Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6–12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.     

Risk of suicidal ideation in adolescents with both self-asphyxial risk-taking behavior and non-suicidal self-injury

This study examined adolescent participation in self-asphyxial risk-taking behaviors (SAB), sometimes known as the "choking game," and its relationship with other adolescent risk behaviors, including non-suicidal self-injury (NSSI). Researchers proposed that participation in SAB and NSSI would be associated with suicidal behavior, disordered eating, and substance use. Using a large community-based sample, results revealed preliminary associations between SAB and other risk-taking behaviors. Adolescents who had engaged in both SAB and NSSI reported more concurrent risk behaviors than adolescents who participated in only one of the behaviors or neither behavior. Results indicate that greater awareness of SAB is important, and continued research can evaluate the possible link between the behavior and risk for suicide.     

Peer Victimization and Suicidal Thoughts and Behaviors in Depressed Adolescents

Suicide is a leading cause of death among youth worldwide, and depressed adolescents are at a significantly elevated risk to report suicidal ideation, planning, and attempts. Peer victimization is a robust predictor of adolescent suicidal thoughts and behaviors (STBs), but little research has focused on why bullying leads to suicidal thoughts and behaviors. To address this empirical gap, we recruited 340 (246 female) depressed adolescents ages 13–19 (M = 15.59, SD = 1.41) within 48 h of admission for acute psychiatric treatment. At the initial assessment, participants were administered clinical interviews characterizing psychopathology, nonsuicidal self-injury, and STBs (ideation, plans, and attempts). Further, they completed questionnaires assessing 3 forms of victimization (overt, relational, and reputational), recent risky behavior engagement, and psychiatric symptom severity. Controlling for internalizing symptoms and age, overt and reputational bullying were associated with more frequent past month suicide attempts, but not suicide ideation. Past month risky behavior engagement, but not NSSI, mediated the relation between victimization and attempts. However, sex differences revealed that this effect only held for males whereas bullying was directly associated with suicide attempts among females. In contrast, overt and relational bullying were non-linearly associated with suicide plans, and these relations were not mediated by risky behaviors or NSSI. Results highlight the complex network of factors that lead victimized adolescents to engage in STBs and may inform targeted suicide prevention and intervention programs.     

Cognitive and Social Factors Associated with NSSI and Suicide Attempts in Psychiatrically Hospitalized Adolescents

Although non-suicidal self-injury (NSSI) and suicide attempts (SA) frequently co-occur among youth, there is increasing evidence that both the risk factors and the phenomenology of the behaviors are distinct. This study examined how individuals who engage in NSSI only, individuals who attempt suicide only, and those who have histories of both NSSI and at least one suicide attempt may differ in terms of cognitions and perceived social support. Participants were 185 adolescents (78.1 % female) between the ages of 13 and 18 recruited from a psychiatric inpatient facility in the northeastern United States. One hundred forty-eight teens were identified with a history of self-injurious behavior and divided into three groups: NSSI only (n?=?45), SA only (n?=?24) or both NSSI and SA (NSSI+SA; n?=?79). Analyses showed that the NSSI+SA group exhibited more cognitive errors, negative self-statements, and negative views of self, world, and future, as well as less perceived familial support than either the NSSI or SA only groups. There were no differences between groups on perceived support from teachers or peers. No significant demographic or diagnostic differences were found between the NSSI and SA groups. Limitations and clinical implications of the current research are discussed.     

Peer influence and adolescent nonsuicidal self-injury: A theoretical review of mechanisms and moderators

Nonsuicidal self-injury (NSSI) is an increasingly prevalent health risk behavior among adolescents and represents a significant public health concern. Although researchers have identified numerous antecedents or risk factors that precede engagement in NSSI behaviors, few studies have examined the role of peer influence processes. Yet, recent research suggests that adolescents may be more likely to engage in NSSI when close friends or other peers engage in similar behaviors. The following paper reviews past research on peer influence effects, including potential mechanisms and moderating variables. Methodological considerations for future research on peer influence and NSSI are discussed.     

Thought suppression and self-injurious thoughts and behaviors

This study proposes and tests a theoretical model suggesting that the propensity to suppress unwanted thoughts is associated with an increased presence and frequency of self-injurious thoughts and behaviors (SITB). In the model, propensity to suppress unwanted thoughts is hypothesized to be a cognitive mediator of the relationship between emotional reactivity and SITB, and is expected to be related to the extent to which SITB is initiated to escape from aversive emotions. Results of this cross-sectional study of adolescents (N=87) revealed that the self-reported propensity to suppress unwanted thoughts is associated with the presence and frequency of non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts. Furthermore, thought suppression partially mediates the relationship between emotional reactivity and the frequency of NSSI and suicidal ideation. Finally, adolescents with a higher tendency to suppress unwanted thoughts report engaging in NSSI in order to reduce aversive emotions rather than for social communication. Results are discussed within the framework of the negative reinforcement function of SITB.     

Risk for Suicidal Ideation and Attempt among a Primary Care Sample of Adolescents Engaging in Nonsuicidal Self‐Injury

One in five adolescents in the United States has engaged in nonsuicidal self‐injury (NSSI), one in eight have had serious thoughts of suicide, and one in 25 have attempted suicide. Research suggests that NSSI may increase risk for suicide attempt, yet little is known about the relationship between NSSI and suicidal ideation or attempts. In a primary care setting, 1,561 youth aged 14–24 years completed a brief, comprehensive, mental health screen as part of a routine well visit to determine which factors were most likely to predict suicidal ideation and attempt among youth engaging in NSSI. Results of recursive partitioning revealed that current depression and history of alcohol use best differentiated youth engaging in NSSI with low versus high risk for suicidal ideation and attempts. This simple algorithm is presented as a clinical screening tool that might aid medical providers in determining which youth would benefit from more intensive assessment and intervention.     

Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa

Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.     

Validity of the Self-Harm Behavior Questionnaire with Diverse Adolescents

Suicide and non-suicidal self-injurious behavior (NSSI) continue to be significant health problems for adolescents. Although there are many instruments available to assess self-harm behaviors, few have been validated for use with adolescents, and even fewer have been validated for use with different racial/ethnic groups. The Self-Harm Behavior Questionnaire (SHBQ) assesses NSSI, suicidal ideation, suicide threats, and past suicide attempts. Data from 1,386 racially/ethnically diverse adolescents (57.5% minority) were collected to examine the validity of the SHBQ in this age group. Analyses supported the four-factor structure, revealed the SHBQ is internally consistent, and provided evidence for convergent validity within Caucasian, African American, and Hispanic adolescents. However, slight differences were noted. Overall, the findings suggest the SHBQ is a useful assessment tool appropriate for use with Caucasian, African American, and Hispanic adolescents.     

Dialectical Behavior Therapy for Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

Dialectical behavior therapy (DBT) was originally developed for chronically suicidal adults with borderline personality disorder (BPD) and emotion dysregulation. Randomized controlled trials (RCTs) indicate DBT is associated with improvements in problem behaviors, including suicide ideation and behavior, non-suicidal self-injury (NSSI), attrition, and hospitalization. Positive outcomes with adults have prompted researchers to adapt DBT for adolescents. Given this interest in DBT for adolescents, it is important to review the theoretical rationale and the evidence base for this treatment and its adaptations. A solid theoretical foundation allows for adequate evaluation of content, structural, and developmental adaptations and provides a framework for understanding which symptoms or behaviors are expected to improve with treatment and why. We first summarize the adult DBT literature, including theory, treatment structure and content, and outcome research. Then, we review theoretical underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric disorders (i.e., BPD, mood disorders, externalizing disorders, eating disorders, trichotillomania) and problem behaviors (i.e., suicide ideation and behavior, NSSI) across several settings (i.e., outpatient, day program, inpatient, residential, correctional facility). The rationale for using DBT with these adolescents rests in the common underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.     

2010~2020中国内地初中生心理健康问题检出率的元分析

初中生心理健康问题的检出率在诸多研究中存在很大分歧, 未能为心理健康政策制定和服务体系建设提供充分依据。为明确心理健康问题的整体检出率并澄清其影响因素, 对2010~2020年检索到的文献进行了元分析。结果发现, 初中生面临不同程度的心理健康问题, 其中焦虑、抑郁和自我伤害检出率排在前三位; 初中生心理健康问题随年代发展呈恶化趋势, 其中焦虑和自杀企图尤为明显; 初中生心理健康问题检出率饱受测量工具、检出标准和检出时间不统一的影响; 初中生心理健康问题检出率整体上随年级而增加, 其中焦虑尤为明显; 女生的心理健康问题检出率高于男生, 自杀尤为明显; 中西部地区的初中生比东北和东部地区更容易出现心理健康问题, 尤其是焦虑和自我伤害。未来应立足中国大地研制科学的测量工具和筛查标准并建立心理健康动态监测体系和学校心理健康服务体系。     

Nonsuicidal self-injury and gender: patterns of prevalence, methods, and locations among adolescents

Nonsuicidal self-injury (NSSI) among adolescents is a growing concern. However, little is known about gender and features of this behavior. Gender differences in NSSI among a sample of 7,126 adolescents were investigated, 1,774 of whom reported having engaged in NSSI. Gender differences in prevalence, method, and location of NSSI were examined. Findings revealed that females reported higher rates of NSSI, more cutting and scratching, and more injuries to arms and legs than their male counterparts. Males reported more burning and hitting-type behavior, as well as injuries to the chest, face, or genitals. This highlights an interesting pattern of NSSI, which future research should consider to accurately examine NSSI in females and males.     

The Relationship Between Non-Suicidal Self-Injury and Both Perceived Burdensomeness and Thwarted Belongingness

Prior research has established a connection between non-suicidal self-injury (NSSI) and suicidal behavior. The interpersonal-psychological theory of suicidal behavior (IPTS) posits that an individual must possess both a desire and capability for suicide in order to engage in a lethal suicide attempt. The IPTS conceptualizes the role of NSSI in suicidal behavior as contributing to an individual’s acquired capability. The primary aim of this study was to investigate the relationship between frequency of engagement in NSSI and suicidal desire (thwarted belongingness and perceived burdensomeness). In this study, undergraduate students (n = 999) completed various questionnaires online. Results revealed a significant, positive association between NSSI frequency and thwarted belongingness and a non-significant association between NSSI frequency and perceived burdensomeness. Additionally, results indicated a significant indirect effect of NSSI frequency on burdensomeness and belongingness through depression and borderline personality disorder symptoms. The direct effect of NSSI frequency on belongingness remained significant; however, the direct effect of NSSI frequency on burdensomeness did not. These findings suggest that the relationship between NSSI and suicide is not strictly limited to acquired capability, but rather includes a component of suicidal desire.     

Risk factors associated with suicide attempts and other self-injury among Hong Kong adolescents

This study examined 1,361 Chinese adolescents who reported self-injurious behaviors. Groups A and B both acknowledged deliberate self-injury, but only Group A had made a suicide attempt. Group C reported accidental self-injury. Deliberate self-injurers (Groups A and B) were more frequently girls, older, and with more suicidal ideation. Group A had more psychopathology, environmental and suicide-related risk factors than group B and C. Group C had higher depressive symptoms than noninjured controls. The study clarifies differences among self-injurious behavior groups based on expressed deliberate self-injury and self-reported suicide attempt. These three groups appear to present a continuum of risk.     

Self-Injurious Thoughts and Behaviors Interview: development, reliability, and validity in an adolescent sample

The authors developed the Self-Injurious Thoughts and Behaviors Interview (SITBI) and evaluated its psychometric properties. The SITBI is a structured interview that assesses the presence, frequency, and characteristics of a wide range of self-injurious thoughts and behaviors, including suicidal ideation, suicide plans, suicide gestures, suicide attempts, and nonsuicidal self-injury (NSSI). This initial study, based on the administration of the SITBI to 94 adolescents and young adults, suggested that the SITBI has strong interrater reliability (average kappa = .99, r = 1.0) and test-retest reliability (average kappa = .70, intraclass correlation coefficient = .44) over a 6-month period. Moreover, concurrent validity was demonstrated via strong correspondence between the SITBI and other measures of suicidal ideation (average kappa = .54), suicide attempt (kappa = .65), and NSSI (average kappa = .87). The authors concluded that the SITBI uniformly and comprehensively assesses a wide range of self-injury-related constructs and provides a new instrument that can be administered with relative ease in both research and clinical settings.     

青少年自我伤害行为的潜在转变分析:一项纵向研究

研究采用潜在转变分析探究了青少年自我伤害行为的发展。对3600名青少年进行为期18个月的追踪,对其自我伤害行为进行了三次测量。通过纵向数据分析识别出过渡组这一以往研究未发现的群体,该组被试仅出现程度较轻的自我伤害行为,且占总体的比例随时间快速下降。通过转变矩阵解释了过渡组和高发组的不稳定性是自我伤害行为发生率降低的原因,并发现冲动性、负向情绪等个体易感因素比家庭等人际因素对自我伤害行为存在更为显著的预测作用。在性别差异上,女生比男生更容易产生自我伤害行为,也更容易受到各方面因素的影响。最后,文章针对青少年自我伤害行为的预防和控制工作提出了建议。     

Non-Suicidal Self-Injury Among Male Adjudicated Adolescents: Psychosocial Concerns,Coping Responses,Diagnoses, and Functions

Non-suicidal self-injury (NSSI) refers to self-inflicted physical injury without suicidal intent. NSSI is particularly common in forensic settings and associated with several psychosocial concerns, coping responses, diagnoses, and functions, but little information is available regarding NSSI in adjudicated male adolescents. The present study examined the frequency and types of NSSI among adjudicated male adolescents (n?=?103) and assessed the relationships between NSSI history, psychosocial concerns, coping responses, diagnoses, and functions within this population. Approximately two-thirds (66%) reported NSSI history. Participants with NSSI history reported poorer social adaptation and greater alienation and boredom, aggression, and emotional lability than controls. Youth with high-frequency NSSI were also more likely to utilize emotional discharge as an unhealthy coping response than controls. In addition, participants with high-frequency NSSI were more likely than controls to meet criteria for a mood or anxiety disorder. Function of NSSI primarily surrounded anxiety reduction/affect regulation, punishment, dissociation reduction, and social/sensation-seeking. NSSI appears to be prevalent among male adjudicated youths, and the findings suggest that the relationship between NSSI history, psychosocial concerns, coping responses, and functions is nuanced and could inform more calibrated assessment and treatment strategies.     

自伤行为的神经生理机制及共病障碍比较

非自杀性自伤行为（Non-Suicidal Self-Injury, NSSI）,简称自伤行为,意为个体在没有明确的自杀意图的情况下,故意、重复地改变或伤害自己的身体组织,是一种不具致死性或致死性较低的、以自身为伤害目标的破坏性行为。本文主要基于近十年的研究文献,从神经生理层面对自伤行为相关脑区、神经递质以及与共病障碍的异同展开述评,并尝试建立一个整合性的自伤行为认知神经机制模型。 关于自伤行为的神经生理机制,综合以往研究发现,自伤患者边缘系统中情绪脑区的异常（如杏仁核的过度激活等）使患者可能产生情绪调节障碍进而导致自伤;控制脑区如前额叶皮层的异常导致其抑制控制能力受损;奖赏脑区如眶额皮层等的过度激活或许会成为自伤复发的维持因素;自伤患者疼痛感知区域如HPA轴的反应水平的减弱使其疼痛敏感性较低并主动追寻疼痛感。除此之外,相关的神经递质和基因的异常也是自伤研究领域关注的重点。比如5-羟色胺转运体其基因连锁多态区的短等位基因会减弱该递质的调节功能,诱使个体出现情绪调节障碍;又比如内源性阿片肽参与了疼痛和情绪调节的过程,且其水平会因个体早期挫折经历和遗传因素而降低,而自伤行为可以促进该递质的释放;同样的,在阿片受体被刺激之后,自伤者体内的多巴胺水平将会升高,个体对自伤行为产生愉悦感。 此外,还将其与自杀、成瘾、进食障碍和抑郁障碍进行了比较。自伤和自杀尝试者在脑电指标上有某些不同的表现,但二者从行为研究和功能成像的角度也呈现出相似性。个体的自伤行为与物质成瘾显著相关,且二者都伴随着抑制控制能力的损伤、阿片类和多巴胺系统异常引发的对某种物质或行为的渴望等。进食障碍患者和自伤行为存在较高的共病率,前者可能就是一种间接的自伤,且二者的脑电和功能成像的指标部分相似。最后,抑郁障碍也是和自伤行为有着较高共病率的一种障碍,部分抑郁障碍患者会通过自伤来调节情绪,且二者有共同的风险因素以及部分重叠的神经机制。研究以上障碍与自伤行为的异同有助于我们从不同角度认识自伤,并多方位实施预警和干预。 在此基础上,本文尝试构建了自伤行为的认知神经机制假设模型,将自伤的认知过程与各阶段起主要作用的神经生理机制相联系。未来的研究可以关注于自伤行为的性别差异、发展特点、干预以及与注意脑区异常的联系等。     

Rates of Non-Suicidal Self-Injury: A Cross-Sectional Analysis of Exposure

Research on the social influences associated with rates of non-suicidal self-injury (NSSI) is scarce and limited to studies of contagion within inpatient and residential treatment settings. Using an archival dataset that included 1,965 college students, the current study examined whether exposure to acts of NSSI and/or suicidal behavior in others was associated with increased rates of NSSI. Results supported hypotheses in that participants who knew someone who had engaged in NSSI only, or knew someone who engaged in both NSSI and suicidal behavior were more likely to have engaged in NSSI compared to those not exposed. The findings provide preliminary, albeit indirect, evidence of the potential for social modeling to influence rates of NSSI within college students. Directions for future studies are offered.     

Frequency of Nonsuicidal Self‐Injury in Adolescents: Differences in Suicide Attempts,Substance Use,and Disordered Eating

The relationship between frequency of nonsuicidal selfinjury (NSSI) and suicide attempts, substance use, and disordered eating was assessed in a community sample of 4,839 adolescents, 922 of whom reported NSSI in the past year. It was expected that the engagement in risk behaviors would significantly increase as NSSI frequency increased. Participants completed the Youth Risk Behavior Survey (Centers for Disease Control and Prevention, 2009) and were subdivided into five NSSI frequency groups: none, 1 time, 2–3 times, 4–5 times, and 6 or more times. A one‐way MANOVA found significant mean differences for all variables across NSSI frequency groups. The no NSSI group was significantly lower than all other groups on all variables. For suicide attempts, all frequency groups were significantly different from each other, with attempt frequency increasing with each increase in NSSI frequency. The six or more group reported significantly more substance use and disordered eating than all other groups. Overall, adolescents with more frequent NSSI represent a group at risk for concurrent unhealthy behaviors and suicide attempts.