The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: a review

Body detachment in response to emotions: Evidence from a rubber hand illusion study in adolescent patients with non-suicidal self-injurious behavior and dissociative symptoms

Previous studies have proposed a connection between dissociation and the sense of body ownership, and initial evidence suggests that emotions could modulate this relationship. Here we aimed to investigate how differently arousing emotions influence the malleability of the bodily self. This study included 50 adolescent psychiatric patients with non-suicidal self-injurious behavior (NSSI)-who were divided into low-dissociation and high-dissociation groups-along with 25 healthy controls. Participants completed six trials of the rubber hand illusion while listening to neutral, sad, or fearful vocalizations. Heart rate, skin conductance level, and non-specific skin conductance responses were concomitantly measured. After each trial, participants completed the rubber hand illusion questionnaire as a subjective illusion measure, and acute dissociation, mood, and proprioceptive drift were assessed. Overall, the NSSI high-dissociation group reported the highest subjective illusion under all conditions. Additionally, fearful vocalizations resulted in a stronger subjective illusion than the neutral condition in the NSSI low-dissociation group, but not in the NSSI high-dissociation and healthy control groups. The NSSI low-dissociation group showed a higher proprioceptive drift than the NSSI high-dissociation group. Moreover, acute dissociation was positively related to subjective illusion, but not related to proprioceptive drift. In conclusion, body detachment in response to emotions may be responsible for the malleability of the sense of body ownership. This finding highlights the need for clinical interventions to stabilize self-experiences during emotional situations, especially in patients with dissociative symptoms.

Role of attachment style in the association between childhood adversities and non-suicidal self-injury among young adults: a multigroup structural equation study

Background

Non-suicidal self-injury (NSSI) is a significant health concern among adolescents and young adults, often resulting from adverse childhood experiences (ACEs). Dissociation, post-traumatic symptoms and attachment style may have a role in shaping such associations.

Aims

This study aims to provide a unified model of the impact of ACEs on NSSI, exploring complex post-traumatic stress disorder (cPTSD) symptoms and dissociation as potential mediators and the role of the predominant attachment style in affecting such associations.

Methods

1010 young individuals attending the last year of high school participated in this cross-sectional study. ACEs, cPTSD, dissociation and NSSI were evaluated using self-report questionnaires. We fitted a path model of NSSI, with ACEs as exogenous variables and cPTSD and dissociation as sequential mediators. Secure, fearful and preoccupied attachment styles were modelled as grouping variables.

Results

Our findings showed that dissociation mediated the impact of ACEs on NSSI in subjects with a fearful attachment style, as opposed to those with a preoccupied attachment for whom cPTSD symptoms mediated the ACEs-NSSI association.

Conclusions

Attachment styles moderate the relationship between ACEs and NSSI, with either dissociation or post-traumatic symptomatology mediating the impact of ACEs on NSSI, depending on the predominant attachment style. Our results highlight the importance of attachment as a pathway modifier in the relationships between different psychopathology dimensions, providing a useful framework to better conceptualise the ACEs-NSSI association.

Interpersonal Sensitivity and Social Problem-Solving in Adolescents with Suicide Attempts or Non-suicidal Self-Injury

OBJECTIVE

Interpersonal dysfunction robustly predicts suicide attempts (SA) and non-suicidal self-injury (NSSI) in adolescents. We sought to better elucidate how two interpersonal constructions (interpersonal sensitivity and social problem-solving strategies) may lead to NSSI vs. SA in adolescents.

METHOD

We compared non-overlapping groups of adolescents engaged in either SA (n = 49, Mage = 15.80, SD = 1.23, 63% female) or NSSI (n = 50, Mage = 15.35, SD = 1.34, 82% female), and healthy controls (HC; n = 43, Mage = 15.46, SD = 1.30, 61% female). We hypothesized: (1) greater interpersonal sensitivity and deficits in social problem-solving strategies would differentiate the three groups and indicate higher risk for being in the NSSI and SA groups, relative to the HC groups, and (2) amongst clinical groups, there would be greater deficits in social problem-solving in the SA group, and greater interpersonal sensitivity in the NSSI group.

RESULTS

NSSI and SA groups demonstrated more interpersonal sensitivity and lower (i.e., worse) social problem-solving skills vs. HCs. Participants were more likely to be in both the SA and NSSI groups based on interpersonal sensitivity (ORSA = 2.61; ORNSSI = 2.75) and social problem-solving (ORSA = 19.11; ORNSSI = 10.89). Significant differences were observed between the NSSI and SA groups on interpersonal sensitivity [t(97) = 4.28, p < .001, d = 0.86; higher levels in the NSSI group], but not on social problem-solving [t(97) = 1.97, p = .052, d = 0.40].

CONCLUSIONS

Both greater interpersonal sensitivity and challenges in social problem-solving predict NSSI and suicidal behavior in adolescents, and interpersonal sensitivity may be a particularly salient risk factor for NSSI. Implications for treatment and future research are discussed.

Non-suicidal self-injury and anorexia nervosa: A systematic scoping review

OBJECTIVES

Psychiatric comorbidities are frequent in anorexia nervosa, non-suicidal self-injury being one of the more frequent. The aim of this study was to review the literature exploring the links between these disorders and thus to improve our understanding of their causality, risks, and consequences.

METHOD

We used electronic searches in Pubmed, Cochrane, PsychInfo, and Web of Science to conduct a systematic scoping review of the publications dealing with the association between non-suicidal self-injury and anorexia nervosa published through November 2023.

RESULTS

The study finally included thirty-three studies, mainly of female adolescents and young women, and most frequently from an epidemiological perspective. The results confirmed a frequent association between non-suicidal self-injury and anorexia nervosa, and a significantly higher prevalence of such self-injury in the anorexia subtype involving binge-eating/purging than in the purely restrictive subtype. This result appears to confirm an earlier finding that only the diagnosis of anorexia nervosa with binge-eating/purging behaviours predicts the occurrence of non-suicidal self-injury during eating disorder. In addition, results reported that the risks of psychiatric comorbidities and of suicide were higher and that the treatment of anorexia was longer and the weight gain slower in those patients.

CONCLUSIONS

This study confirmed the association between these two disorders which makes their management more complex. More rapid identification of non-suicidal self-injury in anorexia nervosa and a better understanding of its underlying psychopathological processes are needed to propose appropriate multidisciplinary care. More systematic studies on the associations between these disorders are essential.

Complex PTSD and identification with the aggressor among survivors of childhood abuse

BACKGROUND

Childhood abuse (CA) is a risk factor for trauma-related disorders including posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD). This severe form of interpersonal trauma may result in "identification with the aggressor" (IWA), in which the individual may take on the beliefs, perspectives, and behaviors of the perpetrator. Although previous evidence suggests that IWA may be particularly related to CPTSD as compared to PTSD, there has been no study that investigated this hypothesis.

OBJECTIVE

The current study explored the relations between IWA and PTSD and CPTSD symptoms, and the contribution of IWA to the excess probability of PTSD and CPTSD classifications, as compared to no classification.

PARTICIPANTS AND SETTING

This cross-sectional study was conducted among 320 Israeli adult CA survivors aged 21-63 (M = 42.04, SD = 10.81).

METHODS

An online survey was completed by a convenience sample of adult CA survivors.

RESULTS

Replacing one's agency with that of the perpetrator as part of IWA had a significant effect on both PTSD and CPTSD symptoms (ES = 0.36 and 0.24, respectively), and served as a risk factor for both PTSD and CPTSD classifications. Moreover, analysis of the models' predicted values reveals that the predicted probability of CPTSD classification was 3 to 5 times higher than on the probability of PTSD classifications, for low to high values of the replacing one's agency scale, respectively.

CONCLUSIONS

The current findings suggest that IWA may describe some of the deep and long-lasting detriments of CA on self, and may contribute to the development of CPTSD symptoms.

Self-harm, Suicide, and ICD-11 Complex Posttraumatic Stress Disorder in Treatment-Seeking Adolescents with Major Depression

Posttraumatic stress disorder (PTSD) is linked with self-harm and suicide, but few studies have examined these severe outcomes in relation to complex trauma. This study examined the associations between self-harm and suicide-related phenomena with ICD-11 complex PTSD (CPTSD) among treatment-seeking youths. A convenience sample of 109 adolescents with major depression (69.7% female; mean age = 15.24) were recruited from an outpatient psychiatric clinic. Participants completed measures for ICD-11 CPTSD, adverse childhood experiences (ACEs), self-harm behaviors, and past-year history of four suicide-related phenomena. Relationships between each self-harm and suicide-related variable with CPTSD were assessed at the symptom and diagnostic levels. Participants reported an average of three ACEs; 33.9% met diagnostic requirements for ICD-11 CPTSD. Past-year suicidal thought and attempt, but not self-harm, significantly associated with CPTSD status. At the symptom level, self-harm associated with CPTSD total symptom and all symptom clusters scores, with strongest associations found with symptoms of negative self-concept. CPTSD total symptom scores also associated strongly with past-year history of suicidal thought, plan, and attempt; the three core PTSD symptom clusters scores consistently and strongly linked with these suicide-related phenomena. For symptoms of complex trauma, relationship disturbances associated with having a suicide attempt, and negative self-concept associated with both having a plan and an attempt. Assessing and targeting ICD-11 CPTSD symptoms have potential to reduce self-harm and suicidality in young people experiencing mental distress, particularly for those with a trauma history and regardless of whether they meet criteria for a diagnosable trauma response.

A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder

Background: While there are well-established treatments for post-traumatic stress disorder (PTSD), these interventions appear to be less effective for individuals with comorbid borderline personality disorder (BPD) symptoms. Dialectical Behavior Therapy (DBT) for PTSD and DBT Prolonged Exposure (PE) are both effective interventions for treating these patients, but a comprehensive analysis evaluating the efficacy of these two interventions is lacking.Objective: To determine the effect sizes of PTSD-specific DBT treatments.Methods: We conducted a systematic review and pre-registered meta-analysis of the DBT literature for treating PTSD (osf.io/62rfq). Eligible trials and treatment evaluations published before September 2023 were searched in SCOPUS, PubMed, and the Cochrane Library databases. Thirteen articles were identified, and data were extracted for primary (PTSD symptoms) and secondary outcomes (BPD, depression, dissociation, non-suicidal self-injury [NSSI]). Treatment effects were calculated for randomised controlled trials, controlled clinical trials, and pre-post evaluations.Results: Overall, the studies involved 663 participants. Compared with control groups, PTSD-specific DBT treatments showed moderate effects in reducing PTSD symptom severity g = -0.69 (95% CI -1.03 to -0.34, p < .001) and depression g = -0.62 (95% CI -1.13 to -0.12, p = .016). Moreover, the pre-post changes showed an overall effect size for dissociative symptoms of g = -0.72 (95% CI -1.05 to -0.40, p < .001), for BPD-associated symptoms of g = -0.82 (95% CI -1.06 to -0.59, p < .001), and for NSSI frequency (g = -0.70, 95% CI -1.12 to -0.28, p = .001).Conclusions: Based on the results of our meta-analysis, DBT-PTSD and DBT PE were effective in reducing PTSD symptom severity and comorbid depressive symptoms. Further research on stage-based treatments should focus on systematically assessing NSSI, BPD symptoms, and suicidality.

Unwanted Pursuit Behavior Victimization as a Predictor of Engagement in Nonsuicidal Self-Injury

While prior research has studied associations between child abuse and nonsuicidal self-injury (NSSI), there is limited research assessing unwanted pursuit behavior (UPB) victimization and NSSI. In addition, few studies have assessed the self-reported functions of NSSI among survivors of violence. Among a sample of 18-25-year-old young adults (N = 333), both UPB victimization and child abuse were significantly associated with NSSI frequency. In regression models, UPB victimization was associated with increased use of affect regulation, antidissociation/feeling-generation, self-punishment, and antisuicide functions, while child abuse was associated only with antidissociation/feeling-generation and self-punishment. Affect regulation mediated the association between UPB victimization and NSSI frequency, but not the association between child victimization and NSSI frequency. Implications for research and clinical practice will be discussed.

The mediating effects of school bullying victimization in the relationship between childhood trauma and NSSI among adolescents with mood disorders

BACKGROUND

Nonsuicidal self-injury (NSSI) is a serious problem in the adolescent population worldwide. Childhood trauma and bullying have been identified as risk factors for NSSI. We explored the relationships among Childhood trauma, Bullying victimization and the severity of NSSI behaviours, and test the effect of Bullying victimization in mediating the association between Childhood trauma and the NSSI behaviours.

METHODS

A total of 123 adolescents were recruited. They were diagnosed with depression or depressive episodes of bipolar disorder and had experienced NSSI in the last year. They were assessed using the Chinese version of the Childhood Trauma Questionnaire (CTQ-C), the Revised Olweus Bullying Victimization Questionnaire (OBVQ-R), and the Adolescent Self-Harm Questionnaire (ASHQ).

RESULTS

Females presented a significantly greater prevalence of sexual abuse and relationship bullying than boys. Individuals in the younger age group (10-14 years) presented a greater incidence of emotional neglect, verbal bullying, relationship bullying, and total bullying, and their NSSI score was also higher than that of those in the older age group (15-19 years). Only children show a greater prevalence of sexual abuse than nononly children. Single-parent families scored higher on emotional abuse, emotional neglect, physical neglect and physical bullying than two-parent families. There was a significant positive correlation between each dimension of childhood trauma and all the dimensions of bullying, between childhood trauma and NSSI, and between bullying and NSSI. Childhood trauma can not only directly affect the severity of NSSI but also indirectly aggravate the severity of NSSI through bullying victimization. The mediating effects of bullying victimization on emotional abuse, physical abuse, emotional neglect and physical neglect were 14%, 21%, 20%, 13% and 20%, respectively.

CONCLUSION

There was a significant positive correlation between childhood trauma and bullying, between childhood trauma and NSSI, and between bullying and NSSI. Childhood trauma can not only directly affect the severity of NSSI but also indirectly aggravate the severity of NSSI through bullying victimization. Bullying victimization played the partial mediating effects between Childhood trauma and NSSI.

Associations among posttraumatic stress disorder symptoms, suicidal ideation, suicide attempts, and reward discounting

Posttraumatic stress disorder (PTSD) is associated with suicidal thoughts and behaviours. Decision-making processes and risk-taking are prominent for coping in both, but the implications for guaranteed and probabilistic reward discounting, important components in behavioural decision-making processes, are unclear. This study explored the relationships between PTSD and suicide risk with tendencies towards devaluing guaranteed rewards that are larger but delayed (i.e., delay discounting; DD) and devaluing larger but uncertain rewards (i.e., probability discounting; PD) for immediate but smaller rewards. The current study evaluated 498 participants (majority male [51.4%] and white [63.8%]; 33.3% screening positive for probable PTSD; 19.2% with lifetime suicide attempts; 30.8% with recent suicide ideation) on both delayed discounting and PD tasks. Provisional PTSD diagnosis, but not suicide attempts or ideation, was associated with increased PD (i.e., more devaluation of uncertain rewards). Conversely, PTSD interacted with both attempt history and ideation to predict increased delayed discounting (i.e., more devaluing of greater but delayed rewards). These results highlight how those with PTSD symptoms assign valuations to rewards, as well as how the addition of suicide risk interacts to impact these decision-making processes. While further research is needed, this suggests potential implications for treatment as they may benefit from structuring progress in smaller, more immediate goals.

Trauma Exposure Moderates the Link Between Cognitive Flexibility and Suicide Risk in Pre-Adolescent Children

OBJECTIVES

Trauma exposure (TE) and cognitive flexibility (CF) are risk factors for self-injurious thoughts and behaviors (SITBs). However, it is unknown whether these risk factors contribute to mechanisms associated with distinct categories of SITBs. The current study examined the potential moderating role of TE in the relationships between CF and multiple SITBs, including active suicidal ideation (SI), passive SI, non-suicidal self-injury (NSSI), and history of suicide attempt (SA), among pre-adolescent children.

METHODS

A total of 11,326 children from the Adolescent Brain Cognitive Development study were included in the present study. SITBs and TE were measured by the Kiddy Schedule for Affective Disorder and Schizophrenia (KSADS). CF was measured using the NIH Cognitive Toolbox.

RESULTS

Cumulative TE moderated the relationship of CF to active SI. Higher CF was associated with lower odds of current SI in children with a single lifetime TE, but not in children without trauma or with two or more TE. As a main effect, two or more TE predicted higher odds of active SI, passive SI, and lifetime SA, but not NSSI. Higher CF was associated with lower odds of passive SI, with effects not moderated by trauma exposure.

CONCLUSION

The current results clarify previously inconsistent findings about the relationship of CF to SI by identifying cumulative TE as a moderator. CF served as a protective factor against SI, but only in children with a single lifetime trauma. Implications for screening and treatment targets of children at risk for distinct categories of SITBs are discussed.

The relationship between childhood maltreatment and self-harm: the mediating roles of alexithymia, dissociation, internalizing and posttraumatic symptoms

Background: Although childhood maltreatment is associated with later self-harm, the mechanism through which it might lead to self-harm is not completely understood. The purpose of this study was to examine the roles of alexithymia, dissociation, internalizing and posttraumatic symptoms in the association between exposure to childhood maltreatment and subsequent self-harm.Methods: A total of 360 adolescents were asked to complete the Childhood Trauma Questionnaire, the Toronto Alexithymia Scale, the Dissociative Experience Scale, the Somatoform Dissociation Questionnaire-20, the Posttraumatic Stress Checklist for DSM-5, and the Deliberate Self-Harm Inventory.Results: Results of structural equation modelling analysis revealed the significant mediation effects of alexithymia and dissociative symptoms in the relationship between childhood maltreatment and self-harm, while internalizing and posttraumatic symptoms did not significantly mediate.Conclusion: The findings indicate that alexithymia and dissociative symptoms may be proximal mechanisms linking maltreatment exposure and adolescence self-harm.

Depressive symptoms and neuroticism mediate the association between traumatic events and suicidality - A latent class mediation analysis of UK Biobank Database

BACKGROUND

Mental disorders that follow traumatic experience may increase risk of suicidality, but a comprehensive approach to understand how these mental disorders mediate the association between psychological traumatic experience and suicidality should be elucidated. In this study, we attempted to provide comprehensive evidence on how depressive symptoms and neuroticism can mediate the association between psychological traumatic experiences and suicidal behaviours including suicidal ideation, suicidal planning, and suicide attempts.

METHODS

We analyzed 111,931 participants from UK Biobank who had completed mental health web-based questionnaire from 2016 to 2017. "Self-harm and suicidal behaviour and ideation (SSBI) score" was calculated by the response from suicidal behaviours and self-harm questionnaires. Conducting multivariate linear regression, depressive symptoms, anxiety symptoms, and neuroticism were selected as potential mediators. We constructed a latent class mediation model estimated direct effect of psychological traumatic events on suicidality and indirect effect of psychological traumatic events mediated by depressive symptoms and neuroticism.

RESULTS

Psychological traumatic events were positively associated with suicidal behaviours. Depressive symptoms and neuroticism significantly mediated the effect of psychological traumatic events on suicidality. Anxiety symptoms did not mediate the association between psychological traumatic events and suicidality.

CONCLUSION

Psychological traumatic events, irrespective of life stage of occurrence, are associated with suicidality. The association between psychological traumatic events and suicidality can be partially explained by depressive symptoms and neuroticism of those who were exposed to psychological trauma.

The role of Theory of Mind in the transition towards suicidal attempts in youth NSSI: an exploratory pilot study

Non-suicidal self-injury (NSSI) can both precede and co-occur with suicidal attempts (SA). Underlying mechanisms/factors leading to the transition to SA in NSSI youths have been proposed (including the role of social cognition), despite they should be yet confirmed. Therefore, the study aims at exploring the role of the Theory of Mind in the differentiation of a sample of NSSI youngsters (aged 15-24) according to the presence of SA. We divided the sample into 4 groups using the Deliberate Self Harm Inventory (DSHI) and Columbia Suicide Severity Rating Scale (C-SSRS): control group (notNSSInotSA), NSSI without SA (NSSInotSA), NSSI with SA (NSSIplusSA), and SA without NSSI (SAonly). NSSIplusSA patients displayed higher Reading the Mind in the Eyes Test (RMET) scores (indicative of ToM abilities) than both the NSSInotSA (p=0.0016) and SAonly groups (p=0.0198), while SAonly patients showed lower RMET scores compared to the control group (p=0.0214). Multiple regression models used to differentiate NSSInotSA and NSSIplusSA found a significant association between RMET and LOSCS-CSC (Level Of Self-Criticism Scale-Comparative Self-Criticism) (pC=0.0802, pD=0.0016, pG=0.0053). Our findings supported the hypothesis that a hypertrophic affective ToM may possibly be associated with the occurrence of SA in youth NSSI. Further larger and longitudinal studies should confirm these preliminary findings, by exploring all social cognition dimensions.

Parental attachment and childhood trauma in adolescents engaged in non-suicidal self-injury

AIM

In this study, it was aimed to compare parental attachment and childhood traumas in adolescents with NSSI with healthy peers.

METHODS

Fifty adolescents aged 14-18 years with lifetime NSSI and 56 healthy peers were included in the study. Inventory of Statements About Self-injury (ISAS), The Parental Bonding Instrument (PBI) and Child Trauma Questionnaire (CTQ-28) scales were used.

RESULTS

Eighty-two percentage of the NSSI group and 70% of the control group were girls. The mean age was 15.6 ± 1.1 years in the NSSI group and 15.3 ± 0.9 years in the control group. There was no significant difference between the groups in terms of age and gender. The NSSI group had more negative scores than the control group in terms of childhood traumas and attachment characteristics to both mother and father. The analyses showed that mother PBI care/control and sexual abuse score had a relationship with both ISAS Autonomic Functions and ISAS Social Functions scores.

CONCLUSIONS

These results suggest that secure attachment with the mother may be protective for both the autonomic and social functions of the NSSI. Therefore, interventions for dysfunctional parental attachment may prevent the development of NSSI.

New pharmacotherapies to tackle the unmet needs in bipolar disorder: a focus on acute suicidality

INTRODUCTION

Suicidal behavior is relatively frequent in patients with bipolar disorder (BD) and constitutes their most frequent cause of death. Suicide rates remain high in patients with BD despite adherence to guidelines recommending lithium as first line, and/or antidepressants, antipsychotics, psychotherapy, psychosocial interventions, and electroconvulsive therapy. Hence the need to identify more effective and rapid anti-suicide interventions.

AREAS COVERED

To tackle the unmet needs of pharmacotherapy, we investigated the PubMed database on 24-25 January 2024 using strategies like ('acute suicid*'[ti] OR 'suicide crisis syndrome' OR 'acute suicidal affective disturbance') AND (lithium[ti] OR clozapine[ti]), which obtained 3 results, and ('acute suicid*'[ti] OR 'suicide crisis syndrome' OR 'acute suicidal affective disturbance') AND (ketamine[ti] OR esketamine[ti] OR NMDA[ti] OR glutamat*[ti]), which yielded 14 results. We explored glutamatergic abnormalities in BD and suicide and found alterations in both. The noncompetitive NMDS antagonist ketamine and its S-enantiomer esketamine reportedly decrease acute suicidality.

EXPERT OPINION

Intranasal esketamine or subcutaneous ketamine, single-bolus or intravenous, and possibly other glutamate receptor modulators may improve suicidal behavior in patients with unipolar and bipolar depression. This may be achieved through prompt remodulation of glutamate activity. The correct use of glutamatergic modulators could reduce acute suicidality and mortality in patients with BD.

Depression and posttraumatic stress disorder in adolescents with nonsuicidal self-injury: comparisons of the psychological correlates and suicidal presentations across diagnostic subgroups

BACKGROUND

Nonsuicidal self-injury (NSSI) combined with suicide ideation increases the risk of suicidal behaviors. Depression and posttraumatic stress disorder (PTSD) are comorbidities of NSSI compounding this relationship. The present study compared diagnostic subgroups of NSSI based on current depression and PTSD on psychological correlates (i.e., vulnerabilities and impairment) and suicidal presentations (i.e., suicidal cognitions and behaviors) in a psychiatric sample of adolescents.

METHODS

Eighty-seven adolescents meeting DSM-5 criteria for NSSI and 104 age-range-matched nonclinical controls (NC) participated. Participants completed self-report measures on psychological vulnerabilities and impairment (e.g., emotion regulation difficulties, negative cognitions). Adolescents with NSSI also completed clinical interviews on psychiatric diagnoses and a recent self-injurious behavior (SIB). Scores on the psychological correlates of NSSI were compared between adolescents with NSSI and NC, and across three diagnostic subgroups of NSSI (A: NSSI+/depression-/PTSD-, n = 14; B: NSSI+/depression+/PTSD-, n = 57; C: NSSI+/depression+/PTSD+, n = 14). Differences between NSSI diagnostic subgroups were tested on the motives for SIB and accompanying suicidal presentations (e.g., desire, intent, motive, lethality).

RESULTS

Common comorbidities of NSSI included depression, panic disorder, generalized anxiety disorder, and PTSD. The NSSI subgroup classification was significantly associated with panic disorder, which was controlled for in the subsequent group comparisons. Overall, adolescents who engage in NSSI with vs. without depression reported more psychological vulnerabilities and impairment and a greater degree of suicidal thoughts/desire in SIB (i.e., groups B, C >A), which remained significant after controlling for panic disorder. An increased odds of the suicidal motive for SIB was found in adolescents with all three conditions (i.e., group C: NSSI+/depression+/PTSD+) compared to those with NSSI but neither depression nor PTSD (i.e., group A: NSSI+/depression-/PTSD-); however, this was not significant after controlling for panic disorder.

CONCLUSIONS

Psychological underpinnings of adolescent NSSI in clinical contexts may be largely associated with concurrent depression. Suicidal motives in adolescents who engage in NSSI in the presence of depression and PTSD may be confounded by the co-occurrence of panic disorder. This study warrants the importance of attending to the comorbid depression with NSSI in adolescents as it is related to an increase in suicidal desire accompanying SIB.

The longitudinal relationship between dissociative symptoms and self-harm in adolescents: a population-based cohort study

Previous studies have reported that dissociative symptoms (DIS) are associated with self-harm (SH) in adolescents. However, most of these studies were cross-sectional, which limits the understanding of their theoretical relationship. We aimed to investigate the longitudinal relationship between DIS and SH in the general adolescent population. We used data from the Tokyo Teen Cohort study (N = 3007). DIS and SH were assessed at times 1 and 2 (T1 and T2) (12 years of age and 14 years of age, respectively). DIS were assessed using the parent-report Child Behavior Checklist (CBCL), and severe dissociative symptoms (SDIS) were defined as a score above the top 10th percentile. The experience of SH within 1 year was assessed by a self-report questionnaire. The longitudinal relationship between DIS and SH was examined using regression analyses. Using logistic regression analyses, we further investigated the risk for SH at T2 due to persistent SDIS and vice versa. DIS at T1 tended to predict SH at T2 (odds ratio (OR) 1.11, 95% CI 0.99 to 1.25, p = 0.08), while SH at T1 did not predict DIS at T2 (B = - 0.03, 95% CI - 0.26 to 0.20, p = 0.81). Compared with adolescents without SDIS, those with persistent SDIS had an increased risk of SH at T2 (OR 2.61, 95% CI 1.28 to 5.33, p = 0.01). DIS tended to predict future SH, but SH did not predict future DIS. DIS may be a target to prevent SH in adolescents. Intensive attention should be given to adolescents with SDIS due to their increased risk of SH.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Role of Developmental Timing of Childhood Adversity in Nonsuicidal Self-Injury Persistence or Desistance

Given the high prevalence of nonsuicidal self-injury (NSSI), scientific interest is on the rise, yet its developmental course remains understudied. Factors that may influence NSSI behavior are also unclear, although early research describes it as a maladaptive form of emotion regulation. In a college student sample (N = 507), the current study examines the extent that developmental timing of, and cumulative exposure to, potentially traumatic events (PTEs) accounts for variance in NSSI frequency, duration, and desistance, as well as the role that emotion regulation difficulties (ERD) play. Of 507 participants, 411 endorsed PTE exposure and were categorized into developmental groups based on age of initial PTE exposure, with the hypothesis that initial exposure during early childhood and adolescence may represent particularly sensitive risk periods. Results revealed that cumulative PTE exposure was significantly positively associated with shorter NSSI desistance, whereas ERD were significantly negatively associated with shorter NSSI desistance. However, the interaction between cumulative PTE exposure, when coupled with current ERD significantly moderated (i.e., strengthened) the path between cumulative PTE exposure and NSSI desistance. When examined individually, this interaction was only significant for the early childhood group, suggesting that the effects of PTE exposure on NSSI persistence may vary not only as a function of emotion regulation capacities but also when in the developmental course initial PTE exposure occurs. These findings contribute to our understanding of the role of PTE and timing, as well as ERD, in predicting NSSI behavior, and can inform programs and policies to prevent and curtail self-harm.

Associations between DSM-5 posttraumatic stress disorder Criterion E2 endorsement and selected self-destructive behaviors in recent-era veterans: A focus on disordered eating

Revisions to the posttraumatic stress disorder (PTSD) criteria in the DSM-5 included a new criterion in the alterations in arousal and reactivity cluster (i.e., engagement in reckless and self-destructive behaviors; Criterion E2). Despite its clinical significance, little is known about how this symptom corresponds to engagement in specific direct and indirect self-harm behaviors. We examined associations between E2 and self-reported recent engagement in direct and indirect self-harm behaviors, including disordered eating, which is not included in the prototypical E2 symptom scope, in a trauma-exposed sample of 1,010 recent-era veterans (61.5% self-identified women, 38.5% self-identified men). We also tested whether gender moderated these associations. We repeated analyses in a subsample of participants with clinically elevated PTSD symptoms. Participants self-reported past-month PTSD symptoms (PCL-5) as well as past-month nonsuicidal self-injury, suicidal ideation, suicide planning, fasting, purging, binge eating, compulsive exercise, and problematic alcohol and drug use. We found no evidence for moderation by gender for any of the behaviors examined in the main sample. However, after controlling for gender and demographic covariates, weighted logistic regressions showed small, significant associations between E2 score and direct self-harm behaviors, substance use, purging, and binge eating, aORs = 1.30-1.91. Criterion E2 was linked to behaviors included in the typical symptom scope (self-directed violence, substance use) and those that are not (disordered eating behaviors). Comprehensive screening for self-destructive behaviors, including disordered eating, among veteran men and women who endorse Criterion E2 is indicated.

The Effects of Social Rank and Neighborhood and School Environment on Adolescent Depression and Suicidal Ideation: A Structural Equation Modeling Approach

Depression and suicide constitute major public health problems, and their prevalence has been increasing among adolescents in the United States. More research is needed to understand the association between multilevel risk factors and depression and suicidal ideation in adolescents, particularly factors related to perceived social rank and environmental stress. The present study examined relationships among family mental history of mental illness, in-utero and perinatal complications, social rank factors, environmental factors, and depression and suicidal ideation in the past month in a clinical population of adolescents. A cross-sectional survey was administered in outpatient clinics to 197 adolescents ages 12-18 who were primarily Black and female. Findings from structural equation modeling showed the largest effects for the social rank factor on depression and suicidal ideation in the past month. These findings highlight the importance of preventive interventions for coping with social hierarchies to prevent depression and suicidal ideation.

Sub-threshold or full-syndrome borderline personality disorder in adolescents with recurrent self-harm - distinctly or dimensionally different?

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder frequently seen in individuals with recurrent self-harm behaviour. To what extent there are distinguishing characteristics between self-harming adolescents who meet the criteria for a full diagnosis of BPD, a sub-threshold number of BPD criteria and those who don't have BPD, with respect to clinical characteristics, is still uncertain and could have important clinical implications.

METHODS

Data from 103 adolescents with recurrent self-harm behaviour recruited from child and adolescent psychiatric outpatient clinics were collected through clinical interviews and self-reports. Bivariate analyses comparing participants with or without a diagnosis of BPD were performed. Group differences based on the number of BPD criteria fulfilled (few-if-any BPD: 0-2 criteria, sub-threshold BPD: 3-4 criteria, full-syndrome BPD: 5 or more criteria) were tested and regression analyses performed.

RESULTS

Adolescents with a diagnosis of BPD (28.2%) had significantly higher numbers of co-morbid DSM-5 disorders, suicide attempts and self-harm methods. They also reported significantly higher levels of suicidal ideation, depression, anxiety and impulsivity, compared with adolescents without BPD. Adolescents with sub-threshold BPD (20.4%) place themselves in the intermediate position between participants with full-syndrome BPD and participants with few-if-any BPD, in terms of these symptoms. Higher levels of emotional regulation difficulties and a lower level of global functioning were significantly associated with fulfilling a higher number of BPD criteria.

CONCLUSION

Adolescents with recurrent self-harm who meet diagnostic criteria for a full-syndrome BPD or sub-threshold BPD seem to have difficulties within the same spectrum. They seem dimensionally, but not categorically, different with respect to the severity of their difficulties. These adolescents need interventions aimed at their dysfunctional self-harm behaviour, emotional regulation difficulties and BPD symptoms at an earlier, rather than at a later stage of symptom development.

Sleep problems mediate the influence of childhood emotional maltreatment on adolescent non-suicidal self-injury: The moderating effect of rumination

BACKGROUND

Non-suicidal self-injury (NSSI) is a highly serious public health problem among adolescents in China, and childhood emotional maltreatment has been found to be a risk factor for NSSI.

OBJECTIVE

Little is known about the longitudinal association between childhood emotional maltreatment and NSSI as well as its underlying mediating and moderating mechanisms. Thus, we hypothesized whether sleep problems mediated the association between childhood emotional maltreatment and NSSI, and whether this indirect effect was moderated by rumination.

PARTICIPANTS AND SETTING

A total of 1987 Chinese adolescents (56.1 % males; ages 10 to 14, M = 12.32, SD = 0.53) completed self-report questionnaires regarding childhood emotional maltreatment, sleep problems, rumination non-suicidal self-injury (NSSI) in three waves.

METHODS

Structural equation model was used to test a moderated mediation model, with gender, age and socioeconomic status and baseline measures as covariates.

RESULTS

Childhood emotional maltreatment was significantly associated with NSSI, and this association was mediated by sleep problems. Moderated mediation analyses revealed that rumination intensified the relation between childhood emotional maltreatment and sleep problems as well as the relation between sleep problems and NSSI.

CONCLUSIONS

Findings of this study demonstrate a relationship among childhood emotional maltreatment, sleep problems, rumination and NSSI. Interventions that target sleep problems and rumination may be beneficial for reducing NSSI for at-risk adolescents.

Is Trauma Exposure More Harmful for Sexual Minority Youth? Differences in Trauma-Suicide Associations in a Nationally Representative Sample of U.S. Youth and Implications for Suicide Prevention

Purpose

Lesbian, gay, and bisexual (LGB) youth experience disproportionately high rates of suicidality and exposure to traumatic events, such as sexual violence and teen dating violence. Rates of suicidality and exposure to traumatic events also vary by sexual minority subgroup. The purpose of this study was to: (1) explore the impact of LGB identity on the relationship between violence exposure and suicide; and (2) to examine variations by sexual identity.

Method

A subsample of respondents who reported on their sexual identity in the Youth Risk Behavior Survey (n = 14,690) was used to examine if the associations between sexual and dating violence with suicide outcomes (suicidal ideation, planning, and suicide attempt) depended on the sexual identity of the respondent. Logistic regression models were fitted with an interaction effect to quantify heterogeneity of associations across identity strata.

Results

Overall interaction tests mostly indicated heterogeneity of associations between sexual violence and physical dating violence. Several contrast of strata associations suggested substantive probability differences between sexual minority respondents and their heterosexual peers.

Conclusion

While exposure to violence was broadly associated with increased probability of experiencing any type of suicidality, LGB and questioning youth were significantly more likely to experience suicidality compared to their heterosexual peers. Gay and lesbian youth demonstrated the strongest probability of experiencing suicidal thoughts and behaviors among survivors of sexual violence, while bisexual youth may be more at risk following dating violence. Implications for future research and suicide prevention are discussed.

Why We Need a Developmentally Appropriate Trauma Diagnosis for Children: a 10-Year Update on Developmental Trauma Disorder

Developmental Trauma Disorder (DTD) was proposed almost two decades ago as a psychiatric diagnosis for children who have been traumatically victimized and whose attachment bonding with primary caregivers has been compromised. DTD was designed to complement and extend post-traumatic stress disorder (PTSD) by addressing forms of trauma-related biopsychosocial dysregulation not included in PTSD, many of which are attributed to other psychiatric disorders. In the past decade, evidence from clinician surveys and research field trial studies has provided evidence of DTD's validity and potential clinical utility. The growing evidence base for DTD is summarized and clinical rationales for the proposed DTD symptoms are described. DTD shows promise as a developmentally-attuned traumatic stress diagnosis for traumatized children.

The Enhancing Role of Emotion Regulation in the Links between Early Positive Memories and Self-harm and Suicidal Ideation in Adolescence

Adolescence is a critical developmental period associated with an increased variety of interrelated risks and vulnerabilities. Previous studies have found associations between early memories of warmth and safeness, as well as emotion regulation, and self-harm and suicidal ideation in adolescence. Additionally, these early emotional memories have been found to be positively linked with some indicators of emotion regulation during this period. The present cross-sectional study extends prior research by exploring the moderating role of emotion regulation in the relationships between early memories of warmth and safeness, as well as each of the following risk-related outcomes in adolescence, in younger (i.e., 13-15) and older (i.e., 16-19) adolescents: suicidal ideation and self-harm and its associated functions (i.e., automatic and social reinforcement. Three self-report measures of these early emotional memories, emotion regulation, and risk-related outcomes, and a sample of 7918 Portuguese adolescents (53.3% females), with ages ranging from 13 to 19 (M_age = 15.5), were used. In both age groups, at high levels of emotion regulation, early memories of warmth and safeness had a greater (negative) effect on suicidal ideation and the automatic reinforcement function of self-harm, compared to at average and low levels of emotion regulation. These findings highlight the enhancing role of emotion regulation on the associations between early memories of warmth and safeness and some risk-related outcomes in adolescents, both younger and older, which reveals the relevance of targeting emotion regulation when preventing or tackling these outcomes, regardless of adolescents' levels of early memories of warmth and safeness.

Self-hate, dissociation, and suicidal behavior in bulimia nervosa

BACKGROUND

Individuals with eating disorders (EDs) often struggle with markedly low self- esteem and are at risk for suicidal behavior. Dissociation and perceived burdensomeness are often cited as facilitators of suicidal outcomes. Specifically, perceived burdensomeness is comprised of self-hate and liability on others, although it remains unclear which variables most heavily influence suicidal behavior in EDs.

METHODS

In a sample of 204 women with bulimia nervosa, the present study examined the potential impact of self-hate and dissociation on suicidal behavior. We hypothesized that suicidal behavior would be equally, and potentially more strongly, related to self-hate than dissociation. Regression analyses investigated the unique effects of these variables on suicidal behavior.

RESULTS

Consistent with our hypothesis, a significant relationship emerged between self-hate and suicidal behavior (B = 0.262, SE = 0.081, p < .001, CIs = 0.035-0.110, R-squared =0.07) but not between dissociation and suicidal behavior (B = 0.010, SE = 0.007, p = .165, CIs = -0.389-2.26, R-squared =0.010). Additionally, when controlling for one another, both self-hate (B = 0.889, SE = 0.246, p < .001, CIs = 0.403-1.37) and capability for suicide (B = 0.233, SE = 0.080, p = .004, CIs = 0.076-0.391) were uniquely and independently associated with suicidal behavior.

LIMITATIONS

Future work should include longitudinal analyses to understand temporal relationships among study variables.

CONCLUSIONS

In sum, when considering suicidal outcomes, these findings support a view that highlights personal loathing rooted in self-hate rather than de-personalizing aspects of dissociation. Accordingly, self-hate may emerge as a particularly valuable target for treatment and suicide prevention in EDs.

Patterns of polysubstance use and clinical comorbidity among persons seeking substance use treatment: An observational study

INTRODUCTION

Polysubstance use is common among individuals seeking treatment for substance use disorders (SUD). However, we know less about patterns and correlates of polysubstance use among treatment-seeking populations. The current study aimed to identify latent patterns of polysubstance use and associated risk factors in persons entering SUD treatment.

METHODS

Patients (N = 28,526) being admitted for substance use treatment reported on their use of thirteen substances (e.g., alcohol, cannabis, cocaine, amphetamines, methamphetamines, other stimulants, heroin, other opioids, benzodiazepines, inhalants, synthetics, hallucinogens, and club drugs) in the month before treatment and prior to the month before treatment. Latent class analysis (LCA) determined the relationship between class membership and gender, age, employment status, unstable housing, self-harm, overdose, past treatment, depression, generalized anxiety disorder, and/or post-traumatic stress disorder (PTSD).

RESULTS

Identified classes included: 1) Alcohol primary, 2) Moderate probability of past-month alcohol, cannabis, and/or opioid use; 3) Alcohol primary, Lifetime cannabis and cocaine use; 4) Opioid primary, Lifetime use of alcohol, cannabis, hallucinogens, club drugs, amphetamines, and cocaine; 5) Moderate probability of past-month alcohol, cannabis, and/or opioid use, Lifetime use of various substances; 6) Alcohol and cannabis primary, Lifetime use of various substances; and 7) High past-month polysubstance use. Individuals who engaged in past-month polysubstance use attended to face elevated risk of screening positive for recent unstable housing, unemployment, depression, anxiety, PTSD, self-harm, and overdose.

CONCLUSIONS

Current polysubstance use is associated with significant clinical complexity. Tailored treatments that reduce harms resulting from polysubstance use and related psychiatric comorbidity may improve treatment outcomes in this population.

Posttraumatic Growth, Dissociation and Identification With The Aggressor Among Childhood Abuse Survivors

Childhood abuse puts individuals at risk for psychopathology and psychiatric symptoms such as posttraumatic stress disorder (PTSD) and anxiety symptoms. At the same time, research has indicated that some survivors report positive transformations in the aftermath of their trauma, known as posttraumatic growth (PTG). Yet the essence of PTG reports is questionable, and some scholars claim that it may reflect maladaptive illusory qualities. Furthermore, according to a recent theoretical model, PTG might be dissociation-based and related to survivors' bonds with their perpetrators. This study aimed to explore these claims by assessing PTG, dissociation, and identification with the aggressor (IWA), as well as PTSD and anxiety symptoms. An online survey was conducted among 597 adult childhood abuse survivors. Study variables were assessed via self-report measures. Analyses indicated positive associations between PTG, dissociation, and IWA. Three distinct profiles were found, reflecting high, medium, and low scores on PTG, dissociation, and IWA. Profile type explained PTSD and anxiety symptoms above and beyond gender, age, and abuse severity. These findings suggest that whereas some childhood abuse survivors might experience a positive transformation subsequent to their trauma, others' PTG reports might reflect dissociative mechanisms and pathological attachments to their perpetrators, and thus might be maladaptive.

Factor Structure and Clinical Correlates of The Dissociative Symptoms Scale (DSS) Korean Version Among Community Sample With Adverse Childhood Experiences

This study examined the factor structure and psychometric properties of the Dissociative Symptoms Scale (DSS) among the Korean community adult population with adverse childhood experiences (ACE). Data were drawn from community sample data sets collected from an online panel investigating the impact of ACE and ultimately consisted of data from a total of 1304 participants. A confirmatory factor analysis revealed a bi-factor model with a general factor and four sub-factors such as depersonalization/derealization, gaps in awareness and memory, sensory misperceptions, and cognitive behavioral reexperiencing, which are the four factors that correspond to the original DSS. The DSS showed good internal consistency as well as convergent validity with clinical correlates such as posttraumatic stress disorder, somatoform dissociation, and emotion dysregulation. The high-risk group with more ACE was associated with increased DSS. These findings support the multidimensionality of dissociation and the validity of Korean DSS scores in a general population sample.

Characteristics, Methods, And Functions Of Non-Suicidal Self-Injury Among Highly Dissociative Individuals

Upto 86% of dissociative individuals engage in non-suicidal self-injury (NSSI). Research suggests that people who dissociate utilize NSSI to regulate posttraumatic and dissociative experiences, as well asrelated emotions. Despite high rates of NSSI, no quantitative study has examined the characteristics, methods, and functions of NSSIwithin a dissociative population. The present study examined thesedimensions of NSSI among dissociative individuals, as well aspotential predictors of intrapersonal functions of NSSI. The sample included 295 participants who indicated experiencing one or more dissociative symptoms and/or having been diagnosed with a trauma- or dissociation-related disorder. Participants were recruited through online trauma- and dissociation- related forums. Approximately 92% of participants endorsed a history of NSSI. The most common methods of NSSI were interfering with wound healing (67%), hitting oneself (66%), and cutting (63%). After controlling for age and gender, dissociation was uniquely associated with cutting, burning, carving, interfering with wound healing, rubbing skin against rough surfaces, swallowing dangerous substances, and other forms of NSSI. Dissociation was correlated with affect regulation, self-punishment,anti-dissociation, anti-suicide, and self-care functions of NSSI;however, after controlling for age, gender, depressive symptoms, emotion dysregulation, and PTSD symptoms, dissociation was no longer associated with any function of NSSI. Instead, only emotion dysregulation was associated with the self-punishment function ofNSSI and only PTSD symptoms were associated with the anti-dissociation function of NSSI. Understanding the unique properties of NSSI among dissociative individuals may improve the treatment of people who dissociate and engage in NSSI.

Daily reciprocal relations between emotion dysregulation and non-suicidal self-injury among individuals with a history of sexual assault: The influence of posttraumatic stress symptoms

INTRODUCTION

Non-suicidal self-injury (NSSI) is a serious public health concern that can be understood within an emotion dysregulation framework. The current study adds to the literature by utilizing a micro-longitudinal design and novel statistical modeling to test reciprocal associations between emotion dysregulation and NSSI, as well as the potential moderating effect of posttraumatic stress symptoms (PTSS).

METHODS

Participants were 81 individuals with a history of sexual assault and NSSI (M_age  = 33.80; 67.9% women; 80.2% white) recruited from the community who self-reported on symptoms of emotion dysregulation and NSSI thoughts/behaviors once daily for 7 days. Average compliance rate was 72.8% (SD = 31.3%) and 34 participants (42.0%) endorsed NSSI thoughts/behaviors over the course of the study.

RESULTS

Findings revealed a significant positive effect of NSSI thoughts/behaviors on subsequent abilities to regulate negative emotions. Furthermore, while results did not detect a moderating influence of baseline PTSS on the relation between emotion dysregulation and NSSI thoughts/behaviors over time, individuals with higher baseline PTSS were found to experience heightened levels of NSSI thoughts/behaviors and emotion dysregulation on average.

CONCLUSION

Information from this study may be useful for future research and intervention development focused on the intersection of NSSI, PTSS, and emotion dysregulation.

The Relationship Between Bullying Victimization and Perpetration and Non-suicidal Self-injury: A Systematic Review

Experience of bullying may be a significant risk factor for non-suicidal self-injury (NSSI). This study had three aims: to systematically investigate the association between bullying and NSSI, analyze the possible mechanisms underlying the two phenomena, and evaluate any differences between bullying victimization and bullying perpetration with respect to NSSI. A systematic search about the association between bullying victimization and perpetration and NSSI was conducted using specific databases (PubMed, Scopus, Science Direct). The following keywords were used in all database searches: "bullying" AND "NSSI" OR "peer victimization" and NSSI. The searches in PubMed, Scopus and Science Direct revealed a total of 88 articles about bullying or peer victimization and NSSI. However, only 29 met our inclusion criteria and were used for the present review. Overall, all studies examined victimization; four studies also evaluated the effects of perpetration and one included bully-victims. According to the main findings, both being a victim of bullying and perpetrating bullying may increase the risk of adverse psychological outcomes in terms of NSSI and suicidality in the short and the long run. To the best of our knowledge, this is the first review to systematically evaluate the relation between bullying victimization/perpetration and NSSI. The main results support a positive association. Future research should evaluate the possible role of specific mediators/moderators of the association between experience of bullying and NSSI.

Adverse childhood experiences, recent negative life events, and non-suicidal self-injury among Chinese college students: the protective role of self-efficacy

BACKGROUND

Non-suicidal self-injury (NSSI) is a severe health problem closely related to adverse childhood experiences (ACEs). However, the underlying mechanisms by which ACEs may affect NSSI are largely unknown. Self-efficacy (NSSI-SE) and recent negative life events (RNLEs) may play important roles in this relationship. This study aimed to clarify the relationship between ACEs and NSSI among college students by examining the role of self-efficacy (NSSI-SE) and RNLEs in this process.

METHOD

Relevant self-report questionnaires were used to evaluate ACEs, RNLEs, NSSI-SE, and NSSI. A questionnaire of 1036 Chinese undergraduates (M_age = 19.65, 28.9% males, 71.1% females) was collected in a cross-sectional manner. The associations between ACEs, RNLEs, NSSI-SE and NSSI were assessed using Pearson correlation analyses. Then, hierarchical multiple linear regressions were used to analyze the effects of ACEs and RNLEs on NSSI, as well as the protective effect of NSSI-SE on the above relations.

RESULTS

NSSI was associated with both ACEs and RNLEs. ACEs and RNLEs could directly increase the risks of participating in NSSI, and the effects of ACEs and RNLEs on NSSI were independent without an interactive effect. NSSI-SE buffered the relationship between ACEs and NSSI, as well as between RNLEs and NSSI. Compared to individuals with a low level of NSSI-SE, ACEs and RNLEs were not significantly associated with NSSI in persons with a high level of NSSI-SE.

CONCLUSION

NSSI-SE may buffer the effect of ACEs and RNLEs on NSSI, indicating that future interventions can be enhanced by targeting NSSI-SE among college students with ACEs or RNLEs to prevent their engagement in NSSI.

The potential addictive mechanism involved in repetitive nonsuicidal self-injury: The roles of emotion dysregulation and impulsivity in adolescents

BACKGROUND AND AIMS

Nonsuicidal self-injury (NSSI) is highly prevalent in adolescents and is associated with various mental health problems. Repetitive NSSI (R-NSSI), as an extreme manifestation of NSSI, is a growing concern and has been proposed as a behavioral addiction. However, little is known about the potential addictive mechanisms of NSSI. This study aimed to examine the mediating effect of emotion dysregulation and the moderating effect of impulsivity using the Interaction of Person-Affect-Cognition-Execution (I-PACE) model in adolescents who repeatedly engage in NSSI.

METHODS

A total of 3,915 adolescents (mean age = 13.21 years, SD = 0.87, 57.6% male) were recruited from three middle schools. Relevant questionnaires were used to evaluate childhood maltreatment, emotion dysregulation, impulsivity, and NSSI. Mediation and moderated mediation analyses were conducted separately for adolescents with occasional NSSI (O-NSSI) and R-NSSI to assess the relationship between childhood maltreatment, emotion dysregulation, impulsivity, and NSSI frequency.

RESULTS

Our study found that childhood maltreatment was directly related to NSSI and indirectly related to NSSI through emotion dysregulation in both the R-NSSI and O-NSSI groups. Furthermore, impulsivity played a moderating role in the relationship between emotion dysregulation and NSSI in the R-NSSI group but not in the O-NSSI group.

DISCUSSION AND CONCLUSIONS

The findings suggest that a high level of impulsivity and a high level of emotion dysregulation may be important risk addictive factors of NSSI through childhood maltreatment. Strengthening the emotion regulation skills and inhibitory control of adolescents with NSSI would be helpful to reduce their self-injury behaviors and maintain their mental health. This finding also supports the validity of the I-PACE model for evaluating R-NSSI.

The psychometric properties of the adolescent dissociative experiences scale (A-DES) in a sample of Portuguese at-risk adolescents

Dissociation is a process that often occurs as a sequela of psychological trauma, and it is interrelated with psychological and behavioral problems. In the at-risk adolescent population, dissociation is often underdiagnosed and undertreated. Having reliable measures to assess this phenomenon can help in identifying adolescents at-risk and improve treatment outcomes. This study assessed the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) with a sample of 402 Portuguese adolescents recruited from three at-risk populations. Participants completed self-report measures of trauma exposure, posttraumatic symptoms, psychological and behavioral problems, and the A-DES. A subset of the sample also completed test-retest measures. Confirmatory factor analyses revealed a best-fitting 3-factor model. Analyses revealed good internal consistencies and good agreement test-retest reliability for the scale overall and the factor-based sub-scales. Construct and predictive validity was supported with results showing that A-DES discriminates between youth reporting high versus low levels of cumulative trauma exposure and youth who meet or do not meet criteria for a probable PTSD diagnosis. Study findings replicate prior research supporting a 3-factor model of dissociation and the usefulness of A-DES to identify adolescents with dissociative symptoms. Clinical and research implications are discussed.

Toward an empirically based Developmental Trauma Disorder diagnosis and semi-structured interview for children: The DTD field trial replication

OBJECTIVE

Developmental trauma disorder (DTD) is a childhood psychiatric syndrome designed to include sequelae of trauma exposure not fully captured by PTSD. This study aimed to determine whether the assessment of DTD with an independent sample of children in mental health treatment will replicate results from an initial validation study.

METHODS

The DTD semi-structured interview (DTD-SI) was administered to a convenience sample in six sites in the United States (N = 271 children in mental health care, 8-18 years old, 47% female, 41% Black or Latinx) with measures of trauma history, DSM-IV PTSD, probable DSM-IV psychiatric diagnoses, emotion regulation/dysregulation, internalizing/externalizing problems, and quality of life. Confirmatory factor (CFA) and item response theory (IRT) analyses tested DTD's structure and DTD-SI's information value. Bivariate and multivariate analyses tested DTD's criterion and convergent validity.

RESULTS

A three-factor solution (i.e., emotion/somatic, attentional/behavioral, and self/relational dysregulation) best fit the data (CFI = 0.91; TLI = 0.89; BIC = 357.17; RMSEA = 0.06; SRMR = 0.05). DTD-SI items were informative across race/ethnicity, gender, and age with three exceptions. Emotion dysregulation was the most informative item at low levels of DTD severity. Non-suicidal self-injury was rare but discriminative in identifying children with high levels of DTD severity. Results supported the criterion and convergent validity of the DTD construct.

CONCLUSION

This replication provides empirical support for DTD as a construct and potential psychiatric syndrome, and the DTD-SI's validity as a clinical research tool.

The Psychosocial Correlates of Non-suicidal Self-Injury Within a Sample of Adolescents With Mood Disorder

Background

According to the integrated theoretical model, adolescents' behaviors were the outcome of the complex interplay between multiple levels. Non-suicidal self-injury (NSSI) is a serious and high prevalent problem among adolescents with mood disorders. However, a systematic perspective on psychosocial correlates among Chinese clinical adolescents is still rare.

Method

The impact of several factors at the individual (i.e., sex, age, self-esteem, and psychological distress), family (i.e., family structure, family income, and family support), and social level (i.e., living environment, peer support, and teacher support) on the frequency of NSSI behaviors were investigated in the current study. This research included 621 Chinese adolescents with mood disorders from 20 hospitals.

Results

Three-steps hierarchical regression analyses indicated that lower levels of psychological distress and higher levels of self-esteem were most associated with less frequency of NSSI behaviors. In addition, family support was negatively associated with the frequency of NSSI behaviors. After controlling the factors at individual and family levels, no significant association was found between the factors at the social level and the frequency of NSSI behaviors.

Conclusion

These findings provide preliminary support for the notion that adolescent self-esteem and family support may effectively shield them from problematic behavior; nevertheless, adolescents suffering from more emotional pain can be even riskier. Thus, further intervention strategies should consider the non-independence of individual capacities, co-combinatory effects of mood disorder, and family environment in treating those vulnerable Chinese adolescents.

Non-Suicidal Self-Injury in Russian Patients with Suicidal Ideation

BACKGROUND

Nonsuicidal self-injury (NSSI) is recognized as a public health concern for its association with unfavorable outcomes, including suicidal behavior. The aim of this study is to identify factors associated with NSSI among patients with nonpsychotic mental disorders (NPMD) and suicidal ideation in Russia.

METHODS

A retrospective cohort study was conducted in the Moscow Research and Clinical Center for Neuropsychiatry between November 2017 and May 2019. The sample was composed of consecutive patients with lifetime suicidal ideation (from the Self-Injurious Thoughts and Behavior Interview) seen in the center's psychiatric ward for NPMD. The patients were divided into two groups: those with and without lifetime NSSI. Sociodemographic variables, psychiatric diagnosis, family history of mental disorders, history of physical or sexual abuse, sexual behavior, ad-hoc psychiatric treatments, suicidal ideation, plans, and gestures or attempts were investigated.

RESULTS

Six thousand, two hundred and four consecutive patients were screened for suicidal ideation. Out of a total of 361 patients (87.3% females) with suicidal ideation, 217 (60.1%) reported NSSI. Variables independently associated with NSSI included age <25 years (OR 6.0, CI 2.5-14.7), dissatisfaction with the perceived parenting style (OR 3.3, CI 1.5-7.4), bullying (OR 2.6, CI 1.0-6.5), severe body modifications (OR 11.9, CI 1.1-134.3), experience with illicit drugs (OR 4.4, CI 1.9-10.3), and eating disorders (OR 4.9, CI 2.0-11.8).

LIMITATIONS

Retrospective design, referral population, single center study, and exclusion of psychotic patients.

CONCLUSIONS

NSSI is associated with age <25 years old, dissatisfaction with perceived parenting style, bullying, severe body modifications, lifetime experience of illicit drug-use, and lifetime eating disorders.HIGHLIGHTSNonsuicidal self-injury is a significant public health concern for its association with suicidal behavior.60.1% of Russian patients with non-psychotic mental disorders (NPMD) and suicidal ideation reported lifetime NSSI.NSSI in Russian patients with NPMD and suicidal ideation is associated with age less than 25 years, dissatisfaction with perceived parenting style, bullying, severe body modifications, lifetime experience of illicit drug use, and lifetime eating disorders.

Identification With the Aggressor and Inward and Outward Aggression in Abuse Survivors

Childhood abuse survivors may display both inward and outward aggression manifested in self-injurious behavior (SIB) and violent acts toward others. Scrutinizing the literature reveals that the relational dynamics between victims and their perpetrators might be involved in these phenomena. Yet, research on this subject matter has been sparse. Filling this gap, this study investigated the contribution of the singular bonds between victims and their perpetrators, known as identification with the aggressor, in explaining survivors' aggression. The study was conducted among 306 Israeli college/university students who reported a history of childhood abuse. Results revealed that levels of adopting the perpetrator's experience, identifying with the perpetrator's aggression, and replacing one's agency with that of the perpetrator were significantly associated with survivors' inward and outward aggression. Moreover, profile type-that is, having high versus low levels of identification with the aggressor-was implicated in participants' SIBs, urge to harm others, and violent acts toward others, above and beyond the effects of gender and posttraumatic stress disorder (PTSD) symptoms. The present findings suggest that identification with the aggressor might make survivors prone to the re-enactment of past abusive dynamics, which, in turn, could eventuate in aggression toward themselves and others.

The Psychoanalytic Study of Suicide, Part I: An Integration of Contemporary Theory and Research

Psychodynamic psychotherapy has an important role in suicide prevention. The psychoanalytic study of suicide has taught us a great deal about the human experience and the process of suicidality. There is also much to be learned from other fields of study and from empirical research that can be integrated into psychoanalytic therapies. Central to the psychoanalytic approach to suicide has been understanding the patient's internal subjective experience of unbearable emotional or psychic pain and the urgent need for relief. Emotional pain can include intense affects such as shame, humiliation, self-hate, and rage. Factors that can increase vulnerability to suicidal states include problems with early attunement, dissociation and deficits in bodily love and protection, conscious and unconscious fantasy, and certain character traits and dynamics. Empirical research has confirmed many basic psychoanalytic concepts about suicide, including escape from unbearable pain as the primary driver of suicidal behavior, the role of dissociation in increasing risk of bodily attack, and the importance of unconscious processes. Further research into implicit processes and their role in the suicidal process holds potential to improve suicide risk assessment and to enhance psychotherapy by bringing otherwise inaccessible material into the treatment.

Is age of self-harm onset associated with increased frequency of non-suicidal self-injury and suicide attempts in adolescent outpatients?

BACKGROUND

Self-harm in adolescents is an increasing public health concern and an important risk factor for suicide. We aimed to examine how age of self-harm onset in adolescents was associated with frequency of subsequent suicidal and non-suicidal self-harm (NSSI) episodes, and how age of onset and duration of self-harm may influence the frequency of self-harm.

METHODS

Data from 103 adolescents with recurrent self-harm recruited from child and adolescent psychiatric outpatient clinics were collected through clinical interviews and self-reports, and analysed with negative binomial and hurdle models.

RESULTS

A lower age of self-harm onset and a longer duration of self-harm were both significantly associated with increased frequency of subsequent episodes of NSSI and risk of a first suicide attempt. There was an increase in repeated suicide attempts when the age of onset of self-harm decreased and the duration increased, and dramatically more for long duration of NSSI before first suicide attempt.

CONCLUSION

Initiating self-harm behaviour at the youngest age had the highest risk of increased frequency of NSSI and suicide attempts. Longer duration of self-harm behaviour increased this risk. This underlines the importance of early identification of self-harm behaviour in adolescents, and the use of effective interventions.

Suicidal ideation, self-injury, aggressive behavior and substance use during intensive trauma-focused treatment with exposure-based components in adolescent and young adult PTSD patients

BACKGROUND

Multiple traumata such as child sexual and/or physical abuse often result in complex psychopathologies and a range of associated dysfunctional behaviors. Although evidence-based interventions exist, some therapists are concerned that trauma-focused psychotherapy with exposure-based elements may lead to the deterioration of associated dysfunctional behaviors in adolescents and young adults. Therefore, we examined the course of suicidal ideation, self-injury, aggressive behavior and substance use in a group of abuse-related posttraumatic stress disorder (PTSD) patients during phase-based, trauma-focused PTSD treatment.

METHODS

Daily assessments from a randomized controlled trial (RCT) of Developmentally adapted Cognitive Processing Therapy (D-CPT) were analyzed to test for differences in the stated dysfunctional behaviors between the four treatment phases. We conducted multilevel modeling and repeated measure ANOVAs.

RESULTS

We did not find any significant differences between the treatment phases concerning the stated dysfunctional behaviors, either at the level of urge or at the level of actual actions. On the contrary, in some primary outcomes (self-injury, aggressive behavior), as well as secondary outcomes (distress caused by trauma, joy), we observed significant improvements.

DISCUSSION

Overall, during D-CPT, adolescents and young adults showed no deterioration in dysfunctional behaviors, while even showing improvements in some, suggesting that trauma-focused treatment preceded by skills building was not deleterious to this population. Hence, the dissemination of effective interventions such as D-CPT should be fostered, whilst the concerns of the therapists regarding exposure-based components need to be addressed during appropriate training. Nevertheless, further studies with momentary assessment, extended measurement methods, a control group and larger sample sizes are needed to confirm our preliminary findings.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787, 18 March 2013, https://www.drks.de/DRKS00004787 .

The subjective experience of non-suicidal self-injury among female Chinese university students

OBJECTIVE

The purpose of this study was to explore the subjective experience of non-suicidal self-injury (NSSI) among female Chinese university students in Hong Kong.

DESIGN

Interpretative phenomenological analysis was used.

METHODS

Seven female students participated in the study, two engaged in biting and scratching, and three in cutting.

RESULTS

The majority of them indicated negative attitudes towards NSSI and saw no particular meaning attached to it. However, they all persisted with their behaviours, which suggested that they were unable to stop. Students found themselves in a paradoxical situation whereby although they saw no real benefit of NSSI, they still engaged in it to cope with distress. Feelings characterised by this distress were about entrapment and issues with academia, intimacy, loneliness, insecurity, negative self-worth, regulating distressing emotions, increasing positive physical sensations, healing oneself, and feeling alive.

CONCLUSIONS

The experience of hurting themselves persistently for these female students symbolised their struggle with academic or relationship difficulties, self-acceptance, emotional regulation and survival without self-injury.

Improving care for SUD patients with complex trauma-relationships between childhood trauma, dissociation, and suicidal behavior in female patients with PTSD and SUD

BACKGROUND

Posttraumatic disorders are among the most frequent co-occurring diagnoses in patients with substance use disorders (SUD). Individuals with this dual diagnosis often present with special treatment needs, especially after childhood traumatic experiences (CT). Along with posttraumatic stress disorder (PTSD) and dissociative symptoms, suicidal behaviors belong to the clinical challenges in this group of patients and may influence the course and outcome of SUD treatment. Therefore, a better understanding of the relationships between different forms of CT, psychopathology and suicidal behaviors seems to be important to tailor adequate concepts of care.

MATERIALS AND METHODS

We examined 343 female patients with SUD and Posttraumatic stress disorder (PTSD). All patients completed the Childhood Trauma Questionnaire (CTQ), the Dissociative Experiences Scale-Taxon (DES-T) and the Structured Clinical Interview Axis I Disorders (SCID-I). To determine relationships between different symptoms with potential importance for concepts of treatment, we conducted analyses of moderated mediation for different models. We examined the direct and indirect effects of associations between the type of CT, dissociation and suicidal behavior, as well as the moderation effect of PTSD.

RESULTS

All participants met DSM-criteria for either full PTSD (75.2%) or subsyndromal PTSD (24.8%). Almost all (94.5%) received at least one substance dependence diagnosis and the remaining 5.5% met substance abuse criteria. Most participants (93.3%) reported at least one type of childhood trauma. In all models, dissociation was a risk factor for suicidal ideation (SI) and for suicide attempts (SA). In both, participants with subsyndromal PTSD and participants with full PTSD, dissociation mediated the relationship between childhood sexual abuse and SI as well as SA. Moreover, we report direct effects between different childhood traumas and SI and SA. Furthermore, emotional abuse was a significant predictor of dissociation.

DISCUSSION

In our sample of female patients with SUD and co-occurring PTSD, dissociation significantly increased suicidal behavior and served as a mediator of the relationship between childhood sexual abuse and suicidal behavior. Our findings underline the need to include interventions to address dissociative symptoms and other more complex consequences of childhood trauma into concepts of care for patients with SUD.

Comparison of Patterns of Non-suicidal Self-Injury and Emotion Dysregulation Across Mood Disorder Subtypes

INTRODUCTION

Non-suicidal self-injury (NSSI) is frequently encountered in patients with mood disorders. Emotion dysregulation (ED), frequently observed in mood disorders, could be a major mediating factor in NSSI. The aim of this study was to explore differences in NSSI behavior and ED across mood disorder subtypes. The relationships between childhood trauma and NSSI and ED were also explored.

METHODS

A total of 191 patients with mood disorders were included in this study. The patterns of NSSI behavior and ED across patients with bipolar I disorder (BD-I), bipolar II disorder (BD-II), and major depressive disorder (MDD) were compared.

RESULTS

More than half (54%) of the subjects experienced NSSI. Patients with BD-II and MDD engaged in NSSI behavior more frequently than those diagnosed with BD-I. NSSI behaviors in patients with BD-II most commonly included cutting, whereas hitting behaviors were most common among other groups. Patients with BD-II and MDD reported more severe ED than those with BD-I. In the case of childhood trauma, those with BD-II and MDD reported greater emotional neglect than those with BD-I. Structural equation modeling revealed that ED mediated the association between childhood trauma and NSSI.

CONCLUSION

BD-I was associated with less frequent NSSI behavior and less severe ED than BD-II and MDD. ED mediated the association between childhood trauma and NSSI. Promoting emotion regulation strategies could prevent NSSI behavior in patients with mood disorders.