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Wang Z, Chen Y, Tao Z, Yang M, Li D, Jiang L, Zhang W. Quantifying the Importance of Non-Suicidal Self-Injury Characteristics in Predicting Different Clinical Outcomes: Using Random Forest Model. J Youth Adolesc 2024; 53:1615-1629. [PMID: 38300442 DOI: 10.1007/s10964-023-01926-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/03/2023] [Indexed: 02/02/2024]
Abstract
Existing research on non-suicidal self-injury (NSSI) among adolescents has primarily concentrated on general risk factors, leaving a significant gap in understanding the specific NSSI characteristics that predict diverse psychopathological outcomes. This study aims to address this gap by using Random Forests to discern the significant predictors of different clinical outcomes. The study tracked 348 adolescents (64.7% girls; mean age = 13.31, SD = 0.91) over 6 months. Initially, 46 characteristics of NSSI were evaluated for their potential to predict the repetition of NSSI, as well as depression, anxiety, and suicidal risks at a follow-up (T2). The findings revealed distinct predictors for each psychopathology. Specifically, psychological pain was identified as a significant predictor for depression, anxiety, and suicidal risks, while the perceived effectiveness of NSSI was crucial in forecasting its repetition. These findings imply that it is feasible to identify high-risk individuals by assessing key NSSI characteristics, and also highlight the importance of considering diverse NSSI characteristics when working with self-injurers.
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Affiliation(s)
- Zhenhai Wang
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Yanrong Chen
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Zhiyuan Tao
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Maomei Yang
- Tangxia No.2 Junior High School, Dongguan, Guangdong, China
| | - Dongjie Li
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Liyun Jiang
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Wei Zhang
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China.
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Ahmad SI, Hinshaw SP. A Qualitative Analysis of Perspectives on Self-directed Violence in a Prospective Longitudinal Study of Young Women With and Without Childhood ADHD. J Atten Disord 2024; 28:1255-1266. [PMID: 38294171 PMCID: PMC11168017 DOI: 10.1177/10870547231221729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Non-suicidal self-directed violence (NSSDV) is a significant and growing youth public health crisis. Girls with ADHD are at increased risk of engaging in NSSDV, yet qualitative studies with this population-to better understand manifestations, motivations, and developmental course-are lacking. METHOD We conducted semi-structured, qualitative interviews with a sub-sample of 57 young women (32 with childhood ADHD, 25 neurotypical comparisons; mean age of 27 years, part of a larger prospective longitudinal study) regarding histories and manifestations of NSSDV. RESULTS Inductive and deductive analysis revealed several key themes, including self-perceived reasons for engaging in NSSDV (affect regulation, attention seeking, self-punishment, asserting control), impulsivity, secretiveness, and in some cases motivations for desistance. CONCLUSION Findings underscore the importance of early education and screening, especially among high-risk clinical populations. Increased resources and supports for professionals, parents, and peers are indicated, along with countering the persistent stigma associated with ADHD and NSSDV.
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Affiliation(s)
| | - Stephen P. Hinshaw
- University of California, San Francisco, USA
- University of California, Berkeley, USA
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Van Hove L, Baetens I, Vanderstichelen S. Conceptualizing Self-Harm through the Experiences of Psychogeriatric Experts. Psychopathology 2024:1-9. [PMID: 38599197 DOI: 10.1159/000537809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 02/11/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Fewer studies thus far have focused on self-harm and its specific forms among older adults. Moreover, the limited available literature applies varying terminology. The categorization of self-harm used in younger populations may not be as appropriate for this population. This means that less is known about this phenomenon in older adults. The current study aimed to reduce this gap. METHODS Nine Flemish psychogeriatric experts participated in a semi-structured interview. Transcripts were thematically analyzed. RESULTS Themes emerging from the interviews suggest that self-harm in older adults may also include distinct elements, such as the omission of certain behaviours and engagement in indirect self-harm to cause bodily harm. According to the experts, self-harm may be engaged in to cope with emotions, express life fatigue, hasten death, and communicate a cry for help. DISCUSSION Self-harm is prevalent in older adults, and some characteristics may be specific to self-harm in an older age group. These findings may enable clinicians to be more alert to self-harm in older adults and consequently prevent serious suicidal behaviour. More research is needed to further uncover this phenomenon.
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Affiliation(s)
- Lisa Van Hove
- Brussels University Consultation Center (BRUCC), Department of Clinical Psychology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Imke Baetens
- Brussels University Consultation Center (BRUCC), Department of Clinical Psychology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Steven Vanderstichelen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels/Ghent University, Ghent, Belgium
- Compassionate Communities Centre of Expertise (COCO), Vrije Universiteit Brussel, Brussels/Ghent University, Ghent, Belgium
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Hiew Y, Powell NL, Wong QY, Fong ZH, Fong YJ, Chee TT. Factors associated with informal and formal help-seeking among Asian adolescents with nonsuicidal self-injury. Clin Child Psychol Psychiatry 2024:13591045241241109. [PMID: 38565258 DOI: 10.1177/13591045241241109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Although nonsuicidal self-injury (NSSI) is prevalent among adolescents and is associated with an increased risk of adverse outcomes, many adolescents with NSSI do not seek help. However, there is a lack of research on the factors that may increase the likelihood of help-seeking, especially within Asia. To address this gap, the present study examined whether certain factors were associated with informal and formal help-seeking - specifically gender, severity of NSSI, functions of NSSI and authoritative parenting. 121 adolescents (Mage = 16.2 years, 71.1% female) were recruited from specialist outpatient clinics and inpatient psychiatric wards from a public hospital in Singapore. One caregiver per adolescent was also recruited. Data from self-report questionnaires were analysed using logistics regression analyses. The results suggest that the severity of NSSI increases the likelihood of informal help-seeking, while adolescents who have parents with more authoritative parenting style are less likely to seek informal help. Gender and functions of NSSI were not found to be associated with help-seeking. The findings from this study can guide professionals in their efforts to encourage help-seeking within Asian populations, as well as inform prevention and treatment programs for Asian adolescents with NSSI.
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Affiliation(s)
- Yvette Hiew
- Department of Psychology, National University of Singapore, Singapore
| | | | - Qiu Yan Wong
- Department of Psychology, National University of Singapore, Singapore
| | - Zhi Hui Fong
- Department of Psychological Medicine, National University Health System, Singapore
| | - Ying Jie Fong
- Department of Psychological Medicine, National University Health System, Singapore
| | - Tji Tjian Chee
- Department of Psychological Medicine, National University Health System, Singapore
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Wang J, Wei Z, Jia L, Yu J, Wang Y, Meng Y, Feng Y, Chen R. Can digital self-harm relate to suicidal thoughts and behaviors beyond physical self-harm? Acta Psychiatr Scand 2024; 149:256-266. [PMID: 38254329 DOI: 10.1111/acps.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/15/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Digital self-harm (DiSH) is a recently identified self-harm distinct from physical self-harm (PSH, also known as non-suicidal self-injury, NSSI). Although prior research has shown that DiSH was associated with suicidal thoughts and behaviors (STBs), it was still unclear whether DiSH has a unique association with STBs after controlling for PSH. METHOD A cross-sectional survey was conducted on Chinese college students. The lifetime prevalence of DiSH and PSH, the functions of DiSH, recent suicide experiences (including suicide ideation, plans, and attempts), anxiety and depression were examined. A total of 5281 participants were analyzed. RESULTS A total of 10.83% of participants had ever engaged in DiSH, and 1.59% of participants reported histories of both DiSH and PSH. Among participants with a history of PSH, 30.11% engaged in DiSH. Engagement in DiSH was significantly associated with suicide ideation (SI), suicide plans (SPs), and suicide attempts (SAs). More importantly, participants who engaged in both DiSH and PSH showed higher odds of SI and SPs compared to those who had only engaged in PSH. Regarding the functions of DiSH, using DiSH for self-punishment was associated with SI and SPs, and using DiSH for sensation seeking was associated with SPs and SAs. Similar results were found for the association between DiSH and anxiety and depression. CONCLUSIONS Our findings suggest that DiSH has a unique association with the risks of STBs beyond PSH. Early identification and intervention for DiSH are crucial, even for individuals who already engage in PSH.
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Affiliation(s)
- Juan Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Ziqian Wei
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Luxia Jia
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Jiaao Yu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Yuanyuan Wang
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, School of Psychology, Center for Studies of Psychological Application, and Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou, China
| | - Yaxuan Meng
- School of Foreign Studies, Shanghai University of Finance and Economics, Shanghai, China
| | - Yi Feng
- Mental Health Center, Central University of Finance and Economics, Beijing, China
- Psychology Application Center for Enterprise and Society, School of Sociology and Psychology, Central University of Finance and Economics, Beijing, China
| | - Runsen Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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de la Torre-Luque A, Essau CA, Lara E, Leal-Leturia I, Borges G. Childhood emotional dysregulation paths for suicide-related behaviour engagement in adolescence. Eur Child Adolesc Psychiatry 2023; 32:2581-2592. [PMID: 36418505 DOI: 10.1007/s00787-022-02111-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
This study aimed at identifying the heterogeneous trajectories of emotional dysregulation across childhood and to study the relationship between specific trajectories and adolescent suicide-related behaviour (SRB). Data from the Millennium Cohort Study (N = 13,853 children; 49.07% female, M = 3.13 years at baseline, SD = 0.2) were used to identify the emotional dysregulation trajectories from 3 to 8 years old, using growth mixture modelling. Moreover, 1992 participants (52.86% female) from the initial sample were used to study the relationship between childhood emotional dysregulation trajectory and engagement in both self-harm and suicide attempt at age 17, using logistic regression. Some other time-invariant and proximal (adolescent) risk factors were incorporated into this analysis. Six emotional dysregulation trajectories were identified. Self-harm at age 17 was significantly associated with the history of self-harm and other proximal factors, but not with emotional dysregulation trajectory membership. Childhood trajectories featured by earlier emotional dysregulation were associated with higher risk of lifetime suicide attempt, as well as other proximal factors (concurrent self-harm). This study found differential risk profiles involved in both SRB forms. A relationship between early emotional dysregulation and suicide attempt engagement in adolescence was identified. Early interventions should be developed to deal with SRB risk factors from childhood.
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Affiliation(s)
- Alejandro de la Torre-Luque
- Department of Legal Medicine, Psychiatry and Pathology, Centre for Biomedical Research in Mental Health (CIBERSAM)School of Medicine, Universidad Complutense de Madrid, 2 Seneca Avenue, 28046, Madrid, Spain.
- Centre for Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain.
| | | | - Elvira Lara
- Centre for Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain
- Department of Psychiatry, Universidad Autonoma de Madrid, Madrid, Spain
| | - Itziar Leal-Leturia
- Centre for Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain
- Department of Psychiatry, Universidad Autonoma de Madrid, Madrid, Spain
- Department of Psychiatry, Instituto de Investigacion Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Guilherme Borges
- Instituto Nacional de Psiquiatria Ramon de la Fuente Muñiz, Mexico City, Mexico
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Aleva A, van den Berg T, Laceulle OM, van Aken MAG, Chanen AM, Betts JK, Hessels CJ. A smartphone-based intervention for young people who self-harm ('PRIMARY'): study protocol for a multicenter randomized controlled trial. BMC Psychiatry 2023; 23:840. [PMID: 37964199 PMCID: PMC10647141 DOI: 10.1186/s12888-023-05301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Self-harm in young people is a public health concern connected with severe mental health problems, such as personality pathology. Currently, there are no specific evidence-based interventions available for young people who self-harm. Therefore, we developed PRe-Intervention Monitoring of Affect and Relationships in Youth (PRIMARY), a smartphone-based intervention, co-designed by clinicians and young people with lived experience of mental ill-health. PRIMARY combines the Experience Sampling Method (ESM) with weekly report sessions. The study aims to examine the effectiveness of PRIMARY with regard to reducing self-harm, and improving emotion regulation and quality of relationships. METHODS This study is a multicenter, parallel groups, randomized controlled trial (RCT) comparing the PRIMARY intervention to a waiting list control group. PRIMARY comprises 28 consecutive days of questionnaires five times each day (i.e., ESM) and four weekly report sessions. Participants will comprise 180 young people referred for treatment to the participating Dutch mental healthcare institutions and (1) are aged 12 to 25 years, and (2) engaged in ≥ 1 act of self-harm in the past year. Participants are randomly allocated to a study group after screening in a 1:1 ratio by an independent researcher using computer-generated randomization sequences with stratified block randomization by age (12 to 15 years / 16 to 25 years). Staff will conduct assessments with all participants at baseline (Wave 1), after 28 days (Wave 2), and in a subsample after 10 weeks of subsequent specialized treatment (Wave 3). The primary outcomes are self-harm, emotion regulation, and quality of relationships. Secondary outcomes include patient and clinician satisfaction. Exploratory analyses of ESM data will examine the relationship between emotions, social relationships, and self-harm. DISCUSSION The results of this trial will clarify whether an innovative smartphone-based intervention is effective for reducing self harm and improving emotion regulation and the quality of social relationships. It has the potential to fill a treatment gap of interventions specifically targeting self-harm. If proven effective, it would provide an accessible, easy-to-implement, low-cost intervention for young people. Furthermore, the ESM-data will allow detailed analyses into the processes underlying self-harm, which will contribute to theoretical knowledge regarding the behavior. TRIAL REGISTRATION ISRCTN42088538 ( https://doi.org/10.1186/ISRCTN42088538 ), retrospectively registered on the 26th of October 2022.
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Affiliation(s)
- Anouk Aleva
- HYPE Centre of Expertise on Early Intervention for Borderline Personality Disorder, GGz Centraal, Amersfoort, The Netherlands.
- Department of Developmental Psychology, Utrecht University, Utrecht, The Netherlands.
| | - Tessa van den Berg
- HYPE Centre of Expertise on Early Intervention for Borderline Personality Disorder, GGz Centraal, Amersfoort, The Netherlands
- Department of Developmental Psychology, Utrecht University, Utrecht, The Netherlands
| | - Odilia M Laceulle
- HYPE Centre of Expertise on Early Intervention for Borderline Personality Disorder, GGz Centraal, Amersfoort, The Netherlands
- Department of Developmental Psychology, Utrecht University, Utrecht, The Netherlands
| | - Marcel A G van Aken
- Department of Developmental Psychology, Utrecht University, Utrecht, The Netherlands
| | - Andrew M Chanen
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Jennifer K Betts
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Christel J Hessels
- HYPE Centre of Expertise on Early Intervention for Borderline Personality Disorder, GGz Centraal, Amersfoort, The Netherlands
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Shen Y, Hu Y, Zhou Y, Fan X. Non-suicidal self-injury function: prevalence in adolescents with depression and its associations with non-suicidal self-injury severity, duration and suicide. Front Psychiatry 2023; 14:1188327. [PMID: 37333917 PMCID: PMC10272341 DOI: 10.3389/fpsyt.2023.1188327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Background Given that adolescents with depression are at the highest risk for non-suicidal self-injury (NSSI), a thorough understanding of their NSSI functions, as well as associations between functions and severe behavioral consequences, is essential for risk assessment and invention development. Methods Adolescents with depression from 16 hospitals across China, for whom data was available regarding their NSSI function, frequency, number of methods used, time characteristics, and suicide history were included. Descriptive statistical analyses were performed to determine the prevalence of NSSI functions. Regression analyses were conducted to explore the relationship between NSSI functions and behavioral characteristics of NSSI and suicide attempts. Results Affect regulation was the primary function of NSSI and followed by anti-dissociation in adolescents with depression. Females recognized automatic reinforcement functions more frequently than males, while males had a higher prevalence of social positive reinforcement functions. Automatic reinforce functions played the prominent role in associations between NSSI functions and all the severe behavioral consequences. Specifically, functions of anti-dissociation, affect regulation, and self-punishment were all associated with NSSI frequency, while higher levels of endorsements for anti-dissociation and self-punishment were linked to more NSSI methods, and greater level of endorsement for anti-dissociation was related to longer NSSI duration. Only the increase in endorsement of self-punishment was associated with a greater hazard of suicide attempts. Conclusion The dominant functions of NSSI in adolescents with depression was automatic reinforcement, specifically affect regulation. And prevalence of NSSI function differed between males and females. Anti-dissociation and self-punishment seemed to be the most risky factors as they were linked to severe NSSI or suicide behaviors. More attention should be given to these functions in risk evaluation, and the targeted interventions should be developed accordingly in a timely manner.
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Affiliation(s)
- Ying Shen
- Psychosomatic Medicine, The Third People’s Hospital of Ganzhou, Ganzhou, China
| | - Yingzi Hu
- Department of Psychology, Fudan University, Shanghai, China
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center of Tongji University, Shanghai, China
| | - Yongjie Zhou
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen, China
| | - Xiwang Fan
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center of Tongji University, Shanghai, China
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Liljedahl SI, Daukantaitė D, Kleindienst N, Wångby-Lundh M, Westling S. The five self-harm behavior groupings measure: empirical and thematic data from a novel comprehensive self-harm assessment. Front Psychiatry 2023; 14:1147206. [PMID: 37215657 PMCID: PMC10196393 DOI: 10.3389/fpsyt.2023.1147206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/31/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction The Five Self-Harm Behavior Groupings Measure (5S-HM) is a novel assessment that evaluates behaviours which may go undetected by existing measures. Self-harm is formulated across directness and lethality spectra, including under-studied behaviors such as indirect self-harm, harmful self-neglect and sexual self-harm. Aims of the study were to: (1) empirically evaluate the 5S-HM; (2) to determine whether the 5S-HM generates relevant new information with respect to the forms and functions given by participants for self-harm within a clinical sample; (3) to test the utility and novel contributions of the Unified Model of Self-Harm and the 5S-HM by extension. Methods Data were collected from N = 199 individuals (Mage = 29.98, SD = 8.41, 86.4% female), receiving specialized evidence-based treatments for self-harm, borderline personality disorder or eating disorders. Construct validity was determined via Spearman correlations, and internal consistency was established from Cronbach's alpha. Inductive thematic analysis was used to analyze and interpret qualitative data on reasons, forms and functions participants reported in relation to self-harm following Braun and Clarke's analytic guidelines. Thematic mapping was used to summarize qualitative data. Results Test-retest reliability on a subsample of n = 24, tested 14 days after Time 1 was supported by a good intraclass correlation (0.68). Internal consistency (Cronbach's alpha = 0.75) was acceptable to good, as was construct validity comparing the 5S-HM total score to two validated self-harm measures (rho = 0.40, p < 0.01; rho = 0.26, p < 0.01). A thematic map depicting antecedents and consequences of self-harm over time suggests that self-harm is initiated by negative emotional states and self-intolerance. Novel findings in relation to sexual self-harm indicated that reasons for these behaviors were either to improve or worsen one's situation through being hurt by someone else. Discussion The empirical analyses of the 5S-HM demonstrate that it is a robust measure for use in clinical and research settings. Thematic analyses proposed explanations for why self-harm behaviors are initiated and how they are reinforced over time. Sexual self-harm in particular requires further careful study.
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Affiliation(s)
- Sophie I. Liljedahl
- Department of Psychiatry for Affective Disorders, National Specialized Medical Care Unit for Severe Self-Harm Behaviour, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Finjagården Treatment Center, Finja, Sweden
| | | | - Nikolaus Kleindienst
- Central Institute of Mental Health, Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Sofie Westling
- Office for Psychiatry and Habilitation, Psychiatric Clinic Lund, Lund, Sweden
- Department of Clinical Sciences Malmö, Psychiatry, Lund University, Lund, Sweden
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