Advancing a temporal framework for understanding the biology of nonsuicidal self- injury: An expert review

Intrinsic Links Between Non-Suicidal Self-Injury and Sleep Quality and Cytokines: A Network Analysis Based on Chinese Adolescents with Depressive Disorders

Background

Non-suicidal self-injury (NSSI) in adolescents has a complex etiology and a wide range of negative consequences. This study aimed to assess the interactions between NSSI and sleep quality and cytokines and explore the association of these factors with cognitive flexibility.

Methods

A cross-sectional survey was conducted from January 2022 to September 2024 in Qingdao, China. Adolescent Non-Suicidal Self-Injury Assessment Questionnaire, Pittsburgh Sleep Quality Index, and Wisconsin Card Sorting Test 128 card version were used to assess the NSSI, sleep quality, and cognitive flexibility. Levels of 12 serum cytokines were measured. Network analysis was performed by R software (version 4.4.1) to identify the central nodes and bridging symptoms of the network and all nodes' association with cognitive flexibility.

Results

A total of 337 adolescents with depressive disorders were included in the study. In the NSSI-Sleep Quality-Cytokines Network "Intentional scratches", "IL-12p70", and "Intentionally hitting oneself with fists or harder objects" were central nodes in the network. Furthermore, sleep-related variables such as "Sleep disturbance" and "Sleep duration" were identified as bridge symptoms. No direct association between NSSI and cognitive flexibility was observed.

Limitations

The cross-sectional design, reliance on self-reported data, and restricted geographic sample limit the ability to establish causal relationships and generalize the findings.

Conclusion

IL-12p70 plays a significant role in the development of NSSI among adolescents with depressive disorders. Sleep problems facilitate the interaction between NSSI and cytokines. Cognitive flexibility may be related to NSSI through indirect pathways.

A daily diary study: The relation between pain tolerance and nonsuicidal self-injury and the moderating role of emotional dysregulation

Recent theory and research suggest that elevated pain tolerance may be an important predictor of nonsuicidal self-injury (NSSI) engagement, particularly among individuals high in emotional dysregulation. However, researchers have yet to examine the role of state pain tolerance in NSSI behaviours in daily life, or the moderating effects of emotional dysregulation. In the present study, the link between pain tolerance and NSSI, as well as the moderating effects of emotional dysregulation, were examined using a daily diary approach. Participants included 130 emerging adults (Mage = 17.96, 72 % female) with recent NSSI engagement who completed a baseline survey and 14 days of daily diary assessments. Participants reported on their daily pain tolerance and NSSI (i.e., urges, engagement, frequency, and NSSI versatility). Using hierarchical linear modelling, it was found that state pain tolerance predicted same day NSSI engagement, NSSI frequency, and NSSI versatility, particularly for those with high trait emotion dysregulation. For individuals high in emotional dysregulation, pain tolerance also predicted next-day NSSI versatility. Pain tolerance may be relevant in NSSI risk assessment and prevention.

Current Phenomenon of Self-Harm in Children and Adolescents

Self-harm is a prevalent phenomenon among children and adolescents, and its incidence has increased over time. This behavior is often a maladaptive coping mechanism caused by difficulties with emotional regulation. Self-harm behavior in children and adolescents is a predictor of future suicide attempts and requires comprehensive management. This study reviewed current holistic management of self-harm in children and adolescents. By synthesizing evidence-based practices, this study shows that management should include the recognition of risk factors for self-harm and suicidal behavior, early detection, pharmacological and non-pharmacological therapies, and prevention programs at all levels. This study aimed to increase awareness and encourage participation from all societal levels, including schools and policymakers, in handling self-harm in children and adolescents.

The role of cytokines in predicting the therapeutic effect of non-suicidal self-injury in adolescents: a longitudinal study

BACKGROUND

Neuroinflammatory processes are directly involved in the pathogenesis of non-suicidal self-injury (NSSI) among adolescents. However, their role in predicting the outcome of adolescent NSSI is unknown. This study aimed to explore the relationship between inflammatory cytokines and their effect on NSSI treatment through a prospective investigation.

METHODS

Thirty-two healthy adolescents and 199 adolescents who had engaged in NSSI were recruited. Blood samples were obtained from all participants to determine the concentration of inflammatory cytokines at enrollment. Thereafter, the NSSI group completed surveys on their NSSI behaviors after 3, 6, and 12 months. The outcomes of their NSSI behaviors were evaluated using the indexes of NSSI number and NSSI impulsivity.

RESULTS

The results showed that the mean NSSI number and NSSI impulsivity of the participants both showed a decline tendency over time. However, regarding the NSSI number, the significant treatment effect only emerged after 6 months. The abnormal rates of IL-1βand IL-8 levels of the NSSI group were significantly higher than those of healthy controls (χ2 = 3.945, 27.394; P < 0.05). In the regression models, high IL-8 level (β: 0.225, 95% CI: 0.001, 0.005; p = 0.001), high TNF-α level (β: 0.157, 95% CI: 0.023, 0.244; p = 0.018), and low IL-10 level (β: - 0.261, 95% CI: - 2.678, - 0.901; p = 0.017) could predict the treatment effect of NSSI number. High level of IL-8 (β: 0.233, 95% CI: 0.002, 0.009; p = 0.001) and long duration of medical treatment (β: 0.285, 95% CI: 0.234, 0.649; p < 0.001) could predict the treatment effect of NSSI impulsivity. When considering the two indexes together, the role of screened-out cytokines, IL-8 (OR = 1.065, 95% CI: 1.032,1.099; p < 0.001), TNF-α (OR = 1.839, 95% CI: 1.063, 3.182; p = 0.029) and IL-10 (OR = 0.031, 95% CI: 0.002, 0.541; p = 0.017), were still stable.

CONCLUSIONS

Employing the assessment of inflammatory cytokines among adolescents who engage in NSSI may be helpful in predicting their treatment outcome and designing other suitable treatment schemes in advance.

TRIAL REGISTRATION

registered in https://www.medicalresearch.org.cn/ . Retrospectively registered: registered in https://www.chictr.org.cn/ .

REGISTRATION NUMBER

ChiCTR2500097375. Date of registration: 18th February, 2025.

N-Acetylcysteine for Nonsuicidal Self-Injurious Behavior in 3 Adults With Williams Syndrome: A Case Series

BACKGROUND

Williams syndrome (WS) is a genetic disorder that results from a microdeletion of 25 to 27 genes on chromosome 7q11.23. Individuals with WS often exhibit comorbid neuropsychiatric symptoms, especially anxiety. To our knowledge, nonsuicidal self-injurious behavior (NSSIB) has not been reported in WS. N-acetylcysteine (NAC) is a safe and readily available drug that may modulate glutamate activity in the brain. NAC is effective for treating various neuropsychiatric symptoms and disorders. There are limited reports in the literature where NAC has been used to treat NSSIB effectively, but none in WS.

METHODS

This report describes using NAC to treat NSSIB in 3 adults with WS.

FINDINGS

Nonsuicidal self-injurious behavior was successfully treated in 3 adults with WS using NAC in doses ranging from 2400 to 3600 mg a day, resulting in significant improvement in their daily functioning. Additionally, NAC was well tolerated.

CONCLUSIONS

NAC was effective for treating NSSIB in 3 adults with WS. By addressing these challenging behaviors, NAC offers a promising pharmacological intervention that can significantly improve the quality of life for patients with WS who engage in NSSIB. Further research and clinical trials are necessary.

Non-suicidal self-injury risk among left-behind children and adolescents in China: A systematic review and meta-analysis

BACKGROUND

Increasing evidence has shown an increased risk of non-suicidal self-injury (NSSI) in left-behind children and adolescents (LBCAs). However, a systematic summary of studies comparing the risk of NSSI between LBCAs and non-LBCAs in China is lacking.

AIM

To investigate the risk of NSSI among LBCAs in China.

METHODS

We performed a systematic search of Embase, PubMed, and Web of Science from initiation to October 25, 2024, for all relevant studies of NSSI and LBCAs. The effect sizes were reported as odds ratios (ORs) with 95% confidence intervals (CI). Sensitivity analyses were conducted to further confirm the stability of the findings.

RESULTS

A total of 10 studies with 165276 children and adolescents were included in this study. LBCAs had significantly higher rates of NSSI compared with non-LBCAs (OR = 1.33, 95%CI: 1.19-1.49), with high heterogeneity observed (I 2 = 77%, P < 0.001). Further sensitivity analyses were consistent with the primary analysis (OR = 1.29, 95%CI: 1.21-1.39, I 2 = 0%).

CONCLUSION

LBCAs are found to be at an increased risk of NSSI compared with children and adolescents of non-migrants. More attention and intervention are urgently needed for LBCAs, especially those living in developing countries.

Mapping punishment avoidance learning deficits in non-suicidal self-injury in young adults with and without borderline personality disorder: An fMRI study

INTRODUCTION

Non-suicidal self-injury (NSSI) is a growing public health concern among young adults in both clinical and non-clinical settings. Despite evidence linking NSSI to alterations in learning from reward and punishment, this area remains understudied, especially in non-clinical populations without borderline personality disorder (BPD).

METHODS

We employed a modified version of the Probabilistic Stimulus Selection (PSS) task in two groups of young adults with recurrent NSSI, with (NSSI+BPD) and without BPD (NSSI), and an additional group of healthy controls (HC). While undergoing functional magnetic resonance imaging (fMRI), participants were asked to choose between pairs of stimuli with different reward probabilities. In the training phase, they received probabilistic feedback and learned to identify the most rewarding option within fixed pairs. In the test phase, these learned stimuli were recombined into novel pairs, where participants' accuracy in selecting the most rewarding and avoiding the most punishing options reflected their ability to learn from reward and punishment, respectively.

RESULTS

Compared to HC, participants in the NSSI and NSSI+BPD groups were less accurate at avoiding the most punishing options than at choosing the most rewarding options, and showed reduced activity in the nucleus accumbens (NAcc) during punishment avoidance relative to reward selection.

LIMITATIONS

The modest sample size, descriptive rather than modeling approach, and absence of ecological momentary assessments may limit the results.

CONCLUSION

Findings suggest that reduced activation of the NAcc when avoiding loss may underlie difficulties in learning to avoid punishment in young adults with NSSI, regardless of the presence of BPD.

Prefrontal oxygenation during experimental pain in adolescents engaging in non-suicidal self-injury

BACKGROUND

The intricate role of pain in non-suicidal self-injury (NSSI) makes the investigation of alterations in brain function during pain processing a critical yet underexplored topic. The aim of this study was to investigate fNIRS correlates of experimental pain and how these differed between adolescent patients engaging in NSSI and healthy controls.

METHODS

154 adolescent patients with NSSI and 48 healthy controls underwent a heat pain stimulation with linearly increasing temperature from 32 °C to max. 50 °C, during which fNIRS activity was recorded. Associations between fNIRS activity and pain perception (i.e. pain threshold, pain tolerance and pain intensity) were examined using linear mixed models and linear regression analyses.

RESULTS

Across groups, we found a decrease in prefrontal oxygenation during increasing pain stimulation: Oxygenated hemoglobin was higher during baseline than during pain threshold (b = -0.36, p < .001) and higher during pain threshold than during pain tolerance (b = -0.10, p < .001). We did not find differential patterns of prefrontal oxygenation across the pain assessment between patients and healthy controls. Also, no association between pain intensity and fNIRS activity was found.

LIMITATIONS

fNIRS was only recorded in prefrontal regions and our design did not include a non-painful stimulation as a control condition.

CONCLUSION

While our study adds to the understanding of prefrontal hemodynamic changes associated with pain processing, it did not contribute further evidence to the few existing findings regarding altered neural processing of pain in adolescents engaging in NSSI.

Impact of social media on triggering nonsuicidal self-injury in adolescents: a comparative ambulatory assessment study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a prevalent and concerning behavior among adolescents, often triggered by negative interpersonal events. As social media is essential in the daily life of adolescents, gaining a better understanding of the impact of negative online events on NSSI urges and behaviors, distinct from that of real-life events, is warranted.

METHODS

We recruited 25 adolescents with a history of NSSI and 25 healthy controls. Participants reported on their stress, affect, and NSSI urges four times daily over seven days using ambulatory assessment. We examined the immediate effects of negative events in real-life and on social media on these psychological outcomes.

RESULTS

In adolescents who engage in NSSI, negative events on social media were positively associated with perceived stress, negative affect, and NSSI urges to a greater extent than real-life negative events. However, NSSI events during the sampling period were mostly triggered by real-life events. While the frequency of social media use was generally similar between groups, those with NSSI reported experiencing more negative events on social media.

CONCLUSIONS

Our findings highlight the significant impact of social media on the mental health of adolescents who engage in NSSI, possibly exacerbating stress and negative affect more than real-life events. These results underscore the need for targeted interventions addressing online interactions to mitigate NSSI behaviors and improve adolescent mental health.

TRIAL REGISTRATION

This study has been registered at the German Clinical Trials Register (ID: DRKS00025905, https://drks.de/search/en/trial/DRKS00025905 ).

Alterations of the endocannabinoid system in adolescents with non-suicidal self-injury as a function of childhood maltreatment

Non-suicidal self-injury (NSSI) is a highly prevalent phenomenon in adolescence, often associated with prior traumatic experiences. The development and maintenance of NSSI is associated with dysregulation of the stress response, and evidence suggests that the hypothalamic-pituitary-adrenal (HPA) axis plays an important role. The endocannabinoid system is a neuromodulatory system in close functional interaction with the HPA axis. Several studies have reported alterations of the endocannabinoid system in adult patients with post-traumatic stress disorder. However, the role of the endocannabinoid system in children and adolescents with NSSI is less clear, and previously no study examined endocannabinoids in youth with experiences of maltreatment. N-arachidonyl ethanolamide (AEA) and 2-arachidonyl glycerol (2-AG) were quantified alongside sociodemographic and clinical characteristics in n = 148 adolescents (12-17 years of age). Analyses addressed group differences comparing healthy controls (HC, n = 38), patients with NSSI without (NSSI - CMT, n = 42) and with a history of childhood maltreatment (NSSI + CMT, n = 68). We show that AEA is reduced in adolescents with NSSI independent of childhood maltreatment. Further, we present first evidence for a negative association between AEA and NSSI frequency as well as AEA and the severity of childhood maltreatment. This is the first study providing evidence for alterations in the endocannabinoid system in children and adolescents engaging in repetitive NSSI. Findings from the study support current endocannabinoid-hypotheses on the neurobiology of trauma and adversity, extending existing findings of altered endocannabinoid signaling following exposure to traumatic events to a well-powered sample of children and adolescents.

Antecedents and risk factors for borderline personality disorder: Etiopathogenic models based on a multi-level meta-analysis

BACKGROUND

Empirically-based developmental psychopathology approach identified three domains involved in the emergence of borderline personality disorder (BPD): i) underlying liabilities to develop psychopathology (i.e., early patterns of internalizing and externalizing manifestations); ii) invalidating relational experiences (e.g., childhood traumatic experiences, maladaptive parenting, problematic peer relationships); iii) regulatory mechanisms of emotions and behaviors. Nevertheless, no studies have quantitatively summarized empirical findings concerning how and to what extent these domains might be temporally associated to the emergence of BPD features from adolescence to adulthood.

METHODS

The current multi-level meta-analysis included 106 studies (N = 86,871 participants) assessing the role of previously mentioned antecedents and risk factors for BPD.

RESULTS

The analysis showed moderate effect sizes capturing temporal associations between early internalizing/externalizing psychopathological manifestations, different invalidating relational experiences, emotion/behavior regulation processes with later BPD features. The effect sizes of these domains were not statistically different from each other.

CONCLUSION

This evidence supports a transactional developmental model of BPD. Consistently, the emergence of BPD could be viewed in the light of dynamic interplays between an underlying liability to psychopathology and invalidating relational experiences across different stages of development, which are progressively reinforced through increasing alterations of emotion and behavior regulation mechanisms.

The neuropathology of Self-Injurious Behavior: Studies using animal models

Self-injurious behavior is a debilitating characteristic that is highly prevalent in autism and other neurodevelopmental disorders. In these populations, self-injury has typically been interpreted in relation to behavioral reinforcement and/or sensory stimulation. However, self-injury is also commonly exhibited by people with a variety of neuropsychiatric disorders, where it is typically described in relation to emotional regulation and the presence or absence of suicidal ideation. Interestingly, self-injury has also been documented in many non-human animal species, especially when exposed to early environmental deprivation, isolation, and distress. Despite the propensity of animals to self-injure under adverse conditions, animal models of self-injury have not been the focus of much research, and translation of the data from these models has largely been limited to autism and neurodevelopmental disorders. This review summarizes evidence that common biological and environmental mechanisms may contribute to vulnerability for self-injury in neurodevelopmental disorders, psychiatric disorders, and distressed animals, and that investigations using animal models may be highly beneficial when considering self-injury as a behavioral phenotype that exists across diagnostic categories. Investigations using animal models have revealed that individual differences in stress responses and anxiety-related behavior contribute to vulnerability for self-injury. Animal models have implicated dysregulation of monoaminergic, glutamatergic, and other neurotransmitter systems in expression of self-injury, and these models have suggested neural targets for pharmacotherapy that have potential relevance for diverse clinical populations.

The role of testosterone and cortisol levels in nonsuicidal selfinjury in adolescents

INTRODUCTION

Nonsuicidal selfinjury (NSSI) is an important problem in adolescence, which is thought to serve several reinforcement functions (positive vs. negative, automatic vs. social). While the psychological mechanisms involved in NSSI are relatively well known, there is an important gap in the knowledge regarding the underlying biological mechanisms. This study examined the role of testosterone (T) and cortisol (C) in the frequency and reinforcement functions of NSSI.

METHODS

A total of 423 adolescents (age range = 13-17; 54.4% girls) from Basque Country (Spain) provided saliva samples to determine T and C levels and completed measures of NSSI 6 months later in 2017-2018.

RESULTS

The results showed that T but not C was significantly associated with higher NSSI frequency and the four types of NSSI functions. In addition, C moderated the predictive association between T and NSSI for automatic negative reinforcement, such that this association was significant only when C was high. Participant sex did not moderate any association between hormones and NSSI.

CONCLUSIONS

These preliminary results suggest that testosterone levels can affect NSSI behaviors in adolescence, thus helping to explain the increase in NSSI during this stage. Moreover, in situations in which NSSI serves to alleviate negative internal states, high levels of cortisol can be involved.

Self-injury and suicidal behaviors in high-risk adolescents: Distal predictors, proximal correlates, and interactive effects of impulsivity and emotion dysregulation

Suicide rates are rising among U.S. youth, yet our understanding of developmental mechanisms associated with increased suicide risk is limited. One high-risk pathway involves an interaction between heritable trait impulsivity and emotion dysregulation (ED). Together, these confer increased vulnerability to nonsuicidal self-injury (NSSI), suicide ideation (SI), and suicide attempts (SAs). Previous work, however, has been limited to homogeneous samples. We extend the Impulsivity × ED hypothesis to a more diverse sample of adolescents (N = 344, ages 12-15 at Baseline, 107 males and 237 females) who were treated for major depression and assessed four times over two years. In multilevel models, the impulsivity × ED interaction was associated with higher levels and worse trajectories of NSSI, SI, and SAs. As expected, stressful life events were also associated with poorer trajectories for all outcomes, and NSSI was associated with future and concurrent SI and SAs. These findings extend one developmental pathway of risk for self-harming and suicidal behaviors to more diverse adolescents, with potential implications for prevention.

Childhood maltreatment and non-suicidal self-injury in adolescent population: A systematic review and meta-analysis

BACKGROUND

Non-suicidal self-injury (NSSI) is highly prevalent among adolescents. However, knowledge about the possible factors that might precede and influence its development remains scarce.

OBJECTIVE

Our goal is to examine the impact of adverse childhood events, and more specifically of different types of childhood maltreatment (CM) in adolescent NSSI. This involves performing a systematic review and meta-analysis of the different CM subtypes (physical and emotional neglect, physical and emotional abuse, sexual abuse) in clinical and non-clinical samples of adolescents with NSSI.

PARTICIPANTS AND METHODS

A digital search of the PsycInfo, PubMed and Web of Science platforms for articles published up to June 2022 was performed. The search terms were "self harm", "non-suicidal self-injury", "childhood maltreatment" and "adolescents".

RESULTS

Forty-six articles that fit the research objectives were included in the study, which covered a total of 1,505,430 adolescents, of whom 560,337 belonged to the NSSI group, while 945,093 were in the control group. The results describe strong positive associations between all CM subtypes and NSSI, especially with emotional abuse (odds ratio [OR] 2.91, 95 % CI 2.37-3.56) and sexual abuse (OR 2.72, 95 % CI 2.12-3.48), in clinical and non-clinical samples of adolescents.

CONCLUSIONS

The experience of CM, and especially emotional and/or sexual abuse, seems to be associated with a greater risk of developing NSSI in adolescence. Therefore, early identification and detection of children who have suffered or are suffering these forms of CM are of vital importance for instigating psychotherapeutic treatments that can minimize the risk of developing NSSI in adolescence.

The STAR collaborative nonsuicidal self-injury study: methods and sample description of the face-to-face sample

BACKGROUND

Nonsuicidal self-injury (NSSI) is highly prevalent in adolescents and young adults worldwide. It is linked to a broad variety of mental disorders and an increased suicide risk. Despite its high prevalence, research on the underlying mechanisms and on potential risk and resilience factors for maintaining or quitting NSSI remains scarce. This manuscript presents an overview of the "Self-injury: Treatment-Assessment-Recovery" (STAR) collaboration, which aimed to address these gaps.

METHODS

We investigated the natural course of NSSI as well as its social, psychological, and neurobiological predictors (observational study; OS). OS data collection occurred at four timepoints (baseline [T0], 4 [post, T1], 12 [follow-up (FU), T2], and 18 [FU, T3] months after baseline) for the NSSI group, which was compared to a healthy control (HC) group at T0 only. Online self-report was used at all timepoints, while semi-structured interviews (face-to-face (f2f)) were conducted at T0 and T3. At T0 only, we conducted ecological momentary assessment and neurobiological investigations. Here, we present the general methodology and sample characteristics of the completed OS including the f2f subprojects, while other subprojects are not within the scope of this paper.

SAMPLE DESCRIPTION

The OS sample consists of 343 participants at T0 (180 NSSI, 163 HC). Mean age in the NSSI group (T0) was 18.1 years (SD = 2.09, range: 15-25), gender-related data is available for 166: 156 = female, 7 = male, 3 = transgender, 10 = not disclosed). In the HC group, mean age (T0) was 19.1 years (SD = 2.35, range: 15-25) (142 = female, 21 = male). At T1, 128 (71.11%) of the NSSI participants completed the questionnaires, at T2 125 (69.44%) and at T3 104 (57.78%). In the fMRI subproject, 126 adolescents participated (NSSI = 66, HC = 60, 100% female; mean age (T0): NSSI = 18.10 years, SD = 2.21; HC = 19.08, SD = 2.36).

CONCLUSION

Understanding predictors is of utmost importance for adequate diagnosis and intervention for NSSI. Our OS applied a multimodal investigation of social, psychological, and neurobiological parameters and is the largest sample of adolescents with NSSI to date including follow-up assessments. As health care providers require specific knowledge to develop new treatments, we believe that our in-depth assessments can potentially enhance care for youths engaging in NSSI.

Association between childhood emotional abuse and non-suicidal self-injury among Guangxi adolescents in China: A moderated mediation model

BACKGROUND

Childhood Emotional Abuse (CEA) is a known risk factor for Non Suicidal Self-injury (NSSI), which could have devastating repercussions. This study aimed to establish whether Parent-Child Attachment (PCA) and depressive symptoms mediated the CEA-NSSI relationship, as well as whether school connectedness moderated both the direct and indirect relationships between CEA and NSSI.

METHODS

Between November and December 2022, 7447 Chinese adolescents in high schools were surveyed through multi-stage cluster random sampling. The participants completed self-reported questionnaires that assessed CEA, PCA, depressive symptoms, school connectedness, and NSSI. Relationships between these variables were examined through moderated mediation analysis using SPSS macro-PROCESS.

RESULTS

After controlling for sociodemographic variables, we found that CEA correlated positively with NSSI through two different pathways: the mediating role of depressive symptoms and the chain-mediating role of both PCA and depressive symptoms. Moreover, school connectedness could moderate the direct and indirect relationships between CEA and NSSI.

LIMITATIONS

The study's cross-sectional design does not allow for causal inferences.

CONCLUSIONS

Overall, PCA, depressive symptoms, and school connectedness could affect the CEA-NSSI relationship.

Emotion dysregulation in nonsuicidal self-injury: Dissociations between global self-reports and real-time responses to emotional challenge

INTRODUCTION

Prominent theories of nonsuicidal self-injury (NSSI) propose that the behaviour is characterised by amplified emotional responses. However, little is known about how people who self-injure respond during emotional challenge.

METHODS

We measured subjective and physiological responding (heart rate, heart rate variability, and electrodermal responding) among young adults with past-year NSSI (n = 51) and those with no lifetime NSSI (n = 50) during a resting baseline, a stress induction, and a post-stress resting phase. Participants reported the extent to which they spontaneously used cognitive reappraisal and expressive suppression during the post-stress phase. Two weeks later, a subset of the sample (n = 42) reported how they remembered feeling during the laboratory session.

RESULTS

Although the NSSI group reported considerably greater emotion dysregulation than Controls, both groups showed similar subjective and psychological reactivity to, and recovery from, emotional challenge. Both groups used reappraisal and suppression regulation strategies following acute stress to a similar extent, and later came to remember the emotional challenge in a similar manner.

LIMITATIONS

Within the NSSI group, past-year self-injury tended to be infrequent and sporadic. Only 43.6% of the sample participated in the follow-up survey assessing memory of emotional challenge.

CONCLUSIONS

Findings demonstrate that the role of emotion in NSSI is more complex than prominent theories can account for, raising substantial questions regarding the nature of emotion in NSSI. A more comprehensive understanding of the role of emotion in NSSI is needed to inform intervention strategies to better support people who self-injure.

Predicting non-suicidal self-injury among Chinese adolescents: The application of ten algorithms of machine learning

Background and aims

High non-suicidal self-injury (NSSI) prevalence among adolescents is a global health issue. However, current prediction models for adolescent NSSI rely on a limited set of algorithms, resulting in biased predictions. Therefore, the aim of this study is to develop multiple machine learning models to enhance prediction accuracy and mitigate biases among Chinese adolescents.

Methods

A total of 4487 junior and senior high school students in China were recruited. Multiple algorithms were included, such as logistic regression, decision tree, support vector machine, Naive Bayes, multi-layer perceptron, K-nearest neighbors, and ensemble learning algorithm like random forest, bagging, AdaBoost, and stacking to build predictive models. Data processing techniques, including standardization and the synthetic minority oversampling technique, were employed to optimize the predictive model. The model was trained on 70 % of the data, reserving 30 % for testing.

Results

The ten prediction models achieved a good performance, with area under the receiver operating characteristic curve (AUC) scores above 0.700 in the test set. The stacking and random forest models achieved AUC scores of 0.904 and 0.898, respectively. The prediction performance of the Naive Bayes model was relatively poor. The top five important variables were resilience, bully, suicidal ideation, internet addiction, and depression.

Conclusions

The ensemble machine learning algorithm showed promising results predicting NSSI among adolescents. Such algorithms should be recommended for future NSSI research to enhance predictive accuracy. Identification of important features in NSSI prediction can help develop screening protocols and lay a foundation for clinical diagnosis and intervention in adolescent populations.

A multi-modal assessment of self-knowledge in adolescents with non-suicidal self-injury: a research domains criteria (RDoC) study

BACKGROUND

Adolescence is a critical period for brain development, consolidation of self-understanding, and onset of non-suicidal self-injury (NSSI). This study evaluated the RDoC (Research Domain Criteria) sub-construct of Self-Knowledge in relation to adolescent NSSI using multiple units of analysis.

METHODS

One hundred and sixty-four adolescents assigned female at birth (AFAB), ages 12-16 years with and without a history of NSSI entered a study involving clinical assessment and magnetic resonance imaging (MRI), including structural, resting-state functional MRI (fMRI), and fMRI during a self-evaluation task. For imaging analyses, we used an a priori defined Self Network (anterior cingulate, orbitofrontal, and posterior cingulate cortices; precuneus). We first examined interrelationships among multi-level Self variables. We then evaluated the individual relationships between NSSI severity and multi-level Self variables (self-report, behavior, multi-modal brain Self Network measures), then conducted model testing and multiple regression to test how Self variables (together) predicted NSSI severity.

RESULTS

Cross-correlations revealed key links between self-reported global self-worth and self-evaluation task behavior. Individually, greater NSSI severity correlated with lower global self-worth, more frequent and faster negative self-evaluations, lower anterior Self Network activation during self-evaluation, and lower anterior and posterior Self Network resting-state connectivity. Multiple regression analysis revealed the model including multi-level Self variables explained NSSI better than a covariate-only model; the strongest predictive variables included self-worth, self-evaluation task behavior, and resting-state connectivity.

CONCLUSIONS

Disruptions in Self-Knowledge across multiple levels of analysis relate to NSSI in adolescents. Findings suggest potential neurobiological treatment targets, potentially enhancing neuroplasticity in Self systems to facilitate greater flexibility (more frequently positive) of self-views in AFAB adolescents.

Neural correlates of reward valuation in individuals with nonsuicidal self-injury under uncertainty

BACKGROUND

Attitudes toward risk and ambiguity significantly influence how individuals assess and value rewards. This fMRI study examines the reward valuation process under conditions of uncertainty and investigates the associated neural mechanisms in individuals who engage in nonsuicidal self-injury (NSSI) as a coping mechanism for psychological pain.

METHODS

The study involved 44 unmedicated individuals who reported five or more NSSI episodes in the past year, along with 42 age-, sex-, handedness-, IQ-, and socioeconomic status-matched controls. During the fMRI scans, all participants were presented with decision-making scenarios involving uncertainty, both in terms of risk (known probabilities) and ambiguity (unknown probabilities).

RESULTS

In the NSSI group, aversive attitudes toward ambiguity were correlated with increased emotion reactivity and greater method versatility. Whole-brain analysis revealed notable group-by-condition interactions in the right middle cingulate cortex and left hippocampus. Specifically, the NSSI group showed decreased neural activation under ambiguity v. risk compared to the control group. Moreover, reduced hippocampal activation under ambiguity in the NSSI group was associated with increased emotion regulation problems.

CONCLUSIONS

This study presents the first evidence of reduced brain activity in specific regions during value-based decision-making under conditions of ambiguity in individuals with NSSI. These findings have important clinical implications, particularly concerning emotion dysregulation in this population. This study indicates the need for interventions that support and guide individuals with NSSI to promote adaptive decision-making in the face of ambiguous uncertainty.

Two-year course of non-suicidal self-injury in an adolescent clinical cohort: The role of childhood adversity in interaction with cortisol secretion

AIM

Non-suicidal self-injury (NSSI) is a highly prevalent phenomenon during adolescence. Nonetheless, research on predictors of the clinical course of NSSI over time is still scarce. The present study aimed at investigating the impact of adverse childhood experiences (ACE) and hypothalamus-pituitary-adrenal (HPA) axis functioning on the longitudinal course of NSSI.

METHODS

In a sample of n = 51 help-seeking adolescents engaging in NSSI, diurnal cortisol secretion (CAR, cortisol awakening response; DSL, diurnal slope), hair cortisol concentrations and ACE were assessed at baseline. Clinical outcome was defined by change in the frequency of NSSI in the past 6 months measured 12 and 24 months after the baseline assessments. Mixed-effects linear regression models were used to test for effects of ACE and HPA axis functioning on the course of NSSI.

RESULTS

ACE and HPA axis functioning did not show main but interaction effects in the prediction of NSSI frequency over time: Adolescents with a low severity of ACE and either an increased CAR or a flattened DSL showed a steep decline of NSSI frequency in the first year followed by a subsequent increase of NSSI frequency in the second year.

CONCLUSIONS

Our findings could be interpreted in the sense of high diurnal cortisol concentrations in the absence of ACE being favorable for clinical improvement on the short-term but bearing a risk of allostatic load and subsequent increase of NSSI frequency. In contrast, adolescents with severe ACE may benefit from elevated cortisol concentrations leading to slower but lasting decreases of NSSI frequency.

Psychiatric Risk Factors and Burn Severity in Self-immolation

Self-immolation, a form of self-harm involving setting oneself on fire, is associated with high mortality, morbidity, and healthcare burden. This study aimed to characterize potential clinical correlates and predisposing factors for self-immolation based on burn severity using TBSA percentage scoring. Additional objectives included identifying motivational elements, associated risk factors, and clinical characteristics to optimize patient care and reduce future self-immolation incidents. A retrospective review of admissions to the Arizona Burn Center from July 2015 to August 2022 identified 103 self-immolation patients for the study. Burn severity was categorized as mild to moderate (TBSA < 20%) or severe (TBSA ≥ 20%) based on TBSA. This study population had a mortality rate of 21%. Positive urine drug screens were found in 44% of subjects, and 63% having chronic substance use, with methamphetamine (37%) and alcohol (30%), being the most prevalent. Underlying psychiatric illnesses were present in 83% of patients. Suicidal intent strongly predicted severe burns (P < .001) among the 68 severe burn cases identified. In conclusion, this study emphasizes that the presence of suicidal intent among self-immolation patients significantly correlates with burn severity. These findings highlight the importance of involving psychiatric services early in patient care to improve outcomes and reduce the recurrence of self-immolation acts.

Attentional Biases and Nonsuicidal Self-Injury Urges in Adolescents

Importance

Nonsuicidal self-injury (NSSI) is a significant clinical concern among adolescents. Exposure to NSSI-related content on social media platforms has been suspected to potentially act as a trigger for NSSI.

Objective

To use free-viewing eye-tracking and dot-probe paradigms to examine attentional bias and psychophysiological responses to NSSI-related pictorial and textual stimuli in adolescents with and without a history of NSSI.

Design, Setting, and Participants

From June 2022 to April 2023, adolescent participants in Vienna, Austria with and without a history of NSSI were exposed to NSSI-related stimuli in this nonrandomized controlled trial. Data were analyzed from December 2023 to January 2024.

Exposure

Exposure to NSSI-related stimuli.

Main Outcomes and Measures

During both tasks, subjective arousal, NSSI urges, and autonomic nervous system activity were assessed.

Results

A total of 50 adolescents in 2 groups, 25 who engaged in NSSI (mean [SD] age 15.86 [1.14] years; 19 female participants [76%]) and 25 who did not (mean [SD] age 16.40 [1.71] years; 19 female participants [76%]) were included. Adolescents with a history of NSSI-but not those without a history of NSSI-showed a clear attentional bias toward NSSI-related images during eye-tracking, as indicated by increased initial fixations (500 ms stimulus presentation mean difference, 28.64%; 95% CI, 18.31%-38.98%; P < .001; 1000 ms stimulus presentation mean difference, 18.50%; 95% CI, 9.05%-27.95%; P < .001) and longer fixation durations (500 ms mean difference, 29.51 ms; 95% CI, 4.3-54.72 ms; P < .001; 1000 ms mean difference, 39.83 ms; 95% CI, 6.90-72.76 ms; P < .001), regardless of stimulus duration. This bias was associated with a heightened urge to engage in NSSI (d = 1.22; 95% CI, 0.69-1.73; P < .001), a trend not seen in adolescents without a history of NSSI. Similarly, in the dot-probe task, only the NSSI group showed an attentional bias toward NSSI images but not toward trauma images, emphasizing the specificity of their attentional bias. Physiological measures revealed no significant differences, suggesting that viewing NSSI images is not associated with increased autonomic arousal. Textual NSSI content did not provoke an attentional bias or heighten NSSI urges in either group.

Conclusions and Relevance

In this nonrandomized controlled trial of 50 adolescents, results highlighted a specific attentional bias toward NSSI-related pictorial stimuli in adolescents with a history of NSSI, particularly a difficulty in disengaging from NSSI images. These findings contribute to understanding maladaptive information processing in NSSI and suggest implications for clinical management and cognitive models addressing NSSI triggers.

Trial Registration

German Clinical Trials Register identifier: DRKS00025905.

Pain tolerance as a 'barrier' to nonsuicidal self-injury: A longitudinal study

Theoretical perspectives underscore that low pain tolerance may be a relevant 'barrier' to non-suicidal self-injury (NSSI). However, there is limited longitudinal work on the link between pain tolerance and NSSI, which is needed to assess if pain tolerance precedes NSSI engagement, and/or if NSSI precedes altered pain tolerance. Further, assessing both NSSI frequency and versatility (or number of NSSI methods), in addition to engagement, can provide a more nuanced understanding of the influence of pain on NSSI severity. In the present study, 1125 undergraduate students at a large university (72 % female, Mage = 17.96) reported on their NSSI frequency, NSSI versatility, and perceived pain tolerance. Four individual regressions were run to examine the potential bidirectional nature of the association between NSSI frequency and pain tolerance, and NSSI versatility and pain tolerance. Pain tolerance predicted both NSSI frequency and versatility over time. Neither NSSI frequency nor versatility predicted pain tolerance. Results suggest that high pain tolerance may be a risk factor for severe NSSI engagement.

Diurnal variation of cardiac autonomic activity in adolescent non-suicidal self-injury

Heart rate (HR) and vagally mediated heart rate variability (HRV) are two distinct biomarkers of cardiac autonomic activity. Decreased cardiac vagal activity (or decreased HRV) in particular has been linked with impairments in the functional flexibility of the central autonomic network (CAN), resulting in impaired stress and emotion regulatory capacities. Decreased HRV is widely used as trait marker of psychopathology. Repetitive engagement in non-suicidal self-injury (NSSI) in adolescence correlates with both deficits in stress and emotion regulation, as well as decreased HRV. Existing research has, however, focused on short-term recordings of HR and HRV under resting and phasic conditions. In this study, we examined whether diurnal variation of cardiac autonomic activity, indexed by cosinor parameters of HR and HRV derived from 48 h of ambulatory ECG recording under natural conditions over a weekend, are altered in female adolescents with NSSI disorder compared to controls (HC; N = 30 per study group). Several important confounds, including physical activity, were controlled for. Female adolescents with NSSI show higher rhythm-adjusted 24 h mean levels and greater respective amplitude of HR, as well as lower rhythm-adjusted 24 h mean levels and smaller respective amplitude of HRV. Peak levels in both HR and HRV in the NSSI group were reached approximately 1 h later compared to HC. Severity of exposure to early life maltreatment might be linked with altered amplitudes of 24 h HR and HRV. Diurnal rhythms of cardiac autonomic activity might hold promise as objective indicators of disordered stress and emotion regulation in developmental psychopathology, and as such should be investigated in future studies with rigorous assessment and control of potential confounds.

Microstructural abnormalities of white matter in the cingulum bundle of adolescents with major depression and non-suicidal self-injury

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.

The Prediction Model of Non-Suicidal Self-Injury in Psychiatric Patients Using Decision Tree Analysis

PURPOSE

The prevalence rate of non-suicidal self-injury (NSSI) in the clinical population is higher than that in the community sample, necessitating the need to investigate the predicting factors of NSSI in this group. The present study aimed to develop a prediction model of NSSI among psychiatric patients in Korea.

MATERIALS AND METHODS

Decision tree analysis was conducted on a sample of 224 psychiatric patients. Emotion regulation strategies (rumination, cognitive reappraisal, and expressive suppression), impulsivity, problematic alcohol use, working memory, depressive mood, and gender were included in the model as predictors of NSSI.

RESULTS

Results indicated that rumination, problematic alcohol use, and working memory predicted lifetime NSSI engagement among psychiatric patients. The best predictor of lifetime NSSI engagement was rumination. Specifically, when the level of rumination was high, the level of working memory was lower, and the risk of NSSI was higher. In the case of low levels of rumination, the higher the level of problematic alcohol use, the higher the risk of NSSI. The highest prevalence of lifetime NSSI engagement was found in a subgroup of patients with high levels of rumination and low levels of working memory.

CONCLUSION

The major contribution of this study is finding a combination of factors to predict the high-risk group of NSSI among psychiatric patients in Korea. This study provides evidence on the effect of rumination, working memory, and problematic alcohol use on NSSI. It is suggested that clinicians and researchers should pay more attention to emotion regulation and related vulnerabilities in preventing and treating NSSI.

A study of the interactive mediating effect of ADHD and NSSI caused by co-disease mechanisms in males and females

Background

Non-suicidal self-injury (NSSI), of which the predisposing factors are complex and diverse, profoundly affects the physical and mental health of young people. Therefore, this work established an NSSI intermediary network model considering the interaction of multiple factors. A mediating effect between attention-deficit/hyperactivity disorder (ADHD) and NSSI, considering the influence of comorbidities, such as depression, anxiety, and impulsive personality, was proposed based on sex differences.

Methods

A total of 2,689 middle school students in Ningbo City, Zhejiang Province, China, were randomly sampled and participated in this study. Data regarding their demographic characteristics, attention deficit, hyperactivity/impulsivity, NSSI, anxiety, depression, internet addiction, and other comorbid symptoms were collected and analyzed. After initially screening the data, variables were assessed for significance using a single-factor inter-group difference analytic method, and a binary logistic regression analysis was performed. The intermediary effect of factors influencing NSSI in males and females was also analyzed.

Results

The overall NSSI rate was 15.16%. The results showed that the impact of individual impulsivity characteristics (impulsiveness, the ADHD with hyperactivity/impulsivity subtype) on NSSI behavior was not significant (regression results, P > 0.05). The degree of association between ADHD with attention deficit and ADHD with comprehension deficit subtypes, and other comorbid symptoms (depression, anxiety, and internet addiction disorder) and NSSI, with odds ratios (ORs) of 7.6/6.42/436.68/3.82/1.86, and 95% bootstrap confidence intervals (CIs) of 4.64, 12.87/3.46, 12.67/137.42, 2659.13/2.32, 6.37/1.31, 2.82, respectively. The results also showed significant effects of ADHD subtypes on comorbid symptoms and the path effects of NSSI (P < 0.01). Among them, the mediating effect was the strongest when anxiety was the mediating variable, and the mediating effect of girls was higher than that of boys.

Conclusion

The results of this work demonstrated the influence of ADHD symptoms on NSSI behavior. Among patients with ADHD, patients with subtypes with obvious attention deficit characteristics were more likely to exhibit NSSI behavior, whereas the hyperactive impulse subtype had no direct impact on NSSI. We conclude that adolescent impulsivity may not be directly related to NSSI behavior and that impulsive characteristics jointly affect NSSI behavior through a series of NSSI comorbid symptoms. Notably, the probability of symptom onset and the degree of comorbidity was significantly higher in girls than in boys of the same age, and girls were more prone to NSSI behavior. These findings provide effective theoretical support for the prevention and treatment of adolescent NSSI behavior.

The quest for a biological phenotype of adolescent non-suicidal self-injury: a machine-learning approach

Non-suicidal self-injury (NSSI) is a transdiagnostic psychiatric symptom with high prevalence and relevance in child and adolescent psychiatry. Therefore, it is of great interest to identify a biological phenotype associated with NSSI. The aim of the present study was to cross-sectionally investigate patterns of biological markers underlying NSSI and associated psychopathology in a sample of female patients and healthy controls. Comprehensive clinical data, saliva and blood samples, heart rate variability and pain sensitivity, were collected in n = 149 patients with NSSI and n = 40 healthy participants. Using machine-based learning, we tested the extent to which oxytocin, dehydroepiandrosterone (DHEA), beta-endorphin, free triiodothyronine (fT3), leukocytes, heart rate variability and pain sensitivity were able to classify participants regarding their clinical outcomes in NSSI, depression and borderline personality disorder symptomatology. We evaluated the predictive performance of several models (linear and logistic regression, elastic net regression, random forests, gradient boosted trees) using repeated cross-validation. With NSSI as an outcome variable, both logistic regression and machine learning models showed moderate predictive performance (Area under the Receiver Operating Characteristic Curve between 0.67 and 0.69). Predictors with the highest predictive power were low oxytocin (OR = 0.55; p = 0.002), low pain sensitivity (OR = 1.15; p = 0.021), and high leukocytes (OR = 1.67; p = 0.015). For the psychopathological outcome variables, i.e., depression and borderline personality disorder symptomatology, models including the biological variables performed not better than the null model. A combination of hormonal and inflammatory markers, as well as pain sensitivity, were able to discriminate between participants with and without NSSI disorder. Based on this dataset, however, complex machine learning models were not able to detect non-linear patterns of associations between the biological markers. These findings need replication and future research will reveal the extent to which the respective biomarkers are useful for longitudinal prediction of clinical outcomes or treatment response.

Self- and co-regulation of physiological activity during mother-daughter interactions: The role of adolescent non-suicidal self-injury

BACKGROUND

Non-suicidal self-injury (NSSI) is a significant public health concern that is thought to increase risk for future self-injurious behaviors, including suicide attempts. Notably, NSSI is especially prevalent among adolescents, which underscores a critical need to identify modifiable risk factors that could be targeted to reduce future risk. The current study examined self- and co-regulation of physiological responses during mother-daughter interactions in adolescent girls with and without a history of NSSI.

METHODS

Participants were 60 girls aged 13-17 with (n = 27) and without (n = 33) a history of NSSI and their mothers. Adolescents and their mothers completed positive and negative interaction tasks during which physiological reactivity was assessed via respiratory sinus arrhythmia (RSA).

RESULTS

Using Actor-Partner Interdependence Modeling (APIM), we found that adolescents with an NSSI history demonstrated a higher RSA setpoint than adolescents without this history during the negative, but not positive, interaction task. In addition, there were differences in co-regulation during the negatively valenced interaction, such that mothers of daughters with NSSI were more reactive to fluctuations in their daughters' RSA than mothers of daughters without an NSSI history.

CONCLUSIONS

These findings highlight intra- and interpersonal aspects of physiological dysregulation associated with NSSI that could provide promising targets of intervention to reduce future risk in adolescent girls.

Plasma Endocannabinoid Levels in Patients with Borderline Personality Disorder and Healthy Controls

Borderline personality disorder (BPD) is a highly prevalent psychiatric disorder and presents a complex therapeutic challenge due to limited treatment modalities. Recent focus has converged on the endocannabinoid system (ECS) as a prospective modulator of psychopathological processes in BPD. To address this hypothesis, we analysed plasma endocannabinoid concentrations, specifically anandamide (AEA) and 2-arachidonoylglycerol (2-AG), in a cohort of 49 female BPD patients and 32 matched healthy controls (HC). Additionally, we examined the effect of the FAAH polymorphism rs324420 and correlates with psychopathology. The results indicate heightened AEA levels and, by trend, augmented 2-AG levels within the patient group, as compared to the HC group. Significant between group differences in AEA levels were evident in the CC genotype (FAAH_rs324420) but not in A-allele carriers while the commonly observed difference in AEA levels between A-allele carriers as compared to the CC genotype was not evident in patients. An effect of genotype was found with higher ratings of depression (Beck's depression inventory, BDI-II) in the CC genotype compared to A-allele carriers (FAAH_rs32442), particularly in the patients. Significant alterations in AEA (and by trend in 2-AG) in patients with BPD may relate to compensatory ECS activity. The finding that the effect is most pronounced in CC homozygotes, might point towards a countermeasure to balance physiologically lower baseline AEA levels. The findings warrant further research to develop potentially beneficial psychopharmacological therapies.

Physiological stress reactivity and self-harm: A meta-analysis

OBJECTIVE

Self-harm is associated with alterations in the psychobiological stress response. Specifically, the reactivity of the autonomic nervous system (ANS) and the endocrine hypothalamic-pituitary-adrenal (HPA) axis may differ in individuals who engage in self-harm. However, evidence in this regard is inconsistent.

BACKGROUND

We conducted a preregistered random-effects meta-analysis of sympathetic ANS, parasympathetic ANS, sympathetic-parasympathetic, i.e., mixed-influence ANS, and HPA axis reactivity following laboratory stress exposure in individuals who engage in self-harm and controls. Stress exposure consisted of paradigms using either social-evaluative (e.g., TSST), emotional (e.g., negatively valenced visual stimuli), or physical (e.g., cold pressor test) challenges. A total of 29 studies (self-harm: n = 954, controls: n = 1122, 74% females) were included in the analysis.

RESULTS

Regarding ANS reactivity to stress, no differences emerged between the two groups. However, parasympathetic ANS activity was lower before stress (g = -0.30, CI -0.51 to -0.09) and after stressor cessation (g = 0.54, CI -1.07 to -0.01) in the self-harm group compared to controls. Regarding HPA axis reactivity, individuals who engage in self-harm showed significantly lower cortisol responses to stress than did controls (g = -0.26, CI -0.45 to -0.08). After stressor cessation (i.e., during stress recovery), cortisol was also lower in individuals who engage in self-harm compared to controls (g = -0.26, CI -0.43 to -0.08).

CONCLUSIONS

Lower basal parasympathetic ANS activity and flattened cortisol responses indicate dysregulation of psychobiological stress systems in individuals who engage in self-harm. A better understanding of the psychobiological underpinnings of self-harm may allow for the establishment of biomarkers of risk stratification and treatment monitoring in affected individuals.

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories.

METHODS

The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires.

RESULTS

At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established.

CONCLUSIONS

While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical.

Patterns of experience, expression, and physiology of stress relate to depressive symptoms and self-injurious thoughts and behaviors in adolescents: a person-centered approach

BACKGROUND

Preliminary evidence shows that discordance in stress experience, expression, and physiology (EEP) in adolescents is linked to depression, suicidal ideation (SI), non-suicidal self-injury (NSSI), and brain functioning. This study employs person-centered analysis to probe the relationship between stress responses, psychopathology, and neural patterns in female adolescents who are oversampled for engagement in NSSI.

METHODS

Adolescent females (N = 109, ages 12-17) underwent a social stress test from which self-report measures of stress experience, observer ratings of stress expression, and physiological metrics of stress (via salivary cortisol) were obtained. Multi-trajectory modeling was employed to identify concordant and discordant stress EEP groups. Depressive symptoms, SI and attempt, NSSI engagement, frontal and limbic activation to emotional stimuli, and resting state fronto-limbic connectivity were examined in the EEP groups derived from the multi-trajectory models.

RESULTS

Four groups were identified, three of which demonstrated relatively concordant EEP and one which demonstrated discordant EEP (High Experience-High Expression-Low Physiology). Further, replicating past research, the High Experience-High Expression-Low Physiology discordant group exhibited higher depressive symptoms, SI, suicide attempt, and NSSI episodes (only for sensitivity analyses based on past year) relative to other EEP groups. No significant group differences in brain functioning emerged.

CONCLUSION

Results indicate that within-person, multi-level patterns in stress responding capture risk for dysfunction including depression and self-injurious thoughts and behaviors. Further interrogating of system-level stress functioning may better inform assessment and intervention efforts.

Early Adverse Family Experiences and Elevated Adrenocorticotropic Hormone Predict Non-Suicidal Self-Injury in Females with Non-Psychotic Mental Disorders and Suicidal Ideation

Nonsuicidal self-injurious behavior (NSSI), prevalent in patients with non-psychotic mental disorders (NPMD), is associated with numerous adverse outcomes. Despite active research into the clinical and psychological aspects of NSSI, the underlying biological mechanisms remain obscure. Early adverse experiences are believed to induce long-lasting changes in neuroendocrine mechanisms of stress control playing a key role in NSSI development. The aim of the study was to evaluate parameters potentially predicting development of NSSI in female patients with NPMD and suicidal ideation. Eighty female patients over 18 years with NPMD and suicidal ideation (40 with and 40 without NSSI) and 48 age matching women without evidence of mental illness (healthy controls) were enrolled. Diagnostic interviews and self-report measures were used to assess childhood maltreatment, presence, frequency, and characteristics of suicidal and self-injurious thoughts and behaviors, the Beck Depression Inventory scale to assess severity of depression. Hypothalamic-pituitary-adrenal axis markers, hormones, and neurotrophic factors were measured in blood serum. The likelihood of developing NSSI in patients with NPMD and suicidal ideation was associated with early adverse family history and elevated adrenocorticotropic hormone levels. Dysregulation of hypothalamic-pituitary-adrenal axis as a result of early chronic stress experiences may represent critical biological mechanism promoting the development of NSSI behaviors in patients with NPMD.

Pain before, during, and after nonsuicidal self-injury: Findings from a large web study

Competing models suggest that physical pain may play an important role in nonsuicidal self-injury (NSSI) via pain onset or pain offset, or that pain may be absent (analgesia). Few studies have tested these models in the same sample or examined factors that could explain differences in NSSI pain experience. We assessed 1,630 individuals with NSSI histories in an online survey. We descriptively examined pain during NSSI and tested preregistered hypotheses that NSSI frequency, NSSI severity, borderline personality disorder (BPD) features, emotional pain, and dissociation during NSSI are associated with experiencing less NSSI pain. Exploratorily, we also tested whether self-punishment motives were associated with less NSSI pain. Almost all participants reported recent and frequent NSSI. Participants were heterogenous in their report of NSSI pain. We found minimal support for analgesia (reported by only 4.3% of participants). More participants reported pain onset than offset, but offset was associated with reductions in emotional pain. Emotional pain was elevated prior to NSSI and decreased significantly during and after NSSI. We found that higher dissociation during NSSI was associated with less NSSI pain. Contrary to hypotheses, NSSI severity, emotional pain prior to NSSI, and self-punishment motives were associated with greater NSSI pain. NSSI frequency and BPD features were not associated with NSSI pain. BPD features interacted with dissociation and emotional pain prior to NSSI. Findings contrast with laboratory pain induction work, suggesting that, though people who self-harm may have heightened pain tolerance, they may seek to self-injure in a manner that results in pain. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Physiological response to pain in female adolescents with nonsuicidal self-injury as a function of severity

BACKGROUND

Preliminary evidence indicates altered hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS) response to experimental pain in individuals with nonsuicidal self-injury (NSSI). This study investigated effects of NSSI severity and severity of psychopathology on the HPA axis and ANS response to pain.

METHODS

N = 164 adolescents with NSSI and n = 45 healthy controls received heat pain stimulation. Salivary cortisol, α-amylase and blood pressure were repeatedly assessed before and after painful stimulation. Heart rate (HR) and heart rate variability (HRV) were assessed continuously. NSSI severity and comorbid psychopathology were derived from diagnostic assessments. Main and interaction effects of time of measurement and NSSI severity, adjusted for severity of adverse childhood experiences, borderline personality disorder and depression, on HPA axis and ANS response to pain were examined using regression analyses.

RESULTS

Increasing NSSI severity predicted an increasing cortisol response (χ2(3) = 12.09, p = .007) to pain. After adjusting for comorbid psychopathology, greater NSSI severity predicted decreased α-amylase levels following pain (χ2(3) = 10.47, p = .015), and decreased HR (χ2(2) = 8.53, p = .014) and increased HRV(χ2(2) = 13.43, p = .001) response to pain.

LIMITATIONS

Future research should implement several NSSI severity indicators, potentially revealing complex associations with the physiological response to pain. Assessing physiological responses to pain in NSSI in a naturalistic setting presents a promising avenue for future research in NSI.

CONCLUSIONS

Findings indicate an increased pain-related HPA axis response and an ANS response characterized by reduced sympathetic and increased parasympathetic activity associated with NSSI severity. Results support claims for dimensional approaches to NSSI and its related psychopathology alongside shared, underlying neurobiological correlates.

The development of Non-Suicidal Self-Injury (NSSI) during adolescence: A systematic review and Bayesian meta-analysis

BACKGROUND

Despite a surge in research on self-injury in the last decade, a summary of research findings about the development of Non-Suicidal Self-Injury (NSSI) over time in community youth samples is not yet present in the scientific literature. This study aims to summarize the empirical literature on this topic, examining both the occurrence (Study 1) and frequency (Study 2) of NSSI over time, and for this reason, a Systematic Review and Bayesian Meta-Analysis were conducted.

METHODS

Following the PRISMA guidelines, the longitudinal studies included in the systematic review consisted of 41 papers (Study 1 = 16; Study 2 = 25). Only studies with available data were included in the meta-analysis (Study 1 = 12; Study 2 = 11).

RESULTS

First, the findings highlight limits related to methodological aspects, the design of the studies, and the availability of data. Meta-analytic results shows that across development, the frequency (i.e., not the occurrence) of NSSI increases for the group of younger adolescents, remains stable in the group of middle adolescents, and it decreases for older adolescents.

LIMITATIONS

This study highlights some limitations that can be summarized in three different macro categories: the first refers to methodological aspects (e.g., the lifetime prevalence of NSSI), the second to the design of the studies (e.g., not homogeneous cohort; short-term covered), and the third to the availability of data.

CONCLUSIONS

The current meta-analysis tries to shed light on the longitudinal research on NSSI behavior and how this behavior develops in terms of both occurrence and frequency, providing practical and methodological indications for future research.

Stress-induced alterations in resting-state functional connectivity among adolescents with non-suicidal self-injury

BACKGROUND

Non-suicidal self-injury (NSSI) is a major mental health problem among youth worldwide. Dysfunction in emotion regulation contributes to NSSI, but research on the underlying neurobiological mechanisms of NSSI is limited. Adolescents with emotion regulation difficulties are vulnerable to stress, making them susceptible to maladaptive coping mechanisms such as NSSI.

METHODS

This study examined the functional neurocircuitry relevant to emotion regulation and stress coping in individuals with NSSI compared with healthy controls. This case-control study included 34 adolescents with NSSI (15.91 years) and 28 (16.0 years) unaffected controls. Participants underwent a functional magnetic resonance imaging scan before and after completing a laboratory stress-induction paradigm (the Montreal Imaging Stress Test). The effects of stress induction were quantified by both physiological measures and self-reports.

RESULTS

Participants with NSSI showed distinctive alterations in functional resting-state following stress induction, which differentiated them from unaffected controls. Results show a reduction in functional connectivity between frontoparietal regions and the angular gyrus within the patient group compared to controls, as well as an increase in functional connectivity between visual regions, the insular cortex, the planum polare, and the central opercular cortex. After conditions of acute stress, adolescents with NSSI show changes in functional connectivity of regions associated with sensorimotor alertness, attention, and effortful emotion regulation.

LIMITATIONS

The patient group showed both NSSI and suicidal behavior, therefore results might be partly due to suicidality.

CONCLUSION

The findings emphasize the importance of targeting emotion regulation within therapeutic approaches to enhance stress coping capacity, which in turn may contribute to counteracting self-injurious behavior.

Prefrontal oxygenation varies as a function of response inhibition performance in healthy participants but not in youth with non-suicidal self-injury

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.

Methylation of the Glucocorticoid Receptor Gene (NR3C1) in Adolescents with a History of Childhood Adversity Engaging in Non-Suicidal Self-Injury

INTRODUCTION

Non-suicidal self-injury (NSSI) is a large phenomenon among adolescents, and adverse childhood experiences (ACEs) are a major risk factor in its development. Malfunctioning of the hypothalamus-pituitary-adrenal (HPA) axis has been repeatedly reported for ACE as well as for NSSI. The glucocorticoid receptor (GR) is essential for the correct functioning of the HPA axis, thus alterations in the expression of the GR through altered methylation of the GR gene (NR3C1) (and more specifically exon 1F) might contribute to the development of NSSI in individuals with a history of ACEs, as has been reported for different other mental disorders.

METHODS

In this case-control study, we compared the methylation levels of exon 1F of the GR gene (NR3C1-1F) in adolescents with engagement in NSSI (n = 67) and a healthy control group (HC; n = 47). We preserved buccal swabs and used a mass spectrometry-based method called EpiTYPER for analyzing mean methylation of NR3C1-1F.

RESULTS

Adolescents in the NSSI group reported significantly more ACEs. The mean methylation level was about 3% in both groups with no significant group differences. Furthermore, no significant relation was found between ACE and methylation of NR3C1-1F, neither in the overall sample nor in the NSSI or HC group.

CONCLUSION

Our results are contradictory to previous research showing an increased methylation in individuals with ACE. Regarding relations between methylation of NR3C1-1F and mental disorders, previous studies reported inconsistent findings. Our study points to NSSI being either unrelated to methylation of NR3C1-1F or to yet not identified moderators on relations between methylation of NR3C1-1F and engagement in NSSI during adolescence.

Non-suicidal self-injury in Chinese population: a scoping review of prevalence, method, risk factors and preventive interventions

Non-suicidal self-injury behavior (NSSI) is a serious public health concern that requires immediate attention. Despite the high prevalence of NSSI among the Chinese population, there is a significant gap in research on the comprehensive picture of this field. Therefore, a scoping review was conducted to investigate the prevalence, methods, risk factors, and preventive intervention programs related to NSSI in China. The review found that the estimated lifetime prevalence of NSSI among Chinese youth population is alarmingly high at 24.7% (N = 1,088,433). Common methods of NSSI include scratching, hitting, and biting. Additionally, the review synthesized 249 risk factors based on the biopsychosocial-ecological framework, highlighting the urgent need for intervention. However, only 12 empirical studies focus on NSSI prevention or intervention programs were included. These findings underscore the necessity for more clinical practices and larger studies to identify effective interventions and ultimately alleviate the burden of NSSI on the Chinese population.

Funding

This review was supported by Humanity and Social Science Youth foundation of Ministry of Education (22YJCZH018), Science and Technology Innovation 2030 (STI2030-Major Projects:2021ZD0200702), National Natural Science Foundation of China (81825009), and Shuimu Tsinghua Scholar. No funding agencies were involved in the data collection, data analysis, and writing of this paper.

Neural Reactivity to Social Punishment Predicts Future Engagement in Nonsuicidal Self-injury Among Peer-Rejected Adolescents

BACKGROUND

Rates of nonsuicidal self-injury (NSSI) increase dramatically in adolescence. Affective reactivity and adverse social experiences have been linked to NSSI, but less is known about whether these factors may separately or interactively predict NSSI, especially longitudinally. This study combined functional magnetic resonance imaging and a sociometric measure to test whether a combination of neural (e.g., amygdala) reactivity to social punishment and peer-nominated peer acceptance/rejection predicts NSSI longitudinally in adolescence. Amygdala reactivity was examined as a potential neural marker of affective reactivity to social punishment, which may heighten NSSI risk in contexts of social adversity.

METHODS

One hundred twenty-five adolescents (63 female) completed a social incentive delay task during neuroimaging and school-based peer nominations to measure peer acceptance/rejection. NSSI engagement was assessed at baseline and 1-year follow-up.

RESULTS

Greater amygdala reactivity to social punishment predicted greater NSSI engagement 1 year later among adolescents with high peer rejection. This effect for the amygdala was specific to social punishment (vs. reward) and held when controlling for biological sex and pubertal development. Exploratory analyses found that ventral striatum reactivity to social reward and punishment similarly interacted with peer rejection to predict NSSI but that amygdala connectivity with salience network regions did not.

CONCLUSIONS

Amygdala reactivity to social punishment, in combination with high peer rejection, may increase NSSI risk in adolescence, possibly via heightened affective reactivity to adverse social experiences. Objective measures of neurobiological and social risk factors may improve prediction of NSSI, while therapeutic approaches that target affective reactivity and increase prosocial skills may protect against NSSI in adolescence.

Clinical Trajectories in Adolescents with and without a History of Non-Suicidal Self-Injury: The BRIDGES Longitudinal Study

Background

Non-suicidal self-injury (NSSI) is a highly prevalent clinical concern in adolescents and is associated with impaired functioning and suicide risk. The BRIDGES (BRain Imaging Development of Girls' Emotion and Self) study was designed to collect longitudinal clinical and neurobiological data to advance our understanding of NSSI in adolescents. The purpose of this paper is to describe the clinical data collected as part of this study, including psychiatric diagnoses, depression symptoms, episodes of non-suicidal self-injury, suicidal thoughts and behaviors, childhood trauma, and personality domains.

Methods

The baseline sample included 164 adolescents aged 12-16 assigned female at birth (Mean age = 14.97, SD = 1.20) with NSSI histories ranging from none to severe. Participants and their parent/guardian were invited to provide data at three time points spaced approximately one year apart. Descriptive analyses were conducted to provide estimates of rates and trajectories of clinical data.

Results

Of the 164 study participants, 75.61% and 57.93% completed the second and third time points, respectively. Visual inspection of the data suggests an overall trend of decreasing severity of psychopathology over time, and adolescents with a history of NSSI appeared to have higher rates of psychopathology than those without.

Conclusions

This paper describes longitudinal clinical trajectories in adolescents with a range of NSSI histories and presents readers with an overview of the rich, publicly available dataset that we hope will inspire future research to advance the understanding of the neurodevelopmental trajectories associated with NSSI, depression, and suicide risk.

Adolescent non-suicidal self-injury during the COVID-19 pandemic: A prospective longitudinal study of biological predictors of maladaptive emotion regulation

BACKGROUND

Non-suicidal self-injury (NSSI) in adolescence is thought to stem from interactions between vulnerability in developing biological systems and experience of stressors. The current study assesses whether multiple levels of the stress system's response to threat could prospectively predict NSSI engagement during the COVID-19 pandemic, a shared, time-locked stressor.

METHODS

Participants were 64 female adolescents (ages 12-16) from community and clinical settings who were oversampled for NSSI histories. Prior to the onset of the COVID-19 pandemic, adolescents completed a protocol that measured hypothalamic-pituitary-adrenal axis response to a social stressor (via salivary cortisol), amygdala volume, amygdala emotion-evoked activation, and frontolimbic resting-state functional connectivity. During early months of the pandemic (Summer 2020), measures of NSSI behavior (Inventory of Statements About Self-Injury), emotion regulation difficulties (Difficulties in Emotion Regulation Scale), perceived stress (Perceived Stress Scale), and pandemic-related stressors (Epidemic Pandemic Impacts Inventory) were collected. Multinomial logistic regression was used to assess if pre-pandemic biomarkers predicted mid-pandemic NSSI engagement: persistence of NSSI (Persist; N = 21), cessation of NSSI (Desist; N = 26), and no history of NSSI (Never; N = 17). Linear regressions explored if pre-pandemic biomarkers predicted mid-pandemic difficulties in emotion regulation and perceived stress.

RESULTS

Higher pre-pandemic overall cortisol response to stress and amygdala emotion-evoked activation characterized adolescents who persisted in NSSI, compared to those who desisted. These findings remained significant when controlling for pandemic related stressors. Lower prepandemic cortisol reactivity predicted more difficulties in emotion regulation during the pandemic. This finding did not remain significant after controlling for pandemic related stressors.

CONCLUSIONS

Findings suggest that patterns in key biological threat response systems may confer vulnerability for risk outcomes including NSSI engagement in adolescent females in the context of a shared, novel, naturally-occurring stressor. The results point to the importance of multi-level, longitudinal approaches for understanding the interface between developing neurobiological systems and experiential stress in at-risk adolescents. Identified patterns give insight into potential risk assessment strategies based on an understanding of the multi-level threat response.

Resting-state functional connectivity predicting clinical improvement following treatment in female adolescents with non-suicidal self-injury

BACKGROUND

Non-suicidal self-injury (NSSI) is highly prevalent among adolescents and predicts future psychopathology including suicide. To improve therapeutic decisions and clinical outcome of patients engaging in NSSI, it seems beneficial to determine neurobiological markers associated with treatment response. The present study investigated whether resting-state functional brain connectivity (RSFC) served to predict clinical improvements following treatment in adolescents engaging in NSSI.

METHODS

N = 27 female adolescents with NSSI took part in a baseline MRI exam and clinical outcome was assessed at follow-ups one, two and three years after baseline. During the follow-up period, patients received in- and/or outpatient treatment. Mixed-effects linear regression models were calculated to examine whether RSFC was associated with clinical improvement.

RESULTS

Patients' clinical outcome improved across time. Lower baseline RSFC between left paracentral gyrus and right anterior cingulate gyrus was associated with clinical improvement from baseline to one-year and from two-year to three-year follow-up. Lower and higher baseline RSFC in several inter- and intrahemispheric cortico-cortical and cortico-subcortical connections of interest were associated with clinical symptomatology and its severity, independent from time.

LIMITATIONS

A relatively small sample size constrains the generalizability of our findings. Further, no control group not receiving treatment was recruited, therefore clinical changes across time cannot solely be attributed to treatment.

CONCLUSIONS

While there was some evidence that RSFC was associated with clinical improvement following treatment, our findings suggest that functional connectivity is more predictive of severity of psychopathology and global functioning independent of time and treatment. We thereby add to the limited research on neurobiological markers as predictors of clinical outcome after treatment.

An RDoC-based approach to adolescent self-injurious thoughts and behaviors: The interactive role of social affiliation and cardiac arousal

Recent theoretical models have posited that increases in self-injurious thoughts and behaviors (SITBs) during adolescence may be linked to failures in biological stress regulation in contexts of social stress. However, there is a lack of data examining this hypothesis during the transition to adolescence, a sensitive period of development characterized by changes across socioaffective and psychophysiological domains. Building on principles from developmental psychopathology and the RDoC framework, the present study used a longitudinal design in a sample of 147 adolescents to test whether interactions among experiences of social (i.e., parent and peer) conflict and cardiac arousal (i.e., resting heart rate) predicted adolescents' engagement in SITBs (i.e., nonsuicidal self-injury, NSSI; and suicidal ideation; SI) across 1-year follow-up. Prospective analyses revealed that adolescents experiencing a combination of greater peer, but not family, conflict and higher cardiac arousal at baseline showed significant longitudinal increases in NSSI. In contrast, social conflict did not interact with cardiac arousal to predict future SI. Findings indicate that greater peer-related interpersonal stress in adolescents may increase risk for future NSSI among youth with physiological vulnerabilities (i.e., higher resting heart rate) that may be markers of maladaptive stress responses. Future research should examine these processes at finer timescales to elucidate whether these factors are proximal predictors of within-day SITBs.