Self-mutilation and contagion: an empirical test

Effects of Group Psychotherapy for Nonsuicidal Self-Injury: A Meta-Analysis

Nonsuicidal self-injury (NSSI) is prevalent and concerning among adolescents and adults. Although prior meta-analytic work has considered the efficacy of individual psychotherapy for reducing NSSI, the efficacy of group psychotherapy remains unclear. We conducted a systematic meta-analysis of group psychotherapy studies with NSSI measures. We identified a total of eight studies, including published articles (n = 6) or dissertations (n = 2) with 10 total effect sizes for group interventions. Overall, random-effects meta-analysis suggests that group psychotherapies have a significant small effect on NSSI. However, when corrected for publication bias, the effect is no longer significant. This meta-analysis cautiously suggests that group psychotherapies, which are cost-effective and efficient, hold promise for attenuating NSSI. The field would benefit from further study and treatment refinement, including consideration of what works for whom.

Adolescents' knowledge of a peer's non-suicidal self-injury and own non-suicidal self-injury and suicidality

OBJECTIVE

Some research suggests that suicidal ideation and attempt among adolescents may be contagious - that is adolescents who are exposed to peers' suicidal behaviour are more likely to experience suicidal ideation or attempt suicide themselves. Less is known about the potential contagion effect of non-suicidal self-injury (NSSI). Our objective was to determine whether knowledge of a friend's NSSI is associated with adolescent's own non-suicidal self-injury and suicidal behaviours.

METHODS

Data from 1483 youth ages 14-17 years were obtained from the 2014 Ontario Child Health Study, a cross-sectional population-based survey of children and adolescents in Ontario, Canada. Logistic regression models were used to examine associations between knowledge of a friend's NSSI and adolescents' own self-reported self-injurious and suicidal behaviours. Interactions with gender, age group and presence of a mental disorder were investigated.

RESULTS

Knowledge of a friend's non-suicidal self-injury was significantly associated with the adolescent's own non-suicidal self-injury (OR = 2.03, 95% CI 1.05-3.90), suicidal ideation (OR = 3.08, 95% CI 1.50-6.30) and suicide attempt (OR = 2.87, 95% CI 1.20-6.87).

CONCLUSION

These findings suggest an apparent contagion effect for non-suicidal self-injury. Awareness of a friend's self-injurious behaviours is associated with an adolescent's own self-injury and suicidality. Interventions aimed at preventing NSSI and suicidality should consider prevention of possible contagion at the school and/or community level.

Position paper for guiding response to non-suicidal self-injury in schools

Around the world, school staff are increasingly expressing concern about nonsuicidal self-injury (NSSI) and how best to address this behavior in the school setting. However, there is a notable lack of informed guidance for schools, and clear inconsistencies in the practices school staff adopt. In this position paper we draw on our collective research and clinical expertise to provide best-practice guidelines for addressing NSSI in school settings. We outline the importance of a school protocol, and the key features all school protocols should contain. We also focus on how schools can minimize contagion of NSSI within their school environment. We believe these guidelines will be an important starting point for schools interested in developing an evidence-based approach to addressing NSSI.

Shifting Conversations on Girls' and Women's Self-Injury: An Analysis of the Clinical Literature in Historical Context

Through a historical review of girls' and women's episodic and repetitive self-injury -scholarship focusing primarily on white, middle-class women in North America and Britain - in the clinical literature from 1913 to the present, the author identifies four shifts over time. These are: 1) varying degrees of clinical interest in and numbers of publications on self-injury, 2) changing conceptualizations of self-injury, 3) changing treatment approaches for self-injury, and 4) changing characterizations of women who self-injure. Moving from research studies which indicate that self-injury typically presents in females during adolescence, this article elucidates how self-injury may reflect girls' developmental struggles within a patriarchal culture and embody a narrative of women's experiences of violation. Bringing together the history of self-injury and a feminist, relational analysis, it is argued that the historical discourse on self-injury mimics women's experiences of objectification and violence by silencing and distorting their self-injury.

Using Implicit and Explicit Measures to Predict Nonsuicidal Self-Injury Among Adolescent Inpatients

OBJECTIVE

To examine the use of implicit and explicit measures to predict adolescent nonsuicidal self-injury (NSSI) before, during, and after inpatient hospitalization.

METHOD

Participants were 123 adolescent psychiatric inpatients who completed measures at hospital admission and discharge. The implicit measure (Self-Injury Implicit Association Test [SI-IAT]) and one of the explicit measures pertained to the NSSI method of cutting. Patients were interviewed at multiple time points at which they reported whether they had engaged in NSSI before their hospital stay, during their hospital stay, and within 3 months after discharge.

RESULTS

At baseline, SI-IAT scores differentiated past-year self-injurers and noninjurers (t121 = 4.02, p < .001, d = 0.73). These SI-IAT effects were stronger among patients who engaged in cutting (versus noncutting NSSI methods). Controlling for NSSI history and prospective risk factors, SI-IAT scores predicted patients' subsequent cutting behavior during their hospital stay (odds ratio (OR) = 8.19, CI = 1.56-42.98, p < .05). Patients' explicit self-report uniquely predicted hospital-based and postdischarge cutting, even after controlling for SI-IAT scores (ORs = 1.82-2.34, CIs = 1.25-3.87, p values <.01). Exploratory analyses revealed that in specific cases in which patients explicitly reported low likelihood of NSSI, SI-IAT scores still predicted hospital-based cutting.

CONCLUSION

The SI-IAT is an implicit measure that is outcome-specific, a short-term predictor above and beyond NSSI history, and potentially helpful in cases in which patients at risk for NSSI explicitly report that they would not do so in the future. Ultimately, both implicit and explicit measures can help to predict future incidents of cutting among adolescent inpatients.

The definition and epidemiology of clusters of suicidal behavior: a systematic review

Suicide clusters are a rare and underresearched phenomenon which attract wide media attention and result in heightened concern in the communities where they occur. We conducted a systematic literature review covering the definition and epidemiology of the time-space clustering of suicidal behavior. Of the 890 articles identified by electronic searching, 82 were selected for inclusion and the extracted data were analyzed by narrative synthesis. Less than a third of studies included a definition of a suicide cluster, and definitions varied considerably. Clusters occurred in various settings, including psychiatric hospitals, schools, prisons, indigenous communities, and among the general population. Most clusters involved young people. The proportion of all episodes that occurred in clusters varied considerably between studies and partly depended on study methodology (e.g., a larger proportion was found in studies of specific clusters compared with general population studies). Future studies should aim to combine the statistical analysis of time-space clustering with a case study of events, which examines potential links between individuals and the wider environmental context.

Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth

The purpose of this study was to review the current evidence base of psychosocial treatments for suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) in youth. We reviewed major scientific databases (HealthSTAR, MEDLine, PsycINFO, PubMed) for relevant studies published prior to June 2013. The search identified 29 studies examining interventions for suicidal or nonsuicidal SITBs in children or adolescents. No interventions currently meet the Journal of Clinical Child and Adolescent Psychology standards for Level 1: well-established treatments. Six treatment categories were classified as Level 2: probably efficacious or Level 3: possibly efficacious for reducing SITBs in youth. These treatments came from a variety of theoretical orientations, including cognitive-behavioral, family, interpersonal, and psychodynamic theories. Common elements across efficacious treatments included family skills training (e.g., family communication and problem solving), parent education and training (e.g., monitoring and contingency management), and individual skills training (e.g., emotion regulation and problem solving). Several treatments have shown potential promise for reducing SITBs in children and adolescents. However, the probably/possibly efficacious treatments identified each have evidence from only a single randomized controlled trial. Future research should focus on replicating studies of promising treatments, identifying active treatment ingredients, examining mediators and moderators of treatment effects, and developing brief interventions for high-risk periods (e.g., following hospital discharge).

Why alternative teenagers self-harm: exploring the link between non-suicidal self-injury, attempted suicide and adolescent identity

BACKGROUND

The term 'self-harm' encompasses both attempted suicide and non-suicidal self-injury (NSSI). Specific adolescent subpopulations such as ethnic or sexual minorities, and more controversially, those who identify as 'Alternative' (Goth, Emo) have been proposed as being more likely to self-harm, while other groups such as 'Jocks' are linked with protective coping behaviours (for example exercise). NSSI has autonomic (it reduces negative emotions) and social (it communicates distress or facilitates group 'bonding') functions. This study explores the links between such aspects of self-harm, primarily NSSI, and youth subculture.

METHODS

An anonymous survey was carried out of 452 15 year old German school students. Measures included: identification with different youth cultures, i.e. Alternative (Goth, Emo, Punk), Nerd (academic) or Jock (athletic); social background, e.g. socioeconomic status; and experience of victimisation. Self-harm (suicide and NSSI) was assessed using Self-harm Behavior Questionnaire and the Functional Assessment of Self-Mutilation (FASM).

RESULTS

An "Alternative" identity was directly (r ≈ 0.3) and a "Jock" identity inversely (r ≈ -0.1) correlated with self-harm. "Alternative" teenagers self-injured more frequently (NSSI 45.5% vs. 18.8%), repeatedly self-injured, and were 4-8 times more likely to attempt suicide (even after adjusting for social background) than their non-Alternative peers. They were also more likely to self-injure for autonomic, communicative and social reasons than other adolescents.

CONCLUSIONS

About half of 'Alternative' adolescents' self-injure, primarily to regulate emotions and communicate distress. However, a minority self-injure to reinforce their group identity, i.e. 'To feel more a part of a group'.

The best friend and friendship group influence on adolescent nonsuicidal self-injury

This study examined associations of peer socialization and selection, over time, with nonsuicidal self-injury (NSSI) among 5,787 (54.2 % females) Chinese community adolescents. Both effects were tested using two aspects of adolescents' friendship networks: the best friend and the friendship group. Participants completed questionnaires assessing NSSI, depressive symptoms and maladaptive impulsive behaviors at two waves of time over a 6-month period. Results showed that even after controlling for the effects of depressive symptoms and maladaptive impulsive behaviors, the best friends' engagement in NSSI still significantly predicted adolescents' own engagement in NSSI. Adolescents' friendship groups' NSSI status also significantly predicted their own NSSI status and frequency. Additionally, adolescents with NSSI tended to join peer groups with other members also engaging in NSSI.

Prone to excitement: adolescent females with Non-suicidal self-injury (NSSI) show altered cortical pattern to emotional and NSS-related material

Emotion-regulation difficulties have been identified as one of the core components in Non-suicidal self-injury (NSSI), a behaviour often beginning in adolescence. This pilot study evaluated differences in emotion processing between 18 female adolescents with and without NSSI by using verbal responses and functional magnetic resonance imaging (fMRI). Responses to pictures taken from the International Affective Picture System and slides with reference to NSSI were recorded both by verbal rating of valence and arousal and by fMRI. The NSSI group rated pictures with self-injurious reference as significantly more arousing than controls. For emotional pictures, the NSSI group showed a significantly stronger brain response in the amygdala, hippocampus and anterior cingulate cortex bilaterally. Depression explained differences between groups in the limbic area. Furthermore, the NSSI group also showed increased activity in the middle orbitofrontal cortex, and inferior and middle frontal cortex when viewing NSSI picture material. Participants with NSSI showed decreased activity in correlation to arousal in the occipital cortex and to valence in inferior frontal cortex when watching emotional pictures. The fMRI data support the notion that individuals with NSSI show an altered neural pattern for emotional and NSSI pictures. Behavioural data highlight proneness to excitement regarding NSSI topics. This fMRI study provides evidence for emotion-regulation deficits in the developing brain of adolescents with NSSI.

Peer influence and nonsuicidal self injury: longitudinal results in community and clinically-referred adolescent samples

Research suggests that adolescents' engagement in nonsuicidal self-injurious (NSSI) behaviors may be increasing over time, yet little is known regarding distal longitudinal factors that may promote engagement in these behaviors. Data from two longitudinal studies are presented to examine whether NSSI may be associated with peer influence processes. Study 1 included 377 adolescents from a community-based sample; Study 2 included 140 clinically-referred adolescents recruited from a psychiatric inpatient facility. In Study 1, adolescents' NSSI was examined at baseline and one year later. Adolescents' nominated best friend reported their own levels of NSSI. In Study 2, adolescents' NSSI was examined at baseline as well as 9 and 18-months post-baseline. Adolescents' perceptions of their friends' engagement in self-injurious behavior (including suicidality) and depressed mood also were examined at all three time points. Baseline depressive symptoms were measured in both studies; gender and age were examined as moderators of peer influence effects. Results from both studies supported longitudinal peer socialization effects of friends' self-injurious behavior on adolescents' own NSSI for girls, but not for boys, even after controlling for depressive symptoms as a predictor. Study 1 suggested socialization effects mostly for younger youth. Results from Study 2 also suggested longitudinal socialization effects, as well as peer selection effects; adolescents' NSSI was associated with increasing perceptions of their friends' engagement in depressive/self-injurious thoughts and behavior. Findings contribute to the nascent literature on longitudinal predictors of NSSI and to work on peer influence.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.

NURSING INTERVENTIONS FOR Parasuicidal Behaviors IN FEMALE OFFENDERS

Parasuicide refers to the nonfatal, intentional, self-injurious behaviors frequently exhibited by individuals with features of a borderline personality disorder. In correctional systems, the rate of parasuicidal behavior among incarcerated female offenders can be high and intertwined with complex behavioral and social issues. Nursing interventions in the management and treatment of parasuicidal behaviors incorporating the principles of dialectical behavior therapy have been developed and implemented at the authors' institution. This treatment approach provides practical, effective nursing interventions including pretreatment orientation, strategies for use with threats to self-harm and during self-harming episodes, and follow-up treatment.

Treatment of patients with severe burn injuries: the impact of schizophrenia

Four patients treated in one ward of a psychiatric clinic were admitted to our burn unit within 2 months due to severe burn injuries. The patients showed signs of a self-mutilation epidemic. All four patients were female and the mean age was 28 years. The psychiatric diagnosis was schizophrenia in all patients (ICD 10: F20.9). The ignition of flammable liquid was the most common method and the mean burned TBSA was 33%. The mean severity score (ABSI) was 8 and the median hospital stay was 50 days. All patients were characterised by a prolonged hospital stay in comparison to patients without additional psychiatric pathology (median 31 days). This prolonged stay was based on a delayed wound healing, more operations, extended time for mobilisation and difficulties in co-operation. It is possible that in patients with schizophrenia, changes in nutrition, activity, sleep and drug use could influence their immune system profoundly. Anxiety and depression is also associated with the impairment of cellular and humoural immunity. Poor sleep reduces the production of an anabolic endocrine environment and sleep disturbances can interfere with macrophage and lymphocyte functions. Poor appetite leads to malnutrition, which is also capable of producing delayed wound healing. On the other hand, apathy and a general lack of motivation interfere with therapeutic strategies, because poor appetite and weight loss often occurs after neuroleptic withdrawal, which is correlated with clinical decompensation. Moreover, this "self-destructive" behaviour, which is acting on the immune system, might make a patient more susceptible to infection. All these aspects and side effects of schizophrenia combine to make the treatment of burned patients with schizophrenia a very special and difficult task.

Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents

OBJECTIVE

The incidence of self-injurious behavior (SIB) in adolescent psychiatric inpatients has been reported to be as high as 61%, yet few data exist on the characteristics and functional role of SIB in this population. Because of the repetitive nature of SIB and its potential to increase in severity, features of SIB and its specific reinforcing effects were examined.

METHOD

Participants were 42 self-injuring adolescents admitted to a hospital over a 4 month period. Data sources consisted of self-report questionnaires and medical chart review.

RESULTS

Mean age was 15.7 +/- 1.5 years. Reported urges to self-injure were almost daily in 78.6% of the adolescents ( n= 33), with acts occurring more than once a week in 83.3% (n = 35). The two primary reasons endorsed for engaging in self-injury were "to cope with feelings of depression" (83.3%, n= 35) and "to release unbearable tension" (73.8%, n= 31). Of the sample, 97.6% ( n= 41) endorsed three or more addictive symptoms.

CONCLUSIONS

SIB in hospitalized adolescents serves primarily to regulate dysphoric affect and displays many addictive features. Those with clinically elevated levels of internalized anger appear at risk for more addictive features of this behavior.

Contagion of deliberate self-harm among adolescent inpatients

OBJECTIVE

To explore the quantitative importance and clinical features of deliberate self-harm (DSH) contagion in a closed adolescent psychiatric unit.

METHOD

The authors investigated with statistical methods and a sociogram whether acts of DSH were clustered during a 12-month study period. Twelve subjects were involved in acts of DSH, and their mean length of hospitalization during the study period was about 90 days. Six adolescents with four or more contagion incidents were interviewed.

RESULTS

DSH incidents were clustered during the study period (p < .05). Most DSH incidents were skin cutting committed by depressed female subjects with borderline personality disorder. The majority of DSH contagion can be understood in terms of small-group rites for feelings of togetherness.

CONCLUSIONS

Even a majority of DSH events in closed adolescent units may be triggered by contagion, and DSH can spread to previously DSH-naive adolescents.

Compulsive targeted self-injurious behaviour in humans with neuropathic pain: a counterpart of animal autotomy? Four case reports and literature review

Four cases of compulsive self-injurious behaviour (SIB) with variable degrees of tissue damage targeted to the painful body part are reported in humans with neuropathic pain. Review of human literature revealed several cases, primarily after central nervous system (CNS) lesions, during which non-psychotic verbally communicating humans (mostly with intact mental status) target specifically the painful part which is usually analgesic or hypoalgesic. In few instances, however, the involved part is not only sentient but also hyperalgesic in part or as a whole. The act is characterized by uncontrollable urge and compulsion, aggravated under conditions of stress, isolation, confusion or depression, and occasionally occurring in patients with personality disorders, ongoing drug abuse and pre-existing compulsive habits (i.e., habitual nail biting or picking). It fails to be deterred by the appearance of the injured part, social mores or even the experience of pain. Successful treatment of underlying painful dysesthesiae with specific medications, neurostimulation or surgery has resulted in marked improvement of dysesthesiae accompanied by wound healing in several cases. The four presented cases and the human literature experience provide evidence that compulsive targeted SIB in humans with neuropathic pain and painful dysesthesiae is consistent with the concept that animal autotomy may result from chronic neuropathic pain after experimental peripheral or CNS lesions.

Role of modelling in in-patient suicide: a lack of supporting evidence

An analysis of the temporal distribution of 115 in-patient suicides that occurred in two Swiss psychiatric hospitals in the years 1977-86 failed to reveal any statistically significant clustering of suicides. Thus, the modelling effect does not generally play a decisive role in psychiatric in-patient suicide.

Self-harm behaviors (carving) in female adolescent drug abusers

Deliberate self-lacerations by rebellious or delinquent adolescent girls, known by them as "carving," may be erroneously diagnosed as a suicide gesture. Carving is an important physical sign suggesting possible drug and alcohol abuse during adolescence. Eighty-five adolescent female patients in a long-term outpatient, self-payment, therapeutic community-type of adolescent drug treatment program, participated in a descriptive survey of "carving" behaviors. Forty-one girls (48%) admitted to deliberate cutting of their own wrists, arms, or other body parts without suicidal intent. Fifteen of the 85 girls (18%) cut themselves six or more times. Many girls had scarified their bodies with their boyfriends' initials as a visible means of demonstrating their affection and loyalty. They also carved rock group symbols or a Christian cross. Large and disfiguring scars were noted on 14 patients. The girls explained the behavior as a method of dealing with depressed affect, anger, emotional pain, or emptiness. Suicide attempts, usually by purposeful overdose of medication, had been made by 24 (59%) of 41 girls who carved themselves. Multiple suicide attempts were associated with habitual carving. Epidemics of carving, led by one or more angry, depressed, or lonely adolescents, may occur in closed facilities such as correctional institutions and drug abuse treatment facilities.

The Werther effect after television films: new evidence for an old hypothesis

In this study it was possible to prove the Werther effect in suicides after watching fictional models for the first time. A twice-broadcast (1981, 1982) six-episode weekly serial showing the railway suicide of a 19-year-old male student provided a quasi-experimental ABABA design to investigate differential effects of suicide imitation. Imitation effects were most clearly observable in the groups whose age and sex were closet to those of the model. Over extended periods (up to 70 days after the first episode), the number of railway suicides increased most sharply among 15- to 19-year-old males (up to 175%); the effect steadily decreased in the older age groups, so that no effect was observable for males over 40 years and females over 30 years. Also, the imitation effects remained detectable for longer periods in the groups closest in age to the model. The increases observed after the first and second broadcast for males aged less than 30 years closely corresponded with the respective audience figures for the two showings.

The challenge of self-mutilation: a review

The challenge of self-mutilation among humans arises from the imprecision of much of the existing literature, as well as the countertransference such disturbing behavior mobilizes. Self-mutilation is defined as an individual's intentionally damaging a part of his or her own body apparently without a conscious intent to die. The importance of understanding this behavior is reflected in the frequency with which it is encountered among psychiatric patients, particularly those diagnosed with borderline personality disorder or schizophrenia. The distinguishing characteristics of dermal, ocular, and genital self-mutilation illustrate the diverse clinical settings in which mutilation arises. Numerous explanations with differing degrees of complexity and merit have been offered; yet, no clear consensus has emerged. Psychotherapy, behavior therapy, and chemotherapy, while controversial, remain the most compelling treatment options. Salient areas for further study include epidemiology both for specific groups and the general population, possible biologic bases for the behavior, and additional management options.

The aftermath of Angie's overdose: is soap (opera) damaging to your health?

In a study designed to evaluate the behavioural impact of a fictional parasuicide--namely, Angie's overdose on the popular television soap opera EastEnders--information about cases of deliberate overdose treated in accident and emergency departments in 63 hospitals throughout Britain was obtained for the week after the televised overdose (experimental period) and the week before the overdose (control period). After adjusting for trends in the equivalent weeks in a control year (1985) the increase in the cases of parasuicide treated by hospitals during the experimental week was not found to be significant. A significant increase (31%) was found among people aged greater than or less than 45, but this is not thought to be reliable. The increase among women alone (21%) was significant with a one tailed test. Contrary to expectations there was a positive association between trends in overdose and distance from London--that is, the further the distance of the region from London the greater the increase in cases of overdose during the experimental period--and a negative association between trends in overdose and viewing figures--that is, the higher the viewing figure the less the impact on the incidence of overdoses. These findings do not lend support to the claim that there was a strong imitation effect after this televised parasuicide.