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Cao P, Peng R, Yuan Q, Zhou R, Ye M, Zhou X. Predictors of non-suicidal self-injury in adolescents with depressive disorder: the role of alexithymia, childhood trauma, and body investment. Front Psychol 2024; 15:1336631. [PMID: 38638510 PMCID: PMC11024233 DOI: 10.3389/fpsyg.2024.1336631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/27/2024] [Indexed: 04/20/2024] Open
Abstract
Purpose This study analyzes the relationship of alexithymia, childhood trauma, and body investment to non-suicidal self-injury (NSSI) behaviors in adolescents with depressive disorder and whether they have predictive and diagnostic value for non-suicidal self-injury (NSSI) behaviors in adolescents with depressive disorder. Patients and methods A total of 225 patients with a diagnosis of adolescent depressive disorder were included in the study and were divided into two groups according to the DSM-5 criteria: 98 cases without NSSI and 127 cases with NSSI. Compare the demographic data, 24-item Hamilton Depression Scale (HAMD-24), 20-item Toronto Alexithymia Scale (TAS-20), Childhood Trauma Questionnaire-Short Form (CTQ-SF), and Body Investment Scale (BIS) scores between two groups. Binary logistic regression was used to analyze the independent risk factors contributing to NSSI behaviors in adolescents with depression, and establish four predictive models. Based on the models' predictive probability, the ROC curves were plotted to calculate the value of the predictive diagnostic effect. Results The group without NSSI had lower scores than the group with NSSI on HAMD-24 total score, TAS-20 total score, difficulty identifying feelings, difficulty describing feelings, and externally focused thinking, as well as lower scores on CTQ-SF total score, physical neglect, emotional neglect, physical abuse, and emotional abuse. In contrast, the BIS total score, body image feelings and attitudes, body care, and body protection factor scores were higher for the group without NSSI. The BIS body care factor score and the CTQ-SF emotional abuse factor score were significantly linked with adolescents diagnosed with depressive disorder who exhibited NSSI behaviors. These results provide a good diagnostic model for adolescents with depressive disorder. Conclusion Low levels of body care and childhood emotional abuse may independently contribute to the implementation of NSSI in adolescents with depressive disorder. Body investment and childhood trauma are valuable in diagnosing and predicting NSSI behaviors and should be considered as potentially important factors in clinical treatment.
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Affiliation(s)
- Panpan Cao
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Hefei, China
| | - Ran Peng
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Hefei, China
| | - Qiuyu Yuan
- Bengbu Mental Health Center, Anhui Veterans Hospital, Anmin Hospital Affiliated to Bengbu Medical College, Bengbu, China
| | - Ruochen Zhou
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Hefei, China
| | - Mengting Ye
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Hefei, China
| | - Xiaoqin Zhou
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Hefei, China
- Department of Psychology and Sleep Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Hu C, Jiang W, Wu Y, Wang M, Lin J, Chen S, Shang Y, Xie J, Kong Y, Yuan Y. Microstructural abnormalities of white matter in the cingulum bundle of adolescents with major depression and non-suicidal self-injury. Psychol Med 2024; 54:1113-1121. [PMID: 37921013 DOI: 10.1017/s003329172300291x] [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: 11/04/2023]
Abstract
BACKGROUND Non-suicidal self-injury (NSSI) is prevalent in major depressive disorder (MDD) during adolescence, but the underlying neural mechanisms are unclear. This study aimed to investigate microstructural abnormalities in the cingulum bundle associated with NSSI and its clinical characteristics. METHODS 130 individuals completed the study, including 35 healthy controls, 47 MDD patients with NSSI, and 48 MDD patients without NSSI. We used tract-based spatial statistics (TBSS) with a region of interest (ROI) analysis to compare the fractional anisotropy (FA) of the cingulum bundle across the three groups. receiver-operating characteristics (ROC) analysis was employed to evaluate the ability of the difficulties with emotion regulation (DERS) score and mean FA of the cingulum to differentiate between the groups. RESULTS MDD patients with NSSI showed reduced cingulum integrity in the left dorsal cingulum compared to MDD patients without NSSI and healthy controls. The severity of NSSI was negatively associated with cingulum integrity (r = -0.344, p = 0.005). Combining cingulum integrity and DERS scores allowed for successful differentiation between MDD patients with and without NSSI, achieving a sensitivity of 70% and specificity of 83%. CONCLUSIONS Our study highlights the role of the cingulum bundle in the development of NSSI in adolescents with MDD. The findings support a frontolimbic theory of emotion regulation and suggest that cingulum integrity and DERS scores may serve as potential early diagnostic tools for identifying MDD patients with NSSI.
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Affiliation(s)
- Changchun Hu
- Department of Psychosomatics and Psychiatry, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Clinical Psychology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenhao Jiang
- Department of Psychosomatics and Psychiatry, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yun Wu
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mei Wang
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Lin
- Department of Clinical Psychology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Suzhen Chen
- Department of Psychosomatics and Psychiatry, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yushan Shang
- Department of Clinical Psychology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Xie
- Department of Clinical Psychology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Youyong Kong
- Jiangsu Provincial Joint International Research Laboratory of Medical Information Processing, School of Computer Science and Engineering, Southeast University, Nanjing, Jiangsu, China
| | - Yonggui Yuan
- Department of Psychosomatics and Psychiatry, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
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Yi X, Xiao Q, Fu Y, Wang X, Shen L, Ding J, Jiang F, Wang J, Zhang Z, Chen BT. Association of white matter microstructural alteration with non-suicidal self-injury behavior and visual working memory in adolescents with borderline personality disorder. Psychiatry Res 2024; 331:115619. [PMID: 38048646 DOI: 10.1016/j.psychres.2023.115619] [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: 11/13/2023] [Accepted: 11/18/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Non-suicidal self-injurious behavior (NSSI) is the core characteristic of adolescent borderline personality disorder (BPD) and visual working memory is involved in the pathological processes of BPD. This study aimed to investigate alterations in white matter microstructure and their association with NSSI and visual working memory in adolescents with BPD. METHODS 53 adolescents diagnosed with BPD and 39 healthy controls (HCs) were enrolled. White matter microstructure was assessed with the fractional anisotropy (FA) and mean diffusivity (MD) from diffusion tensor imaging (DTI). Correlation analysis was performed to assess the association between FA/MD and core features of BPD. A mediation analysis was performed to test whether the effects of white matter alterations on NSSI could be mediated by visual working memory. RESULTS Adolescents with BPD showed a reduced FA and an increased MD in the cortical-limbic and cortical-thalamus circuit when compared to the HCs (p < 0.05). Increased MD was positively correlated with NSSI, impulse control and identity disturbance (p < 0.05), and was negatively correlated with the score of visual reproduction. Reserved visual working memory masked the effects of white matter microstructural alterations on NSSI behavior. CONCLUSIONS White matter microstructural deficits in the cortical-limbic and cortical-thalamus circuits may be associated with NSSI and visual working memory in adolescents with BPD. Reserved visual working memory may protect against NSSI.
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Affiliation(s)
- Xiaoping Yi
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China; National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan 410008, PR China; National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Xiangya Hospital, Changsha, Hunan 410008, PR China; Hunan Key Laboratory of Skin Cancer and Psoriasis, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China; Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Qian Xiao
- Mental Health Center of Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, PR China.
| | - Yan Fu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Xueying Wang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Liying Shen
- Mental Health Center of Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, PR China
| | - Jun Ding
- Department of Public Health, Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen, Guangdong, PR China
| | - Furong Jiang
- Mental Health Center of Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, PR China
| | - Jing Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Zhejia Zhang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA 91010, USA
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Mürner-Lavanchy I, Koenig J, Güzel N, van der Venne P, Höper S, Cavelti M, Kaess M. Prefrontal oxygenation varies as a function of response inhibition performance in healthy participants but not in youth with non-suicidal self-injury. Psychiatry Res Neuroimaging 2023; 334:111697. [PMID: 37562206 DOI: 10.1016/j.pscychresns.2023.111697] [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: 01/27/2023] [Revised: 05/24/2023] [Accepted: 07/27/2023] [Indexed: 08/12/2023]
Abstract
Non-suicidal self-injury (NSSI), a highly prevalent symptom in adolescence, has been associated with impulsivity. Behavioral measures of response inhibition in combination with the recording of brain activity potentially improve the understanding of the etiology of the behavior. We therefore investigated prefrontal cortex (PFC) oxygenation during a response inhibition task using functional near-infrared spectroscopy (fNIRS) in n = 152 adolescents with NSSI and n = 47 healthy controls. We compared groups regarding behavioral performance and PFC oxygenation and tested whether the association between task performance and PFC oxygenation differed between groups. PFC oxygenation was slightly higher in adolescents with NSSI than in controls. Further, there was evidence for a group by performance interaction: In healthy controls, higher oxygenated hemoglobin was associated with better task performance, which was not the case in the NSSI group. We did not find evidence of associations between PFC oxygenation and clinical measures. Our study provides preliminary evidence of altered brain functional correlates of response inhibition in adolescents with NSSI potentially reflecting deficient top-down regulation of limbic regions through prefrontal regions. Due to methodological limitations of the current study, findings must be interpreted with caution and future studies should optimize task designs for fNIRS processing.
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Affiliation(s)
- Ines Mürner-Lavanchy
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland
| | - Julian Koenig
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Cologne, Germany; Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University Hospital Heidelberg, Germany
| | - Nebile Güzel
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University Hospital Heidelberg, Germany
| | - Patrice van der Venne
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University Hospital Heidelberg, Germany
| | - Saskia Höper
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University Hospital Heidelberg, Germany
| | - Marialuisa Cavelti
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland; Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University Hospital Heidelberg, Germany.
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Beyond BMI: cardiometabolic measures as predictors of impulsivity and white matter changes in adolescents. Brain Struct Funct 2023; 228:751-760. [PMID: 36781445 PMCID: PMC10147758 DOI: 10.1007/s00429-023-02615-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023]
Abstract
Obesity is characterized by cardiometabolic and neurocognitive changes. However, how these two factors relate to each other in this population is unknown. We tested the association that cardiometabolic measures may have with impulse behaviors and white matter microstructure in adolescents with and without an excess weight. One hundred and eight adolescents (43 normal-weight and 65 overweight/obesity; 11-19 years old) were medically and psychologically (Temperament Character Inventory Revised, Three-Factor Eating Questionnaire-R18, Conners' Continuous Performance Test-II, Stroop Color and Word Test, Wisconsin Card Sorting Test, Kirby Delay Discounting Task) evaluated. A subsample of participants (n = 56) underwent a brain magnetic resonance imaging acquisition. In adolescents, higher triglycerides and having a body mass index indicative of overweight/obesity predicted a more impulsive performance in Conners' Continuous Performance Test-II (higher commission errors). In addition, higher glucose and diastolic blood pressure values predicted increments in the Three-Factor Eating Questionnaire-R18 emotional eating scale. Neuroanatomically, cingulum fractional anisotropy showed a negative relationship with glycated hemoglobin. The evaluation of the neurocognitive differences associated with obesity, usually based on body mass index, should be complemented with cardiometabolic measures.
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6
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Guldner S, Sarvasmaa AS, Lemaître H, Massicotte J, Vulser H, Miranda R, Bezivin-Frère P, Filippi I, Penttilä J, Banaschewski T, Barker GJ, Bokde AL, Bromberg U, Büchel C, Conrod PJ, Desrivières S, Flor H, Frouin V, Gallinat J, Garavan H, Gowland P, Heinz A, Nees F, Papadopoulos-Orfanos D, Smolka MN, Schumann G, Artiges E, Martinot MLP, Martinot JL. Longitudinal associations between adolescent catch-up sleep, white-matter maturation and internalizing problems. Dev Cogn Neurosci 2023; 59:101193. [PMID: 36610292 PMCID: PMC9841167 DOI: 10.1016/j.dcn.2022.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Sleep is an important contributor for neural maturation and emotion regulation during adolescence, with long-term effects on a range of white matter tracts implicated in affective processing in at-risk populations. We investigated the effects of adolescent sleep patterns on longitudinal changes in white matter development and whether this is related to the emergence of emotional (internalizing) problems. Sleep patterns and internalizing problems were assessed using self-report questionnaires in adolescents recruited in the general population followed up from age 14-19 years (N = 111 White matter structure was measured using diffusion tensor imaging (DTI) and estimated using fractional anisotropy (FA). We found that longitudinal increases in time in bed (TIB) on weekends and increases in TIB-variability between weekdays to weekend, were associated with an increase in FA in various interhemispheric and cortico-striatal tracts. Extracted FA values from left superior longitudinal fasciculus mediated the relationship between increases in TIB on weekends and a decrease in internalizing problems. These results imply that while insufficient sleep might have potentially harmful effects on long-term white matter development and internalizing problems, longer sleep duration on weekends (catch-up sleep) might be a natural counteractive and protective strategy.
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Affiliation(s)
- Stella Guldner
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anna S Sarvasmaa
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; National Institute for Health and Welfare, Department of Public Health Solutions, Mental Health Unit, Helsinki, Finland; Finnish Student Health Service, Helsinki, Finland
| | - Hervé Lemaître
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; Institut des Maladies Neurodégénératives, UMR 5293, CNRS, CEA, Université de Bordeaux, 33076 Bordeaux, France
| | - Jessica Massicotte
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France
| | - Hélène Vulser
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France
| | - Ruben Miranda
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France
| | - Pauline Bezivin-Frère
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France
| | - Irina Filippi
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France
| | - Jani Penttilä
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; Department of Social and Health Care, Psychosocial Services Adolescent Outpatient Clinic, Lahti, Finland
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gareth J Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Arun Lw Bokde
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom; Discipline of Psychiatry, School of Medicine and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Uli Bromberg
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patricia J Conrod
- Department of Psychiatry, CHU Sainte-Justine Research Center, University of Montreal, Montreal, QC, Canada
| | - Sylvane Desrivières
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Herta Flor
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Vincent Frouin
- Neurospin, Commissariat à l'Energie Atomique et aux Energies Alternatives, Saclay, France
| | - Jürgen Gallinat
- University Medical Centre Hamburg-Eppendorf, Clinic and Policlinic for Psychiatry and Psychotherapy; Hamburg, Germany
| | - Hugh Garavan
- Departments of Psychiatry and Psychology, University of Vermont, 05405 Burlington, Vermont, USA
| | - Penny Gowland
- Sir Peter Mansfield Imaging Centre, University of Nottingham, United Kingdom
| | - Andreas Heinz
- Department of Psychiatry and Psychotherapy CCM, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frauke Nees
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig Holstein, Kiel University, Kiel, Germany
| | | | - Michael N Smolka
- Department of Psychiatry and Neuroimaging Center, Technische Universität Dresden, Dresden, Germany
| | - Gunter Schumann
- Centre for Population Neuroscience and Stratified Medicine (PONS), ISTBI, Fudan University Shanghai; and Dept. of Psychiatry and Neuroscience, Charité University Medicine, Berlin, Germany
| | - Eric Artiges
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; EPS Barthelemy Durand, Etampes, France
| | - Marie-Laure Paillère Martinot
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France; AP-HP. Sorbonne Université, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, Paris, France
| | - Jean-Luc Martinot
- Université Paris-Saclay; Institut National de la Santé et de la Recherche Médicale, INSERM U1299 "Trajectoires développementales Psychiatrie", Ecole Normale Supérieure Paris-Saclay, CNRS UMR 9010, Université Paris Cité, Centre Borelli, Gif sur Yvette, France.
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Zhou L, Wang L, Wang M, Dai G, Xiao Y, Feng Z, Wang S, Chen G. Alterations in white matter microarchitecture in adolescents and young adults with major depressive disorder: A voxel-based meta-analysis of diffusion tensor imaging. Psychiatry Res Neuroimaging 2022; 323:111482. [PMID: 35477111 DOI: 10.1016/j.pscychresns.2022.111482] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/18/2022] [Accepted: 04/14/2022] [Indexed: 02/08/2023]
Abstract
Adolescents and young adults are at a critical stage of life development, and depression can have serious consequences. In recent decades, an increasing number of diffusion tensor imaging (DTI) studies of major depressive disorder (MDD) have reported inconsistent alterations in white matter (WM) microarchitecture. To rule out the confounding effects of age, we conducted a meta-analysis of fractional anisotropy (FA) in adolescents and young adults with MDD to identify abnormalities in WM involved in the pathogenesis of MDD using anisotropic effect-size signed differential mapping (AES-SDM). The pooled meta-analysis revealed significantly lower FA mainly in the corpus callosum (CC) extending to the left anterior thalamic projections (ATP) and left cortico-spinal projection (CSP) in depressed adolescents and young adults than that in healthy controls. A reduction in FA was also identified in the right frontal orbito-polar tract (FOPT) extending to the right inferior fronto-occipital fasciculus (IFOF). In the meta-regression analysis, the mean age of patients, percentage of female patients and duration of depression were not linearly associated with abnormalities in FA. These results constitute robust evidence that abnormalities in WM microarchitecture in the interhemispheric connections and frontal-subcortical neuronal circuits may contribute to the pathogenesis of MDD during adolescence and young adulthood.
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Affiliation(s)
- Li Zhou
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Li Wang
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Maohua Wang
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Guidong Dai
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Yan Xiao
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Zhi Feng
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China
| | - Song Wang
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Guangxiang Chen
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan, China.
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8
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Kaess M, Hooley JM, Klimes-Dougan B, Koenig J, Plener PL, Reichl C, Robinson K, Schmahl C, Sicorello M, Westlund Schreiner M, Cullen KR. Advancing a temporal framework for understanding the biology of nonsuicidal self- injury: An expert review. Neurosci Biobehav Rev 2021; 130:228-239. [PMID: 34450182 PMCID: PMC8783544 DOI: 10.1016/j.neubiorev.2021.08.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 07/17/2021] [Accepted: 08/21/2021] [Indexed: 11/04/2022]
Abstract
Nonsuicidal self-injury (NSSI) is a serious clinical problem, particularly for adolescents and young adults. NSSI is a complex behavior that emerges through the intersecting effects of social, psychological, and biological mechanisms. Although the social and psychological contributions to risk for developing NSSI are relatively well understood and have guided the development of effective psychosocial treatments for self-injury, the biological mechanisms underlying NSSI have just begun to come to light. To evaluate and categorize the biological research conducted on the topic of NSSI, we propose a model that distinguishes between trait and state markers. According to this model, risk factors and mechanisms involved in NSSI can be distinguished into both trait and state factors. We review the existing evidence on distal biological traits (predictors) of NSSI, proximal biological traits (correlates) of NSSI, and biological states directly preceding or following NSSI. We conclude by providing recommendations for future research on the neurobiology of NSSI.
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Affiliation(s)
- Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Jill M Hooley
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Bonnie Klimes-Dougan
- Department of Psychology, College of Liberal Arts, University of Minnesota, Minneapolis, MN, USA
| | - Julian Koenig
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Cologne, Germany
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria; Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - Corinna Reichl
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Kealagh Robinson
- School of Psychology, Victoria University of Wellington, Wellington, New Zealand
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Maurizio Sicorello
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | | | - Kathryn R Cullen
- Department of Psychiatry and Behavioral Sciences, Medical School, University of Minnesota, Minneapolis, MN, USA
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9
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Mok PLH, Antonsen S, Agerbo E, Brandt J, Geels C, Christensen JH, Frohn LM, Pedersen CB, Webb RT. Exposure to ambient air pollution during childhood and subsequent risk of self-harm: A national cohort study. Prev Med 2021; 152:106502. [PMID: 34538368 DOI: 10.1016/j.ypmed.2021.106502] [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: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/22/2021] [Indexed: 10/20/2022]
Abstract
A growing body of evidence indicates that exposure to air pollution not only impacts on physical health but is also linked with a deterioration in mental health. We conducted the first study to investigate exposure to ambient particulate matter with an aerodynamic diameter of less than 2.5 μm (PM2.5) and nitrogen dioxide (NO2) during childhood and subsequent self-harm risk. The study cohort included persons born in Denmark between January 1, 1979 and December 31, 2006 (N = 1,424,670), with information on daily exposures to PM2.5 and NO2 at residence from birth to 10th birthday. Follow-up began from 10th birthday until first hospital-presenting self-harm episode, death, or December 31, 2016, whichever came first. Incidence rate ratios estimated by Poisson regression models revealed a dose relationship between increasing PM2.5 exposure and rising self-harm risk. Exposure to 17-19 μg/m3 of PM2.5 on average per day from birth to 10th birthday was associated with a 1.45 fold (95% CI 1.37-1.53) subsequently elevated self-harm risk compared with a mean daily exposure of <13 μg/m3, whilst those exposed to 19 μg/m3 or above on average per day had a 1.59 times (1.45-1.75) elevated risk. Higher mean daily exposure to NO2 during childhood was also linked with increased self-harm risk, but the dose-response relationship observed was less evident than for PM2.5. Covariate adjustment attenuated the associations, but risk remained independently elevated. Although causality cannot be assumed, these novel findings indicate a potential etiological involvement of ambient air pollution in the development of mental ill health.
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Affiliation(s)
- Pearl L H Mok
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK.
| | - Sussie Antonsen
- Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Denmark; National Centre for Register-Based Research, Aarhus BSS, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
| | - Esben Agerbo
- Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Denmark; National Centre for Register-Based Research, Aarhus BSS, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
| | - Jørgen Brandt
- Department of Environmental Science, Aarhus University, Roskilde, Denmark; iClimate - interdisciplinary Centre for Climate Change, Aarhus University, Roskilde, Denmark
| | - Camilla Geels
- Department of Environmental Science, Aarhus University, Roskilde, Denmark; iClimate - interdisciplinary Centre for Climate Change, Aarhus University, Roskilde, Denmark
| | | | - Lise M Frohn
- Department of Environmental Science, Aarhus University, Roskilde, Denmark; iClimate - interdisciplinary Centre for Climate Change, Aarhus University, Roskilde, Denmark
| | - Carsten B Pedersen
- Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Denmark; National Centre for Register-Based Research, Aarhus BSS, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark; Big Data Centre for Environment and Health, Aarhus University, Aarhus, Denmark
| | - Roger T Webb
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
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10
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Matera E, Margari M, Serra M, Petruzzelli MG, Gabellone A, Piarulli FM, Pugliese A, Tassiello AR, Croce F, Renna C, Margari A. Non-Suicidal Self-Injury: An Observational Study in a Sample of Adolescents and Young Adults. Brain Sci 2021; 11:brainsci11080974. [PMID: 34439593 PMCID: PMC8391479 DOI: 10.3390/brainsci11080974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
Non-Suicidal Self-Injury (NSSI) is the self-inflicted destruction of body tissues without suicidal intent with a prevalence of 1.5% to 6.7% in the youth population. At present, it is not clear which emotional and behavioral components are specifically associated with it. Therefore, we studied NSSI in a clinical sample of youth using the Ottawa Self-injury Inventory and the Barratt Impulsiveness Scale 11. The Mann-Whitney test was used to compare the numerical responses provided to the tests. We found 54 patients with NSSI, with a mean age of 17 years. Scores were analyzed in the total sample and in four subgroups. In the total sample, Internal Emotion and External Emotion Regulation, Craving, Non-Planning and Total Impulsivity were significantly associated with NSSI. There were statistically significant differences in Craving between patients with multiple NSSI episodes, suicide attempts and multiple injury modes and patients of other corresponding subgroups, in Internal Emotion Regulation, Sensation Seeking and Motor Impulsivity between NSSI patients with suicide attempts and no suicide attempts, and in Cognitive Impulsivity between NSSI patients with multiple injury modes and one injury mode. It is necessary to carefully evaluate the components underlying NSSI in order to activate personalized treatment options.
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Affiliation(s)
- Emilia Matera
- Department of Biomedical Sciences and Human Oncology, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy;
- Correspondence:
| | - Mariella Margari
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Maria Serra
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Maria Giuseppina Petruzzelli
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Alessandra Gabellone
- Department of Biomedical Sciences and Human Oncology, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy;
| | - Francesco Maria Piarulli
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Assunta Pugliese
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Anna Rita Tassiello
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Federica Croce
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
| | - Caterina Renna
- Center for Treatment and Research on Eating Disorders Mental Health Department AL, Via Miglietta 5, 73100 Lecce, Italy;
| | - Anna Margari
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University Hospital “A. Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy; (M.M.); (M.S.); (M.G.P.); (F.M.P.); (A.P.); (A.R.T.); (F.C.); (A.M.)
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11
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Neuroimaging Studies of Nonsuicidal Self-Injury in Youth: A Systematic Review. Life (Basel) 2021; 11:life11080729. [PMID: 34440473 PMCID: PMC8399885 DOI: 10.3390/life11080729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 01/14/2023] Open
Abstract
Nonsuicidal self-injury (NSSI) is prevalent and affects mainly the youth population. It is prospectively associated with suicide attempts, making it a target for suicide prevention. Recently, several studies have investigated neural pathways of NSSI using neuroimaging. However, there is a lack of systematized appraisal of these findings. This systematic review aims to identify and summarize the main neuroimaging findings of NSSI in youth. We followed PRISMA statement guidelines and searched MEDLINE, APA PsycInfo, and Google Scholar databases for neuroimaging studies, irrespective of imaging modality, specifically investigating NSSI in samples with a mean age of up to 25 years old. Quality assessment was made using the Newcastle–Ottawa and Joanna Briggs Institute scales. The initial search retrieved 3030 articles; 21 met inclusion criteria, with a total of 938 subjects. Eighteen studies employed functional neuroimaging techniques such as resting-state and task-based fMRI (emotional, interpersonal exposure/social exclusion, pain, reward, and cognitive processing paradigms). Three studies reported on structural MRI. An association of NSSI behavior and altered emotional processing in cortico-limbic neurocircuitry was commonly reported. Additionally, alterations in potential circuits involving pain, reward, interpersonal, self-processing, and executive function control processes were identified. NSSI has complex and diverse neural underpinnings. Future longitudinal studies are needed to understand its developmental aspects better.
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12
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Alterations of core structural network connectome associated with suicidal ideation in major depressive disorder patients. Transl Psychiatry 2021; 11:243. [PMID: 33895787 PMCID: PMC8068724 DOI: 10.1038/s41398-021-01353-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/08/2021] [Accepted: 04/01/2021] [Indexed: 02/08/2023] Open
Abstract
Suicide ideation (SI) is a most high-risk clinical sign for major depressive disorder (MDD). However, whether the rich-club network organization as a core structural network is associated with SI and how the related neural circuits are distributed in MDD patients remain unknown. Total 177 participants including 69 MDD patients with SI (MDDSI), 58 MDD without SI (MDDNSI) and 50 cognitively normal (CN) subjects were recruited and completed neuropsychological tests and diffusion-tensor imaging scan. The rich-club organization was identified and the global and regional topological properties of structural networks, together with the brain connectivity of specific neural circuit architectures, were analyzed. Further, the support vector machine (SVM) learning was applied in classifying MDDSI or MDDNSI from CN subjects. MDDSI and MDDNSI patients both exhibited disrupted rich-club organizations. However, MDDSI patients showed that the differential network was concentrated on the non-core low-level network and significantly destroyed betweeness centrality was primarily located in the regional non-hub regions relative to MDDNSI patients. The differential structural network connections involved the superior longitudinal fasciculus and the corpus callosum were incorporated in the cognitive control circuit and default mode network. Finally, the feeder serves as a potentially powerful indicator for distinguishing MDDSI patients from MDDNSI or CN subjects. The altered rich-club organization provides new clues to understand the underlying pathogenesis of MDD patients, and the feeder was useful as a diagnostic neuroimaging biomarker for differentiating MDD patients with or without SI.
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13
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Auerbach RP, Pagliaccio D, Allison GO, Alqueza KL, Alonso MF. Neural Correlates Associated With Suicide and Nonsuicidal Self-injury in Youth. Biol Psychiatry 2021; 89:119-133. [PMID: 32782140 PMCID: PMC7726029 DOI: 10.1016/j.biopsych.2020.06.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 12/23/2022]
Abstract
There is no definitive neural marker of suicidal thoughts and behaviors (STBs) or nonsuicidal self-injury (NSSI), and relative to adults, research in youth is more limited. This comprehensive review focuses on magnetic resonance imaging studies reporting structural and functional neural correlates of STBs and NSSI in youth to 1) elucidate shared and independent neural alternations, 2) clarify how developmental processes may interact with neural alterations to confer risk, and 3) provide recommendations based on convergence across studies. Forty-seven articles were reviewed (STBs = 27; NSSI = 20), and notably, 63% of STB articles and 45% of NSSI articles were published in the previous 3 years. Structural magnetic resonance imaging research suggests reduced volume in the ventral prefrontal and orbitofrontal cortices among youth reporting STBs, and there is reduced anterior cingulate cortex volume related to STBs and NSSI. With regard to functional alterations, blunted striatal activation may characterize STB and NSSI youth, and there is reduced frontolimbic task-based connectivity in suicide ideators and attempters. Resting-state functional connectivity findings highlight reduced positive connectivity between the default mode network and salience network in attempters and show that self-injurers exhibit frontolimbic alterations. Together, suicidal and nonsuicidal behaviors are related to top-down and bottom-up neural alterations, which may compromise approach, avoidance, and regulatory systems. Future longitudinal research with larger and well-characterized samples, especially those integrating ambulatory stress assessments, will be well positioned to identify novel targets that may improve early identification and treatment for youth with STBs and NSSI.
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Affiliation(s)
- Randy P. Auerbach
- Department of Psychiatry, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA,Division of Clinical Developmental Neuroscience, Sackler Institute, New York, New York, USA, Corresponding author: 1051 Riverside Drive, Pardes 2407, New York, NY 10032;
| | - David Pagliaccio
- Department of Psychiatry, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Grace O. Allison
- Department of Psychiatry, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Kira L. Alqueza
- Department of Psychiatry, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
| | - Maria Fernanda Alonso
- Department of Psychiatry, Columbia University, New York, New York, USA,New York State Psychiatric Institute, New York, New York, USA
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