation, department managers in 83 adult psychiatric inpatient institutions across all health regions in Norway were invited to participate in a brief, prepared, telephone interview.

RESULTS

Sixty-one interviews were completed. Extensive hospitalization (prolonged or multiple) due to extreme self-harm was reported for the last year in all health regions and in 427 individual cases. Mean number of cases did not differ by region. Psychiatric hospitalizations were more frequent in hospital units than mental health centers. In 109 of the cases, self-harming behavior had severe medical consequences, including five deaths. In 122 of the cases, substantial collaboration problems within the health services were reported (disagreements on diagnosis, treatment needs and resources). Extensive (long-term) hospitalization was particularly associated with the combination of severe medical sequelae and collaboration problems.

CONCLUSION

This investigation confirms a noteworthy, nationwide, population of severely self-harming inpatients with extensive health service use, prevalent severe medical complications, and unsatisfactory collaboration within health services. These preliminary results are alarming, and indicate a need for more profound understanding of highly complex and severe cases.

Complex PTSD in ICD-11: A Case Report on a New Diagnosis

The World Health Organization (WHO) has included complex post-traumatic stress disorder (C-PTSD) in the final draft of the 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), which was published in June, 2018 and is scheduled to be submitted to WHO's World Health Assembly for official endorsement in 2019. Mental health providers will want to be informed about this diagnosis in order to provide effective treatment. Complex PTSD, or developmental PTSD as it is also called, refers to the constellation of symptoms that may result from prolonged, chronic exposure to traumatic experiences, especially in childhood, as opposed to PTSD which is more typically associated with a discrete traumatic incident or set of traumatic events. Although it has been a controversial diagnosis and is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), lines of evidence support its distinct profile and utility. In this case study, we elucidate and discuss some aspects of the diagnosis and its treatment.

DSM-5 Criteria and Its Implications for Diagnosing PTSD in Military Service Members and Veterans

This review addresses how changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 posttraumatic stress disorder (PTSD) criteria has the potential to affect the care and careers of those who have served in the military, where the diagnosis often determines fitness for duty and veterans' benefits. PTSD criteria changes were intended to integrate new knowledge acquired since previous DSM editions. Many believe the changes will improve diagnosis and treatment, but some worry these could have negative clinical, occupational, and legal consequences. We analyze the changes in classification, trauma definition, symptoms, symptom clusters, and subtypes and possible impacts on the military (e.g., over- and under-diagnosis, "drone" video exposure, subthreshold PTSD, and secondary PTSD). We also discuss critiques and proposals for future changes. Our objectives are to improve the screening, diagnosis, and treatment of those service members who have survived trauma and to improve policies related to the military mental healthcare and disability systems.