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Exploring the suicidal continuum: Deliberate self-harm diversity and severity as predictors of suicidal ideation and suicide attempts

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Abstract

Deliberate self-harm (DSH) in adolescence is a predictor of suicidal thoughts and behaviors (STBs). However, there is still a lack of research systematizing the association between DSH and STBs. Therefore, our main goal was to analyze if DSH diversity and severity predicted suicidal ideation and suicide attempts. Our sample comprised 237 Portuguese adolescents and young adults with a history of DSH, from community (80.2%, n=190) and clinical (19.8%, n=47) settings, aged between 14 and 23 years (M=17.31, SD=1.36). Results showed that DSH diversity and severity were significant predictors of suicidal ideation and suicide attempts. These results were further discussed, underlining the impact that DSH has for suicide risk and highlighting the need to address further variables to understand these suicidality trajectories.

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Background: Adolescents with previous self-injurious thoughts and behaviors (SITB) have over 2-fold risk of dying by suicide, higher than older ages. This meta-analysis aims to disentangle the association of each SITB with subsequent suicidal behavior in adolescence/young adulthood, the contribution of each SITB, and the proportion of suicide deaths with no previous suicide attempt. Methods: We searched 6 databases until June 2015. Inclusion criteria: 1. Assessment of any previous SITB [a) suicidal thoughts and behaviors (ideation; threat/gesture; plan; attempt); b) non-suicidal thoughts and behaviors (thoughts; threat/gesture; self-injury); c) self-harm] as a risk factor of suicide attempt or suicide death; 2. Case-control or cohort studies; 3. Subjects aged 12-26y. Random effect models, metaregression analyses including mental health and environmental variables, and population attributable risks (PAR)s were estimated. Results: From 23,682 potentially eligible articles, 29 were included in the meta-analysis (1,122,054 individuals). While 68% of all youth suicide deaths had no previous suicide attempt, suicide death was very strongly associated with any previous SITB (OR=22.53, 95%CI: 18.40-27.58). Suicide attempts were also associated with a history of previous SITB (OR=3.48, 95%CI: 2.71-4.43). There were no moderating effects for mental health and environmental features. The PAR of previous SITB to suicide attempts is 26%. Limitations: There is considerable heterogeneity between the available studies. Due to limitations in the original studies, an over-estimation of the proportion dying at their first attempt cannot be ruled out, since they might have missed unrecognized previous suicide attempts. Conclusions: Although more than two thirds of suicide deaths in adolescence/young adulthood have occurred with no previous suicidal behavior, previous SITBs have a much higher risk of dying by suicide than previously reported in this age group.
Article
Adolescent non-suicidal self-injury (NSSI) and suicidality are serious health concerns; however, factors that contribute to the transition from NSSI to suicide ideation and suicide attempts are unclear. To address this gap, we investigated whether demographic characteristics, child maltreatment, and psychiatric factors are associated with the level suicidality among adolescents with a history of self-injury. Participants were three groups of adolescent inpatient self-injurers (n = 397, 317 female), aged 13-18 years (M = 15.44, SD = 1.36): (a) non-ideators (n = 96; no current suicide ideation and no lifetime suicide attempts), (b) suicide ideators (n = 149; current ideation and no lifetime attempts), and (c) suicide attempters (n = 152; current ideation and at least one lifetime attempt). Participants completed interviews assessing psychiatric diagnoses, suicidality, and NSSI characteristics, as well as questionnaires on childhood trauma, psychiatric symptoms, and risky behavior engagement. Depression severity was associated with greater odds being a suicide ideator (p < .001, OR=1.04) and an attempter (p < .001, OR = 1.05) compared to a non-ideator. Suicide attempters used more NSSI methods and reported greater risky behavior engagement than non-ideators (p = .03, OR = 1.29 and p = .03, OR = 1.06, respectively) and ideators (p = .015, OR = 1.25 and p = .04, OR = 1.05, respectively); attempters used more severe NSSI methods (e.g., burning). Our results identify a wide range of risk markers for increasing lethality in a sample at high risk for suicide mortality; future research is needed to refine risk assessments for adolescent self-injurers and determine the clinical utility of using risk markers for screening and intervention.
Article
This correlational study was conducted with 403 undergraduate college students from 2 universities. The authors used path analysis and bootstrap regression to analyze the relationships between variables. Locus of control and family connectedness related to current nonsuicidal self-injury (NSSI) engagement. However, when entered into the same regression, the variables current NSSI engagement and current NSSI number of methods used mediated all other relationships with suicidal ideation. Implications to current theories and clinical practice are provided.
Article
The study aims to determine the prevalence of self-harm (SH) and related psychosocial factors in a large sample of Portuguese adolescents. A total of 1713 pupils, aged 12 to 20 years, completed an anonymous questionnaire in a school setting. 7.3% reported at least one episode of SH: rates were three times higher for females than males. Almost half reported repeated SH, most commonly self-cutting. Anxiety, depression and substance abuse were linked to SH, and particularly repeated SH. Anxiety, trouble with the police, and exposure to SH or suicide of others, were independently associated with SH in both genders. These findings indicate that SH is a public health concern in Portugal as in other European countries.
Article
Existing research supports a relationship between nonsuicidal self-injury (NSSI) and the emotional disorders (i.e., anxiety, mood, and related disorders). The aim of this investigation was to conduct a meta-analysis of the associations between NSSI and the emotional disorders, and evaluate the quality of evidence supporting this relationship. A literature search was conducted from database inception through June 2014, and two reviewers independently determined the eligibility and quality of studies. A total of 56 articles providing data on engagement in NSSI among individuals with and without emotional disorders met eligibility criteria. Compared to those without an emotional disorder, individuals with an emotional disorder were more likely to report engagement in NSSI (OR=1.75, 95% CI: 1.49, 2.06). This increase of risk of NSSI was shown for each disorder subgroup, with the exceptions of bipolar disorder and social anxiety disorder. The largest associations were observed for panic and post-traumatic stress disorder; however, the risk of NSSI did not differ significantly across disorders. The quality of evidence was variable due to inconsistent methodological factors (e.g., adjustment for confounding variables, NSSI assessment). Overall, these findings provide evidence for a relationship between NSSI and the emotional disorders, and support conceptualizations of NSSI as transdiagnostic. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Nonsuicidal self-injury (NSSI) is a risk factor for suicide attempts, but little is known about NSSI among military personnel and veterans, or about the temporal sequencing of NSSI relative to suicide ideation and attempts. This study evaluates trajectories of suicide ideation, NSSI, and suicide attempts in a sample of 422 military personnel and veterans. Of those with a history of NSSI, 77% also experienced suicide ideation. Suicide ideation emerged before NSSI (67%) more often than the reverse (17%). Of those with a history of suicide attempt, 41% also engaged in NSSI. NSSI emerged prior to the first suicide attempt (91%) more often than the reverse (9%). The length of time from suicide ideation to suicide attempt was longer for those who first engaged in NSSI (median = 3.5 years) compared with those who did not engage in NSSI (median = 0.0 years), Wald χ2(1) = 11.985, p = .002. Age of onset was earlier for participants reporting NSSI only compared with those reporting both NSSI and suicide attempts (16.71 vs. 22.08 years), F(1, 45) = 4.149, p = .048. NSSI may serve as a “stepping stone” from suicide ideation to attempts for 41% of those who attempt suicide.
Article
Although there is a general consensus among researchers that engagement in nonsuicidal self-injury (NSSI) is associated with increased risk for suicidal behavior, little attention has been given to whether suicidal risk varies among individuals engaging in NSSI. To identify individuals with a history of NSSI who are most at risk for suicidal behavior, we examined individual variability in both NSSI and suicidal behavior among a sample of young adults with a history of NSSI (N = 439, Mage = 19.1). Participants completed self-report measures assessing NSSI, suicidal behavior, and psychosocial adjustment (e.g., depressive symptoms, daily hassles). We conducted a latent class analysis using several characteristics of NSSI and suicidal behaviors as class indicators. Three subgroups of individuals were identified: 1) an infrequent NSSI/not high risk for suicidal behavior group, 2) a frequent NSSI/not high risk for suicidal behavior group, and 3) a frequent NSSI/high risk for suicidal behavior group. Follow-up analyses indicated that individuals in the 'frequent NSSI/high risk for suicidal behavior' group met the clinical-cut off score for high suicidal risk and reported significantly greater levels of suicidal ideation, attempts, and risk for future suicidal behavior as compared to the other two classes. Thus, this study is the first to identity variability in suicidal risk among individuals engaging in frequent and multiple methods of NSSI. Class 3 was also differentiated by higher levels of psychosocial impairment relative to the other two classes, as well as a comparison group of non-injuring young adults. Results underscore the importance of assessing individual differences in NSSI characteristics, as well as psychosocial impairment, when assessing risk for suicidal behavior.
Article
In order to assess the frequency and correlates of self-injurious behavior (SIB), 569 Portuguese adolescents aged 12 to 20 years completed questionnaires assessing SIB and psychopathological symptoms. Almost 28% (n = 158) reported a lifetime history of SIB and nearly 10% had performed it in the previous month. The most frequently injured body parts were arms, hands and nails. Most of the self-injurers admit that "now and then" they feel some "mild" to "moderate" pain during SIB. Most of them admitted using these behaviors to avoid/suppress negative feelings, painful images or memories, to punish themselves and to avoid doing something bad. Positive emotions increased significantly after SIB. The self-injurer group reported more psychopathological symptoms. SIB appears to be a common phenomenon with specific functions in adolescence and this must be addressed by clinicians and educational professionals.
Article
Self-injurious behaviors (SIB) refer to behaviors that cause direct and deliberate harm to oneself, including nonsuicidal self-injury (NSSI), suicidal behaviors, and suicide. Although in recent research, NSSI and suicidal behavior have been differentiated by intention, frequency, and lethality of behavior, researchers have also shown that these two types of self-injurious behavior often co-occur. Despite the co-occurrence of NSSI and suicidal behavior, however, little attention has been given as to why these self-injurious behaviors may be linked. Several authors have suggested that NSSI is a risk factor for suicidal behavior, but no comprehensive review of the literature on NSSI and suicidal behavior has been provided. To address this gap in the literature, we conducted an extensive review of the research on NSSI and suicidal behavior among adolescents and adults. First, we summarize several studies that specifically examined the association between NSSI and suicidal behavior. Next, three theories that have been proposed to account for the link between NSSI and suicidal behavior are described, and the empirical support for each theory is critically examined. Finally, an integrated model is introduced and several recommendations for future research are provided to extend theory development.
Article
Joiner's (2005) interpersonal-psychological theory of suicide hypothesizes that painful and provocative events increase pain tolerance. The theory further proposes that increased pain tolerance represents one component of increased suicidal capability. Although initial studies have been consistent with this model, several key aspects remain untested. In 67 undergraduates, we investigated associations among painful and provocative events, nonsuicidal self-injury, acquired capability for suicide, and pain tolerance, threshold, and perceived intensity. Results were highly consistent with the interpersonal-psychological theory: a multiple mediation model specified that pain tolerance - but not other pain variables - accounted for significant variance within the association between painful and provocative events and acquired capability for suicide. These results held even when the pain tolerance item was removed from the suicidal capability questionnaire. Results also supported the interpersonal-psychological theory hypothesis that nonsuicidal self-injury represents an important painful and provocative event that increases suicidal capability. Specifically, participants with a history of nonsuicidal self-injury displayed increased suicidal capability and decreased pain perception. Overall, these results indicate that pain tolerance plays an important and specific role in suicidal capability.
Article
Although attempted suicide and non-suicidal self-injury (NSSI) differ in several important ways, a significant number of individuals report histories of both behaviors. The current study further examined the relations between NSSI and attempted suicide among psychiatric inpatients. Self-report questionnaires were administered to 117 psychiatric inpatients at a general hospital (M=39.45 years old, S.D.=12.84 years, range=17-73 years). We found that presence and number of NSSI episodes were significantly related to presence and number of suicide attempts. Supporting the importance of NSSI assessment, patients' history of NSSI (presence and frequency) was more strongly associated with history of suicide attempts than were patients' depressive symptoms, hopelessness, and symptoms of borderline personality disorder, and as strongly associated with suicide attempt history as current levels of suicidal ideation. Finally, among patients with a history of suicide attempts, those with an NSSI history reported significantly greater lethal intent for their most severe attempt, and patients' number of prior NSSI episodes was positively correlated with the level of lethal intent associated with their most severe suicide attempt.
Article
Nonsuicidal self-injury (NSSI) is a prevalent but perplexing behavior problem in which people deliberately harm themselves without lethal intent. Research reveals that NSSI typically has its onset during early adolescence; most often involves cutting or carving the skin; and appears equally prevalent across sexes, ethnicities, and socioeconomic statuses. Less is known about why people engage in NSSI. This article presents a theoretical model of the development and maintenance of NSSI. Rather than a symptom of mental disorder, NSSI is conceptualized as a harmful behavior that can serve several intrapersonal (e.g., affect regulation) and interpersonal (e.g., help-seeking) functions. Risk of NSSI is increased by general factors that contribute to problems with affect regulation or interpersonal communication (e.g., childhood abuse) and by specific factors that influence the decision to use NSSI rather than some other behavior to serve these functions (e.g., social modeling). This model synthesizes research from several different areas of the literature and points toward several lines of research needed to further advance the understanding of why people hurt themselves.
Article
This study examined the prevalence of non-suicidal self-injury (NSSI), suicide attempts, suicide threats and suicidal ideation in a German school sample and compared the rates with a similar sample of adolescents from the midwestern USA by using cross-nationally validated assessment tools. Data were provided from 665 adolescents (mean age 14.8 years, S.D.=0.66, range 14-17 years) in a school setting. Students completed the Self-Harm Behavior Questionnaire (SHBQ), the Ottawa Self-Injury Inventory (OSI) and a German version of the Center for Epidemiological Studies-Depression Scale (CES-D). A quarter of the participants (25.6%) endorsed at least one act of NSSI in their life, and 9.5% of those students answered that they had hurt themselves repetitively (more than four times). Forty-three (6.5%) of the students reported a history of a suicide attempt. No statistically significant differences were observed between the German and US samples in terms of self-injury or suicidal behaviors. By using the same validated assessment tools, no differences were found in the prevalence and characteristics of self-injury and suicidal behaviors between adolescents from Germany and the USA. Thus, it seems that NSSI has to be understood as worldwide phenomenon, at least in Western cultures.
Article
The term self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and superficial cutting in response to intolerable tension. As with suicide, rates of self-harm vary greatly between countries. 5-9% of adolescents in western countries report having self-harmed within the previous year. Risk factors include socioeconomic disadvantage, and psychiatric illness--particularly depression, substance abuse, and anxiety disorders. Cultural aspects of some societies may protect against suicide and self-harm and explain some of the international variation in rates of these events. Risk of repetition of self-harm and of later suicide is high. More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within 9 years. Assessment after self-harm includes careful consideration of the patient's intent and beliefs about the lethality of the method used. Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk. Management after self-harm includes forming a trusting relationship with the patient, jointly identifying problems, ensuring support is available in a crisis, and treating psychiatric illness vigorously. Family and friends may also provide support. Large-scale studies of treatments for specific subgroups of people who self-harm might help to identify more effective treatments than are currently available. Although risk factors for self-harm are well established, aspects that protect people from engaging in self-harm need to be further explored.
Article
The current study examined whether common indicators of suicide risk differ between adolescents engaging in non-suicidal self-injury (NSSI) who have and have not attempted suicide in an effort to enhance clinicians' ability to evaluate risk for suicide within this group. Data were collected from 540 high school students in the Midwest who completed the RADS, RFL-A, SIQ, and SHBQ as part of a larger adolescent risk project. Results suggest that adolescents engaging in NSSI who also attempt suicide can be differentiated from adolescents who only engage in NSSI on measures of suicidal ideation, reasons for living, and depression. Clinical implications of the findings are discussed.
Article
High rates of nonsuicidal self-injury (NSSI; 14%-17%) in adolescents and young adults suggest that some self-injurers may exhibit more or different psychiatric problems than others. In the present study, the authors utilized a latent class analysis to identify clinically distinct subgroups of self-injurers. Participants were 205 young adults with a history of 1 or more NSSI behaviors. Latent classes were identified on the basis of method (e.g., cutting vs. biting vs. burning), descriptive features (e.g., self-injuring alone or with others), and functions (i.e., social vs. automatic). The analysis yielded 4 subgroups of self-injurers, which were then compared on measures of depression, anxiety, borderline personality disorder, and suicidality. Almost 80% of participants belonged to 1 of 2 latent classes characterized by fewer or less severe NSSI behaviors and fewer clinical symptoms. A 3rd class (11% of participants) performed a variety of NSSI behaviors, endorsed both social and automatic functions, and was characterized by high anxiety. A 4th class (11% of participants) cut themselves in private, in the service of automatic functions, and was characterized by high suicidality. Clinical and research implications are discussed.
Article
Deliberate self-harm among young people is an important focus of policy and practice internationally. Nonetheless, there is little reliable comparative international information on its extent or characteristics. We have conducted a seven-country comparative community study of deliberate self-harm among young people. Over 30,000 mainly 15- and 16-year-olds completed anonymous questionnaires at school in Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway. Study criteria were developed to identify episodes of self-harm; the prevalence of self-harm acts and thoughts, methods used, repetition, reasons given, premeditation, setting for the act, associations with alcohol and drugs, hospitalisation, and whether other people knew, were examined. Self-harm was more than twice as common among females as males and, in four of the seven countries, at least one in ten females had harmed herself in the previous year. Additional young people had thought of harming themselves without doing so. More males and females in all countries except Hungary cut themselves than used any other method, most acts took place at home, and alcohol and illegal drugs were not usually involved. The most common reasons given were 'to get relief from a terrible state of mind' followed by 'to die', although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime. Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally.