Nonsuicidal self-injury among adolescents with disorders of emotion and behavior: clinical characteristics and association with suicidality
Abstract
Abstract
Introduction: Nonsuicidal self-injury (NSSI) is defined as a separate entity of the DSM-V classification of mental disorders, as a “condition for further study”. Although the NSSI is not driven by suicidal intention, studies do show its association with suicidal phenomena, but this relationship is still unclear.
The aim: The aim of our paper was to examine the characteristics of the NSSI phenomenon among adolescents with disorders of emotion and behavior, with special emphasis on its association with suicidal behavior.
Material and methods: The study included 100 older adolescents with depressive disorders, anxiety disorders, adjustment disorders and mixed disorders of conduct and emotion, who were treated in day hospital. The data was obtained from the existing medical records, and included information of NSSI and suicidal phenomena, psychiatric symptoms, diagnoses, rating scales for depression and global functioning, and data from personal and family history.
Results: In our sample, the NSSI was more common in girls, and among younger adolescents. When it comes to clinical characteristics, this phenomenon was associated with higher depression symptom scores at admission and discharge, the presence of hypobulia-anhedonia, panic attacks, tension and restlessness, heteroaggressive manifestations, more frequent use of alcohol and borderline personality disorder. NSSI was also significantly associated with the presence of suicidal ideation during life, as well as with more severe suicidality level. Among NSSI patients, suicidal attempts were more common among those who were neglected in childhood, with younger age of maltreatment onset, those with lower global functioning on admission, with cognitive problems, and with problematic compliance at admission.
Conclusion: High prevalence of NSSI in our sample, as well as numerous clinical features associated with it, may speak in favor of this phenomenon as a separate diagnostic entity. The observed association to suicide can be of clinical significance in terms of directing preventive steps.
Keywords: nonsuicidal self-injury, self-harm, adolescents, suicidality
References
Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med. 2007; 37(8):1183-1192.
Zetterqvist M. The DSM-5 diagnosis of nonsuicidal self-injury disorder: A review of the empirical literature. Child Adolesc Psychiatry Ment Health. 2015; 9:31.
Bentley KH, Cassiello-Robbins CF, Vittorio L, Sauer-Zavala S, Barlow DH. The association between nonsuicidal self-injury and the emotional disorders: A meta-analytic review. Clin Psychol Rev. 2015; 37:72-88.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition.Washington, DC: American Psychiatric Publishing; 1994.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. Arlington, TX: American Psychiatric Publishing; 2013.
Klonsky ED, Victor ES, Saffer YB. Nonsuicidal self-injury: What we know and what we need to know. Can J Psychiatry. 2014; 59(11): 565-568.
Andover MS, Gibb BE. Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Res. 2010; 178(1):101-105.
Victor SE, Styer D, Washburn JJ. Characteristics of nonsuicidal self-injury associated with suicidal ideation: evidence from a clinical sample of youth. Child Adolesc Psychiatry Ment Health. 2015; 9:20.
Guan K, Fox RK, Prinstein JM. Nonsuicidal self-injury as a time-invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. J Consult Clin Psychol. 2012; 80(5): 842-849.
Dhingra K, Ali P. Non-suicidal self-injury: clinical presentation, assessment and management. Nursing standard. 2016; 31(5):42-49.
Grandclerc S, De Labrouche D, Spodenkiewicz M, Lachal J, Moro MR. Relations between nonsuicidal self-injury and suicidal behavior in adolescence: A systematic review. PloS One. 2016; 11(4):e0153760.
Brown CR, Plener LP. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep. 2017; 19(3):20.
Pejović-Milovančević M, Minčić T, Kalanj D (ured.); Alimpijević Đ, Vidojević O, Vidosavljević M, Đorđević M, Kalanj D, Lakić A et al. Priručnik za primenu Posebnog protokola sistema zdravstvene zaštite za zaštitu dece od zlostavljanja i zanemarivanja. Beograd: Institut za mentalno zdravlje; 2012.
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960; 23:56-62.
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959; 32:50-55.
Kroenke K, Spitzer IS. The PHQ-9: A new depression and severity measure. Psychiatric Annals. 2002; 32(9):509-515.
Bresin K, Schoenleber M. Gender differences in the prevalence of nonsuicidal self-injury: A meta-analysis. Clin Psychol Rev. 2015; 38:55-64.
Sornberger MJ, Heath NL, Toste JR, McLouth R. Nonsuicidal self-injury and gender: patterns od prevalence, methods, and locations among adolescents. Suicide Life Threat Behav. 2012; 42(3):266-278.
Hoeksema-Nolen S, Aldao A. Gender and age differences in emotion regulation strategies and their relationship to depressive symptoms. Personality and individual differences. 2011; 51(6):704-708.
Pejović-Milovančević M, Krgović I, Mitković-Vončina M. Adolescentni mozak – promene i izazovi razvoja. Med Podml. 2017; 68(2):8-13.
Kranzler A, Fehling KB, Anestis MD, Selby EA. Emotional dysregulation, internalizing symptoms, and self-injurious and suicidal behavior: Structural equation modeling analysis. Death Stud. 2016; 40(6):358-366.
Zielinski MJ, Veilleux JC, Winer ES, Nadorff MR. A short-term longitudinal examination of the relation between depresion, anhedonia, and self-injurious thoughts and behaviors in adults with a history of self-injury. Compr Psychiatry. 2017; 73:187-195.
Kleindienst N, Bohus M, Ludascher P et al. Motives for nonsuicidal self-injury among women with borderline personality disorder. J Nerv Ment Dis. 2008; 196:230–236.
Smith NB, Kouros CD, Meuret ARE. The role of trauma symptoms in nonsuicidal self-injury. Trauma Violence Abuse. 2014; 15:41–56.
Zielinski MJ, Hill MA, Veilleux JC. Is the first cut really the deepest? Frequency and recency of nonsuicidal self-injury in relation to psychopathology and dysregulation. Psychiatry Res. 2018; 259:392-397.
Glenn CR, Klonsky ED. A multimethod analysis of impulsivity in nonsuicidal self-injury. Personal Disord. 2010; 1(1): 67-75.
Lockwood J, Daley D, Townsend E, Sayal K. Impulsivity and self-harm in adolescence: a systematic review. Eur Child Adolesc Psychiatry. 2017; 26(4):387-402.
Bracken-Minor KL, McDevitt-Murphy ME. Differences in features of non-suicidal self-injury according to borderline personality disorder screening status. Arch Suicide Res. 2014; 18(1): 88-103.
Nixon MK, Cloutier PF, Aggarwal S. Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry. 2002; 41(11):1333-41.
Favazza AR. Self-injurious behavior in college students. Pediatrics. 2006; 117(6):2283-4.
Peterson J, Freedenthal S, Sheldon C, Andersen R. Nonsuicidal self injury in adolescents. Psychiatry (Edgemont). 2008; 5(11):20-26.
Yildirim F, Küçükgöncü S, Beştepe EE, Yildirim MS. The relationship of childhood abuse and neglect with suicide attempts in an adult unipolar depression sample. Noro Psikiyatr Ars. 2014; 51(2):133-140.
Mitković-Vončina M, Pejović Milovančević M, Mandić Maravić V, Lečić Toševski D. Timeline of intergenerational child maltreatment: the mind-brain-body interplay. Curr Psychiatry Rep. 2017; 19:50.
Mitković-Vončina M, Leštarević S, Pejović-Milovančević M, Radosavljev-Kirćanski J, Kalanj M, Lečić Toševski D. Child maltreatment predicting more severe psychiatric and biological phenotype among adolescent patients with depressive symptoms. Programme of the 31st ECNP eCongress, Barcelona, 6-9 October, 2018: P573.
Teicher MH, Samson JA. Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes. Am J Psychiatry. 2013; 170(10):1114-33.
Gibb BE, Alloy LB, Abramson LY, Rose DT, Whitehouse WG, Hogan ME. Childhood maltreatment and college students current suicidal ideation: a test of the hopelessness theory. Suicide Life Threat Behav. 2001; 31(4):405-15.