Neuroimaging Studies of Nonsuicidal Self-Injury in Youth: A Systematic Review

Altered brain structure and function correlate with non-suicidal self-injury in children and adolescents with transdiagnostic psychiatric disorders

Non-suicidal self-injury (NSSI) is a prevalent mental problem among children and adolescents, cutting across psychiatric disorders. Studies in specific disorders such as depression and ADHD have revealed associations with alterations in brain regions responsible for reward processing and emotion regulation. However, it remains largely unknown whether such associations are shared among different disorders. Here, we aimed to examine brain structural and functional associations with NSSI in a transdiagnostic psychiatric cohort of children and adolescents. A total of 386 patients (age = 10.72 ± 3.53, range = 5.04 to 21.22) diagnosed primarily with ADHD, autism and generalized anxiety disorder from the Healthy Brain Network study were included. Using linear regression models, we examined brain volumes (N = 386) and functional connectivities (N = 277) associated with NSSI and whether potential alterations could moderate/mediate the links between internalizing/externalizing symptoms and NSSI. We found that increased severity of NSSI was associated with decreased bilateral putamen volumes, and reduced connectivities of the left putamen with bilateral regions of temporoparietal junction and of the right putamen with the left temporoparietal junction, demonstrating the role of putamen in NSSI behavior. Moreover, some of these associations played moderating roles: in patients with lower putamen volumes or weaker functional connectivities, increased internalizing/externalizing symptoms were associated with higher NSSI severity. Our findings suggest that transdiagnostic NSSI is linked to structural alterations and functional dysfunctions in putamen, highlighting that putamen may serve as a neural marker of NSSI and as a potential target for neuromodulation treatments across mental conditions.

Associations between multiple sleep dimensions and suicide and non-suicidal self-injury: a cross-sectional study of 3828 Chinese young people

PURPOSE

Suicide and non-suicidal self-injury (NSSI) are preventable concerns in young people. Suicidal ideation (SI), suicidal plans (SP) and suicidal attempt (SA) are closely related to death. Sleep problems are known risk factors for suicide and NSSI. This study aimed to explore the relationship between sleep, suicidality and NSSI.

METHODS

Participants were 3,828 middle school and college students aged 11-23 years from urban and rural areas of Henan Province. Sleep, suicidal phenomena and NSSI were assessed by applying self-reported questionnaires. Chi-squared tests were utilized to demonstrate the demographic data and sleep variables. The correlation between sleep, suicidality and NSSI were explored by using binary logistic regression, while adjusting socio-demographic characteristics with multivariate models.

RESULTS

Sleep variables except mid-sleep time were related to suicidal phenomena (P < 0.05). Greater social jet lag (SJL) [≥ 2 h (h)] was associated with increased risk of SI [Odds ratios (OR) = 1.72, 95% confidence intervals (CI):1.40-2.11], SP (OR = 2.10, 95%CI:1.59-2.79) and SA (OR = 1.50, 95%CI:1.00-2.26). Non-only child participants with SJL (≥ 2 h) had significantly increased odds of SI (OR = 1.75, 95%CI: 1.41-2.18) and SP (OR = 2.25, 95%CI: 1.66-3.05). Eveningness chronotype had the strongest correlation with SI (OR = 3.87, 95%CI:2.78-5.38), SP (OR = 4.72, 95%CI:2.97-7.50), SA (OR = 6.69, 95%CI:3.08-14.52) and NSSI (OR = 1.39, 95%CI:1.02-1.90).

CONCLUSION

Overlong or short sleep duration, SJL, eveningness chronotype and other sleep abnormalities (e.g., daytime dysfunction, low sleep efficiency) were associated with a higher prevalence of SI, SP and SA. Additionally, eveningness was significantly correlated with NSSI among young people. These findings suggested the importance of assessing and intervening in sleep habits to prevent suicide and NSSI in young people.

Impulse control deficits among patients with nonsuicidal self-injury: a mediation analysis based on structural imaging

BACKGROUND

Nonsuicidal self-injury (NSSI) is posited to arise from a complex interaction of biopsychosocial factors, with impulsivity playing a critical role. Given that current research on the neural mechanisms underlying this hypothesis remains inconsistent and limited in scope, we sought to explore how NSSI behaviours are associated with impulsivity resulting from structural brain alterations.

METHODS

We recruited patients with NSSI behaviours and healthy controls from 11 psychiatric hospitals. We assessed the differences in impulse control between the 2 groups using the Barratt Impulsiveness Scale version 11 and the Attention Network Test. We also conducted T 1-weighted magnetic resonance imaging (MRI) and diffusion tensor imaging. Finally, we analyzed the associations among brain structure, psychological characteristics, and self-injurious behaviour among patients with NSSI.

RESULTS

We included 293 patients with NSSI behaviours and 140 healthy controls. Among them, 182 patients with NSSI and 95 controls underwent the T 1-weighted MRI and diffusion tensor imaging. Patients with NSSI showed increased impulsivity and alerting function, with the strongest correlation between NSSI frequency and motor impulsivity. Compared with controls, patients with NSSI exhibited decreased grey matter volume and increased white matter volume, with no significant difference in cortical thickness. Pathway analysis demonstrated that motor impulsivity significantly mediated the association between white matter volume and the NSSI frequency in the right superior frontal gyrus and right inferior parietal lobe. When examining the connecting fibre tracts in the right frontoparietal area, patients with NSSI showed decreased integrity of white matter microstructure in the right cingulum, right superior corona radiata, and the splenium of the corpus callosum.

LIMITATIONS

Accurately measuring executive control linked to NSSI is challenging in cognitive behavioural tasks, as impulsive tendencies during NSSI occurrence are not effectively captured.

CONCLUSION

Our findings suggested that motor impulsivity, a prominent psychopathological characteristic of NSSI, is primarily modulated by the frontoparietal regions. These results provide empirical neuroimaging evidence for the impaired impulse control observed in NSSI.

Molecular Pathways, Neural Circuits and Emerging Therapies for Self-Injurious Behaviour

Nonsuicidal self-injurious behaviour (SIB) is a debilitating manifestation of physical aggression commonly observed across neurodevelopmental, psychiatric, and genetic disorders. This behaviour arises from a multifactorial aetiology involving genetic predispositions, epigenetic modifications, neurotransmitter dysregulation, and environmental stressors. Dysregulation in dopaminergic, serotonergic, glutamatergic, and GABAergic systems has been implicated in the pathophysiology of SIB, alongside structural and functional abnormalities within fronto-limbic-striatal circuits. These disruptions impair key processes, such as emotional regulation, reward processing, and behavioural inhibition, contributing to the emergence and reinforcement of SIB. Advances in preclinical research using genetic, lesion-based, pharmacological, and environmental animal models have been instrumental in elucidating the molecular and neurocircuitry underpinnings of SIB. Emerging neuromodulation therapies targeting critical nodes within the fronto-limbic-striatal network, particularly deep brain stimulation, have shown promise in treating severe, refractory SIB and improving quality of life. This review integrates current evidence from clinical studies, molecular research, and preclinical models to provide a comprehensive overview of the pathophysiology of SIB and therapeutic approaches. By focusing on the molecular mechanisms and neural circuits underlying SIB, we highlight the translational potential of emerging pharmacological and neuromodulatory therapies. A deeper understanding of these pathways will pave the way for precision-based interventions, bridging the gap between molecular research and clinical applications in SIB and related conditions.

Temporal Framework and Biological Indicators of Non-Suicidal Self-Injury and Related Behaviours

Adolescence is a transitional stage between puberty and maturity. Significant alterations in brain chemistry and hormone activity cause mood swings and other psychological and physical symptoms. On their journey to adolescence, adolescents deal with complex emotions, moral dilemmas, sexual concerns, identity crises and particular societal expectations related to their upbringing. Impulsivity in adolescents is frequent and causes multiple issues. Impulsivity often lead towards non-suicidal self-injury (NSSI), which has devastating consequences, which are both physical and mental. Both impulsivity and NSSI have their roots in brain chemistry and its related functions. The aim of this special communication was to delve into brain chemistry through studying the function of neurotransmitters and brain areas in NSSI and impulsivity. Multiple papers were sought on the topic of neurochemistry and neuroanatomy. The results identified serotonin, dopamine and glutamate as the neurotransmitters responsible for NSSI and impulsivity. Dysregulation in these neurotransmitters lead to the presentation of NSSI and impulsivity. Other than the neurotransmitters, the brain areas identified were prefrontal cortex, medial prefrontal cortex and ventrolateral prefrontal cortex. The compiled results of this research would help individuals in understanding the neurotransmitters and the brain areas responsible. This would also help in generating awareness regarding the biological nature of the phenomenon as well, leading to less stigmatisation. The less stigmatisation towards these phenomena can help the affected individuals to seek help without any guilt or shame, along with support from society as well.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prefrontal cortex neural activity predicts reduction of non-suicidal self-injury in adolescents with major depressive disorder: An event related potential study

Background

Non-suicidal self-injury (NSSI) is common in adolescent MDD, which is also a risk factor for suicide. However, there is few research on biomarkers and predictors about treatment response of NSSI. The purpose of this study was to find the difference of P300 between adolescent MDD with NSSI and healthy controls, and to explore whether the baseline electrophysiological level can predict the change of NSSI after treatment.

Methods

We collected 62 first-episode drug-naïve MDD adolescents with NSSI (MDD with NSSI group) and 44 healthy controls (HC group). The demographic data, HAMD score, self-injury frequency and electrophysiological level of NSSI group and HC group were collected. The HAMD score, frequency of NSSI in was also collected after 8 weeks of antidepressant treatment.

Results

Compared to HC, the latency of the N2, P3a, and P3b components were significantly prolonged, whereas the amplitude of P3a and P3b were decreased in the MDD with NSSI group (P < 0.001). The frequency of self-injury decreased significantly after treatment (P < 0.001). Regression analysis showed that the amplitudes of P3b had a significant positive predictive effect on the rate of change of NSSI frequency after 8 weeks.

Conclusion

P3b at baseline can be used as potential predictor for the reduction of NSSI in adolescent MDD.

Elevated levels of monocyte-lymphocyte ratio and platelet-lymphocyte ratio in adolescents with non-suicidal self-injury

BACKGROUND

Neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) are blood indicators of systemic inflammation. This study aims to compare the levels of inflammatory indicators derived from blood routine tests between adolescents with non-suicidal self-injury (NSSI) and those with non-NSSI.

METHODS

A total of 201 adolescents with mood or emotional disorders were enrolled in this study, among which 106 had engaged in NSSI and 95 had never engaged in NSSI. NLR, MLR, and PLR were calculated based on the complete blood cell count.

RESULTS

There was no significant difference in demographic data between the two groups. The NSSI group exhibited significantly higher MLR (P = 0.001) and PLR (P = 0.007) than the non-NSSI group. Multivariate logistic regression analysis revealed that MLR (OR 1.545, 95%CI [1.087-2.281], P = 0.021) and PLR (OR 1.327, 95%CI [1.215-1.450], P < 0.001) were independently associated with NSSI. Receiver operating characteristic (ROC) curve analyses demonstrated that for differentiating NSSI from non-NSSI, the optimal cut-off value of MLR was 0.135 and the area under curve was 0.638 ([0.561- 0.715], P < 0.001), with a sensitivity of 90.60% and a specificity of 33.70%; the optimal cut-off value of PLR was 127.505 and the area under curve was of 0.611 ([0.533-0.689], P < 0.001), with a sensitivity of 39.60% and a specificity of 81.10%.

CONCLUSIONS

Systemic inflammation, as indicated by elevated MLR and PLR, was found to be strongly associated with NSSI among adolescents.

Nonsuicidal Self-Injury: A Nurse-Led Quality Improvement Project to Address Self-Harm

Nonsuicidal self-injury (NSSI) behaviors, such as cutting, scratching, or more severe injuries, are frequently comorbid with neurodevelopmental, intellectual, trauma, personality, and major depressive disorders, complicating treatment and placing added care burdens on hospital nursing staff and advanced practice nurses. Although specific psychopharmacological treatment guidelines and approved medications for NSSI are non-existent, patients are treated with medications approved for co-morbid disorders and behavioral interventions targeting intrapersonal (poor emotional self-regulation) and interpersonal (communication of distress) functions. The current article describes a nurse-led quality improvement project, using the Plan-Do-Study-Act cycle, in a case example. Outcomes include improved staff competencies and policies, yet we remain challenged in implementing planned actions that add additional time burdens to already stretched care providers. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 7-10.].