Self-injurious behavior in adolescent girls. Association with psychopathology and neuropsychological functions

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Exploring working memory, self-criticism, and rumination as factors related to self-harm

The prevalence of self-harm and the relative emotional influences are well understood, but certain cognitive factors such as working memory, rumination, and self-criticism are not fully explored. The aim of the current study is to examine specific aspects of cognition to explore their influence on self-harming behaviors. Participants included 101 undergraduates from a British University. Factors were measured using the Centre for Epidemiological Studies Depression Scale, the Depressive Experiences Questionnaire, Ruminative Response Scale, and the Automated Working Memory Assessment. Findings indicated a greater incidence of self-harming behaviors among those who demonstrated higher depressive symptoms, but depression scores were not significantly related to self-harm. Additionally, a binary logistic regression indicated that self-criticism was associated with the presence of self-harming behavior, and a Classification and Regression Trees found that the single strongest predictor of self-harming behavior was a belief that love needs to be continually earned from others. Incorporating treatments that reduce self-criticism, such as improving self-compassion with Compassionate Mind Training, may address underlying mechanisms that trigger self-harm behavior. Keywords: rumination, depression, self-criticism, working memory, self-harm.

Non-Suicidal Self-Injury Among Incarcerated Adolescents: Prevalence, Personality, and Psychiatric Comorbidity

Introduction: Incarcerated adolescents represent a risk group for non-suicidal self-injury (NSSI), but research on this population has been limited and no studies have been conducted in Russia. To address this deficit, this study examined NSSI and the factors associated with it among youth in a juvenile correctional facility in Russia. Methods: NSSI and psychopathology were assessed using a psychiatric interview and self-report questionnaire in 368 incarcerated male adolescents aged 14-19 years (mean age 16.4 years, S.D. 0.9) from Northern Russia. Results: 18.2% (N = 67) of the study participants had a history of NSSI and also had higher rates of anxiety, post-traumatic stress disorder (PTSD), depression, community violence exposure and scored higher on most of the Youth Self-Report problem scales. In addition, 31.3% of the NSSI group reported previous suicidal ideation and had thought about a specific suicide method compared to 12.0% in the No-NSSI group. Adolescents with NSSI also differed significantly from the No-NSSI group on self-directedness (lower) and self-transcendence (higher) personality traits. Conclusion: NSSI is common in incarcerated adolescents in Russia and is associated with extensive psychiatric comorbidity, suicidal ideation and specific personality traits.

Temperament and Character Traits of Female Eating Disorder Patients with(out) Non-Suicidal Self-Injury

Eating disorder (ED) patients show alarmingly high prevalence rates of Non-Suicidal Self-Injury (NSSI). Adolescents seem to be particularly at risk, as EDs and NSSI both have their onset in mid-adolescence. It has been suggested that personality could be a transdiagnostic mechanism underlying both EDs and NSSI. However, little attention has been given to adolescent clinical samples compared to adult and/or community samples. Therefore, the current study investigated the role of personality in a sample of 189 female inpatients with an ED (M = 15.93, SD = 0.98). Our results confirmed the high prevalence of NSSI in EDs, specifically in patients with bingeing/purging behaviours (ED-BP). Temperamental differences were found between ED-BP and the restrictive ED subtype (ED-R). Namely, ED-BP patients showed more harm avoidance and less self-directedness compared to ED-R. Temperamental differences were found in NSSI as well, regardless of ED subtype: ED patients who had engaged in NSSI during their lifetime reported less self-directedness and more harm avoidance. Interestingly, only ED patients who recently engaged in NSSI showed less novelty seeking. These temperamental profiles should be recognised as key mechanisms in the treatment of adolescent ED patients with and without NSSI.

Nonsuicidal self-injury among adolescents in south-east Serbia

Background

Nonsuicidal self-injury (NSSI) refers to the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned. The aim of this study was to explore the variety of self-injury behaviors as well as the function of NSSI among adolescents in South-East Serbia.

Methods

The study included 50 adolescents of both sexes, aged 13–18 years, who had deliberately engaged in self-injury at least once. A general socio-demographic questionnaire and the Inventory of Statements About Self-Injury (ISAS) were used in the study.

Results

The average age of the respondents was 15 (1.17); the most common NSSI methods were cutting (60%), followed by biting and severe scratching (14%); the average age of onset was 14.12 (0.77); the majority confirmed experiencing pain during self-injury (42%); the respondents more commonly performed NSSI when they were alone (68,0%); in 90% of the cases, the time elapsed between sensing the urge to self-injury and acting on it was less than 1 h; the majority of the respondents stated that they did not want to stop self-injuring (56%). In terms of the NSSI function, the obtained scores were the highest for affect regulation 3.36 (1.47), self-punishment 1.90 (1.39) and marking distress 1.72 (1.26). In terms of gender, there was a statistically significant difference for the antidissociation (P = .043), interpersonal influence (P = .004) and revenge (P = .019).

Conclusion

The results may have practical implications when it comes to taking preventive and therapeutic measures in the vulnerable adolescent population.

What is the relationship between dissociation and self-harming behaviour in adolescents?

Deliberate self-harm in adolescents is an increasing clinical problem, but there is a limited understanding of the mechanisms causing or maintaining this behaviour. One proposed mechanism is that of dissociation. However, the role this mechanism may play is unclear: although some suggest that adolescents engage in self-harm to end the aversive experience of dissociation, others propose that self-harm is used to purposefully trigger a dissociative state to avoid emotional pain. This systematic review is the first to evaluate the available evidence regarding the relationship between dissociation and deliberate self-harm in adolescents (aged 18 or younger). Nineteen relevant studies were identified. These studies were limited by cross-sectional design and poor methods of measurement, but some important conclusions could be drawn. The majority of studies found a positive correlation between the severity of dissociation and the severity and frequency of deliberate self-harm in adolescents, and a small number of results suggest that dissociation mediates the relationship between childhood trauma and adolescent self-harm.

Adolescent personality traits, low self-esteem and self-harm hospitalisation: a 15-year follow-up of the Norwegian Young-HUNT1 cohort

Affective disorders are closely related to self-harm and suicidal behaviours. Less is known about how adolescent personality traits and self-esteem influence the development of later self-harm. We examined associations between personality traits such as neuroticism, psychoticism and extroversion, and self-esteem, in adolescence, and the risk of future self-harm hospitalisation. Baseline information from 13 to 19-year-old participants in the Norwegian Young-HUNT1 study in 1995-97 (n = 8965) was linked to endpoint data recorded from participants' hospital records, describing self-harm hospitalisation episodes within the catchment area. Crude and adjusted hazard ratios (HR) were estimated by Cox regression analyses. A one-unit increase on the 0-6 scale for neuroticism was associated with a HR of 1.29, 95% confidence interval (CI) 1.14-1.47. Corresponding HR for psychoticism was 1.30, 95% CI 1.03-1.63 per unit increase, and for extroversion risk was reduced (HR 0.89, 95% CI 0.77-1.04). Positive perception of self-esteem was more strongly associated with reduced risk of self-harm hospitalisation (HR per unit increase on the 0-12 scale was 0.74, 95% CI 0.68-0.82). Additional adjustment for alcohol use and symptoms of combined anxiety and depression symptoms attenuated effect estimates, in particular for neuroticism (HR 1.13, 95% CI 0.96-1.32) and psychoticism (HR 1.07, 95% CI 0.82-1.40). In contrast, self-esteem associations remained largely the same after adjustment. Our results indicate that brief assessments of personality and self-esteem might add additional relevant information, and could be included as a supplement to standard suicidal risk assessment in adolescents.

Association between bullying behavior, perceived school safety, and self-cutting: a Japanese population-based school survey

BACKGROUND

No previous population-based studies have examined associations between self-cutting, perceived school safety, and bullying behavior among East Asian adolescents.

METHOD

We examined whether bullying, victimization, and perceived school safety were associated with self-cutting by getting 1865 students with a mean age of 13.9 years (standard deviation 0.2 years) to complete questions on these variables. Psychiatric problems were assessed with the Strengths and Difficulties Questionnaire.

RESULTS

About 5.6% of males and 11.9% females had practiced self-cutting and when we controlled these results for psychiatric symptoms, self-cutting was associated with being both a bully and a victim among males and females. In addition, self-cutting was independently associated with perceived school safety among females. Those who felt unsafe at school and were victimized were much more likely to engage in self-cutting.

CONCLUSIONS

Self-cutting among Japanese adolescents was linked with bullying behavior and feeling unsafe at school. Secure school environments and school-based antibullying programs could help to prevent adolescent self-injurious behavior.

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.

The influence of personality traits and emotional and behavioral problems on repetitive nonsuicidal self-injury in a school sample

BACKGROUND

Nonsuicidal self-injury (NSSI) is highly prevalent among adolescents and associated with various mental health problems and suicidality. Previous studies have found that certain personality traits are related to NSSI behavior, however only few studies examined personality traits in adolescents with NSSI. Our study aimed to assess the relationship between personality traits and emotional and behavioral problems in predicting repetitive NSSI among adolescents from a school sample.

METHODS

Four hundred and forty-seven students (M=14.95years, SD=0.74, 52% male) completed self-report measures on NSSI, personality traits, and emotional and behavioral problems.

RESULTS

The past year prevalence of occasional and repetitive NSSI was 4.9% and 6.3% respectively. Repetitive NSSI was significantly associated with female gender, higher levels of age, novelty seeking, harm avoidance, self-transcendence, antisocial behavior, and positive self and lower levels of persistence and self-directedness in univariate analyses. However, multivariate logistic regression analyses indicated that only high levels of antisocial behavior and low levels of self-directedness significantly predicted repetitive NSSI.

CONCLUSIONS

The association between a lack of self-directedness and NSSI emphasizes the significance of targeting self-directedness in psychotherapy by strengthening self-awareness, affect tolerance and emotion regulation, as well as establishing and pursuing long-term goals.

Temperament and character traits in female adolescents with nonsuicidal self-injury disorder with and without comorbid borderline personality disorder

BACKGROUND

Temperament and character traits of adolescents with nonsuicidal self-injury disorder (NSSI) might differentiate those- with and without comorbid borderline personality disorder (BPD).

METHODS

Participants were 57 female adolescents with NSSI disorder without BPD (NSSI - BPD), 14 adolescents with NSSI disorder and BPD (NSSI + BPD), 32 clinical controls (CC), and 64 nonclinical controls (NC). Temperament and character traits were assessed with the Junior Temperament and Character Inventory, and impulsivity with the Barratt Impulsiveness Scale and a Go/NoGo task.

RESULTS

Adolescents with NSSI disorder scored significantly higher on novelty seeking and harm avoidance and lower on persistence, self-directedness, and cooperativeness than CC. The NSSI + BPD group scored even higher than the NSSI - BPD group on novelty seeking and harm avoidance and lower on persistence and cooperativeness (d ≥ 0.72). Adolescents with NSSI reported higher levels of impulsivity than the CC and NC group. However, this difference was not found in a Go/NoGo task.

CONCLUSIONS

The results provide further evidence for a distinct diagnostic entity of NSSI disorder.

Concurrent adversities and deliberate self-harm among indigenous Sami and majority Norwegian adolescents: the Norwegian Arctic Adolescent Health Study

Background:

Few studies have investigated proximal relationships between deliberate self-harm (DSH) and concurrent adversities.

Objective:

We aimed to investigate these relationships in a community population of 4881 indigenous Sami and majority Norwegian adolescents, 15 to 16 years old, and related to ethnicity and gender.

Methods:

Youth with and without self-reports of DSH last year were compared on 12 concurrent adversities, on scales measuring family and peer functioning, and on sociodemographic conditions.

Results:

DSH last year was reported by 22.3% of the adolescents, and by more girls (28.8%) than boys (15.9%). All 12 concurrent adversities were related strongly to DSH last year. Deliberate self-harmers reported twice as many concurrent adversities as non-DSHs, and a large effect size (Cohen’s d = 0.80) indicated a strong multiple additive relationship, but among DSHs no ethnic or gender differences were found. Multivariately, among Sami youth sexual abuse [odds ratio (OR), 8.4] was strongly related to DSH, whereas among majority Norwegians sexual abuse (OR, 3.9) and violence (OR, 4.5) were identified as the strongest predictors. Similarly, among boys violence from adults (OR, 8.8) was associated most strongly with DSH, whereas among girls sexual abuse (OR, 4.3) was the most robust predictor. DSHs reported more conflicts with parents, less family support and involvement, and more peer problems than non-DSHs, and DHS girls had more difficulties in these relationships than DHS boys. Only small ethnic differences were found.

Conclusion:

Adolescent DSHs reported twice as many concurrent adversities as non-DSHs, sexual abuse and violence were strongly related to DSH. Ethnic and gender differences in risk factors were found. Clinicians should inquire about traumatic experiences such as sexual and physical abuses, and should have a family, peer, and gender perspective in their work.

The underlying neurobiology of key functional domains in young people with mood and anxiety disorders: a systematic review

BACKGROUND

Mood and anxiety disorders are leading causes of disability and mortality, due largely to their onset during adolescence and young adulthood and broader impact on functioning. Key factors that are associated with disability and these disorders in young people are social and economic participation (e.g. education, employment), physical health, suicide and self-harm behaviours, and alcohol and substance use. A better understanding of the objective markers (i.e. neurobiological parameters) associated with these factors is important for the development of effective early interventions that reduce the impact of disability and illness persistence.

METHODS

We systematically reviewed the literature for neurobiological parameters (i.e. neuropsychology, neuroimaging, sleep-wake and circadian biology, neurophysiology and metabolic measures) associated with functional domains in young people (12 to 30 years) with mood and/or anxiety disorders.

RESULTS

Of the one hundred and thirty-four studies selected, 7.6 % investigated social and economic participation, 2.1 % physical health, 15.3 % suicide and self-harm behaviours, 6.9 % alcohol and substance use, whereas the majority (68.1 %) focussed on clinical syndrome.

CONCLUSIONS

Despite the predominance of studies that solely examine the clinical syndrome of young people the literature also provides evidence of distinct associations among objective measures (indexing various aspects of brain circuitry) and other functional domains. We suggest that a shift in focus towards characterising the mechanisms that underlie and/or mediate multiple functional domains will optimise personalised interventions and improve illness trajectories.

Inhibitory control in people who self-injure: evidence for impairment and enhancement

Self-injury is often motivated by the desire to reduce the intensity of negative affect. This suggests that people who self-injure may have difficulty suppressing negative emotions. We sought to determine whether self-injuring individuals exhibit impaired inhibitory control over behavioral expressions of negative emotions, when responding to images containing aversive emotional content. Self-injuring participants and healthy controls completed a Stop Signal Task in which they were asked to judge the valence (positive or negative) of images. Three types of images depicted emotional content (neutral/positive/negative). A fourth type depicted self-cutting. An unpredictable "stop signal" occurred on some trials, indicating that participants should inhibit their responses to images presented on those trials. Compared to controls, self-injuring participants showed poorer inhibition to images depicting negative emotional content. Additionally, they showed enhanced inhibition to self-injury images. In fact, self-injuring participants showed comparable response inhibition to cutting images and positive images, whereas controls showed worse inhibition to cutting images compared to all other types of images. Consistent with the emotion regulation hypothesis of self-injury, people who self-injure showed impaired negative emotional response inhibition. Self-injuring individuals also demonstrated superior control over responses to stimuli related to self-injury, which may have important clinical implications.

The role of dissociation in self-injurious behavior among female adolescents who were sexually abused

The study aimed to examine the role of dissociation (persistent versus peritraumatic) in self-injurious behavior among at-risk Israeli female adolescents. In addition, the relationship between childhood sexual abuse, depression, dissociation, and potency was investigated. A convenience sample of 93 female adolescents aged 12 years to 18 years were recruited from institutions for at-risk adolescent girls in Israel. Participants were administered an anonymous self-report questionnaire that included six measures: Demographics, Dissociative Experiences Scale, Center for Epidemiologic Studies Depression Scale, the Peritraumatic Dissociative Experiences Questionnaire, the Traumatic Events Questionnaire, and the Potency Scale. Results indicated that childhood sexual abuse increases the risk for self-injurious behavior more than threefold. Higher levels of persistent dissociation were found among girls who reported child sexual abuse compared to those who did not. Self-injurious behavior was predicted by persistent dissociation. Girls who engaged in self-injurious behavior had lower potency and higher depression levels, regardless of childhood sexual abuse history.

Nonsuicidal self-injury: an emotion regulation perspective

BACKGROUND

Nonsuicidal self-injury (NSSI) is widely thought to serve an emotion-regulatory function.

METHOD

The focus of the present paper is to provide a conceptual framework for understanding how NSSI might modify a person's emotions.

RESULTS

Drawing upon the process model of emotion regulation, we argue that 5 families of emotion regulation strategies may be engaged by NSSI. Individuals may engage in NSSI as an alternative to more distressing situations. They also may use NSSI to modify their social environment. Individuals may shift their attention away from unpleasant emotions or thoughts via NSSI. NSSI may change cognitions about the self via self-punishment or transformation of the self from higher-order to lower-order awareness. NSSI may also bring about various physiological effects, such as changes in endogenous opioids or parasympathetic nervous system activation, as a way of modulating emotional responses.

CONCLUSION

Simply labeling NSSI as 'emotion regulatory' does not tell us precisely what is going on. This is because at any given moment, NSSI can serve to regulate emotions in many different ways. One key challenge is to clarify the precise functions NSSI may be serving for a given individual in a particular context.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Treatment of a patient with traumatic brain injury-related severe self-injurious behavior

OBJECTIVE

Report a case of severe self-injurious behavior (SIB), paying special attention to treatment.

DESIGN

Case report.

PARTICIPANT

A 26-year-old woman (H.S.) 8 years post-traumatic brain injury with a history of severe SIB.

METHODS

H.S. was treated over a 22-week period with combined behavioral and psychopharmacological interventions.

RESULTS

Marked reduction in SIB was noted after the interventions were initiated.

CONCLUSION

Behavioral treatment and medications may be useful tools in the treatment of SIB after traumatic brain injury.