DSM-5 suicidal behavior disorder: a systematic review of research on clinical utility, diagnostic boundaries, measures, pathophysiology and interventions.

Background: It has been a decade since Suicidal Behavior Disorder (SBD) was introduced in Section III of the DSM-5 under "Conditions for Further Study". SBD is chiefly characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one's own death and occurring in the last 24 months. Aims: To systematically review empirical studies on SBD to identify primary research themes and promising future research directions. Method: A search of empirical articles on SBD published between May 2013 and March 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Screening of 73 records by two independent raters yielded 14 eligible articles. The primary research themes identified from these articles included clinical utility of SBD to predict future suicide risk, association of SBD with closely related disorders, psychometric properties of SBD measures, pathophysiology of SBD, and the effectiveness of interventions for people with SBD. Conclusion: Understanding of SBD has slowly progressed since its introduction a decade ago and has mainly been applied in research to define study groups displaying suicidal behavior. The clinical utility of SBD for predicting future suicide risk is low and more research is needed to understand measurement of the diagnosis and its distinctiveness from related disorders and other self-harming behaviors.

Self-Harm Behaviors, Suicide Attempts, and Suicidal Ideation in a Clinical Sample of Children and Adolescents with Psychiatric Disorders.

Suicidal ideation and self-harm behaviors have been found to be important risk factors for suicide. The aim of this study was to explore the rates of psychiatric disorders among different groups of patients with suicidal ideation, suicide attempts, and non-suicidal self-harm behaviors and to identify the associated socio-demographic and clinical variables. We conducted a cross-sectional study with emergency-admitted patients presenting with non-suicidal self-harm behaviors, suicide attempts, or suicidal ideation to the emergency room of the Child and Adolescent Psychiatry Clinic in Cluj-Napoca, Romania. Data were collected from the patients' charts using a questionnaire that contained socio-demographic and clinical variables. A total of 95 patients aged between 6 and 18 years were included in the study. Ingesting medication and cutting were the most frequently used methods to attempt suicide. Depression and mixed affective and conduct disorders were the diagnoses most commonly associated with suicidal behavior. Girls with depressive symptoms were more probable to have suicide attempts than boys, and girls with depressive symptoms and behavioral problems registered more self-harm behaviors. Further research should systematically examine the relationship between self-harm behaviors and suicide attempts and the profile of patients at risk of future suicide attempts.

Implicit cognitions on self-injurious and suicidal behavior in borderline personality disorder.

BACKGROUND AND OBJECTIVES: Performance on implicit measures of suicidality has been associated with suicidal and nonsuicidal self-injury. Despite the high prevalence of self-harm in patients with borderline personality disorder (BPD), no previous study has assessed implicit measures in this patient group. METHODS: Forty patients with BPD and 25 healthy controls completed three implicit association tests (IATs) (Death words - Me/Others words, Self-Harm pictures - Me/Others, and Self-Harm pictures - Good/Bad words) and a subliminal priming task (effect of the primes "dying"/"growing" on the categorization speed of positive/negative adjectives) as well as measures of psychopathology (suicidal ideation, previous nonsuicidal self-injury, borderline symptomatology, depression, and hopelessness). RESULTS: Patients with BPD had higher scores on all three IATs than healthy controls. The subliminal priming procedure did not reveal group differences. Correlations between implicit measures and psychopathology among patients with BPD were mostly weak and nonsignificant with a few exceptions: Positive correlations were observed between IAT Self-Harm - Good/Bad and lifetime frequency of nonsuicidal self-injury, between IAT Self-Harm - Me/Others and depression, and between IAT Death - Me/Others and depression. Correlations between implicit measures were weak to moderate. LIMITATIONS: The study was cross-sectional only, and the study had reduced power as the sample size was limited. CONCLUSIONS: As expected, patients with BPD had higher scores than healthy controls on the IATs, which indicates higher implicit self-identification with self-harm and death as well as stronger implicit positive attitudes towards self-harm. The mostly weak correlations between implicit and explicit measures speak against the discriminative value of IATs in patients with BPD.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients.

OBJECTIVE: A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention. METHODS: A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact. RESULTS: ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention. CONCLUSIONS: Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

Examining protective factors for substance use problems and self-harm behavior during adolescence: A longitudinal co-twin control study.

Sports participation, physical activity, and friendship quality are theorized to have protective effects on the developmental emergence of substance use and self-harm behavior in adolescence, but existing research has been mixed. This ambiguity could reflect, in part, the potential for confounding of observed associations by genetic and environmental factors, which previous research has been unable to rigorously rule out. We used data from the prospective, population-based Child and Adolescent Twin Study in Sweden (n = 18,234 born 1994-2001) and applied a co-twin control design to account for potential genetic and environmental confounding of sports participation, physical activity, and friendship quality (assessed at age 15) as presumed protective factors for adolescent substance use and self-harm behavior (assessed at age 18). While confidence intervals widened to include the null in numerous co-twin control analyses adjusting for childhood psychopathology, parent-reported sports participation and twin-reported positive friendship quality were associated with increased odds of alcohol problems and nicotine use. However, parent-reported sports participation, twin-reported physical activity, and twin-reported friendship quality were associated with decreased odds of self-harm behavior. The findings provide a more nuanced understanding of the risks and benefits of putative protective factors for risky behaviors that emerge during adolescence.

Suicidality Related to the COVID-19 Lockdown in Romania: Structural Equation Modeling.

Background: Suicidality is a serious public health concern at a global scale. Suicide itself is considered to be preventable death; worldwide, suicide rates and their trends are under constant scrutiny. As part of the international COMET-G cross-sectional study, we conducted a national level investigation to examine the individual disturbances (such as anxiety, depression, or history of life-threatening attempts) and contextual factors (such as adherence to conspiracy theories or Internet use) associated with suicidality related to the COVID-19 lockdown in a lot of Romanian adults. Participants and Methods: One thousand four hundred and forty-six adults responded to an anonymous on-line questionnaire, with mean age ± standard deviation of 47.03 ± 14.21 years (1,142 females, 292 males, 12 identified themselves as non-binary). Data were analyzed using descriptive statistics and structural equation modeling (SEM). Results: Univariate analysis showed strong significant correlation between anxiety and depression scorings among the respondents (Spearman R = 0.776, p < 0.001). Both the suicidality scorings and the Internet use correlated fairly with anxiety and depression, with two-by-two Spearman coefficients between R = 0.334 and R = 0.370 (p < 0.001 for each). SEM analysis substantiated the emotional disturbances, previous life-threatening attempts, and younger age as significant predictors for suicidality. The patterns of reality reading (including religious inquiries, Internet use, and beliefs in conspiracy theories) did not reach the statistical significance as influential factors in the suicidality of these respondents. There was no covariance between the Internet use and belief in conspiracy theories. Conclusion: The study confirmed the suicidality risk initially hypothesized as being associated with the history of life-threatening attempts, increased depression within the younger population, and higher anxiety during the first year of the COVID-19 pandemic and its related lockdown. National strategies for effective interventions at various levels of the healthcare system should be developed.

Mental Health in Elite Student Athletes: Exploring the Link Between Training Volume and Mental Health Problems in Norwegian College and University Students.

OBJECTIVES: To examine mental health problems among elite athletes in a student population, compared to the general student population, and to explore the association between weekly hours of training across mental health indicators. METHODS: Data are from a national study from 2018 of all college and university students in Norway. Participants indicated if they considered themselves to be an elite athlete, and how many hours per week they trained. Mental health problems were assessed using several well-validated questionnaires. RESULTS: Among 50,054 students, 1.3% identified themselves as elite athletes. Both male and female elite athletes had generally better mental health across most health outcomes, reporting fewer mental health problems, less loneliness, higher satisfaction with life, more positive affect, and fewer alcohol problems. Elite athletes in team sports had slightly better mental health compared to athletes of individual sports. Increased hours of weekly exercise was associated with better mental health. However, there was generally little to be gained from increasing the amount of training from 7-10 hours/week to 14+ hours per week. Female athletes who trained 14 or more hours per week reported poorer mental health across most outcome measures. CONCLUSION: This study showed that both male and female elite athletes generally had better mental health across a range of health outcomes, when compared to the general student population. The study also found a positive dose-response relationship between weekly hours of training and mental health, but also a worsening of mental health for females at the extreme end of exercise continuum. The self-report nature of this student sample means that care should be taken when generalizing to other studies of elite athletes.

Clinical Correlates of Deliberate Self-Harm Among Migrant Trauma-Affected Subgroups.

Introduction: Studies have shown that exposure to potentially traumatic events (PTEs) during the migration process has serious consequences on mental health. Migrants with a history of PTEs are more likely to inflict deliberate self-harm (DSH), a spectrum of behavior that includes non-suicidal self-injury (NSSI). With reference to a nonclinical sample of trauma-exposed migrants, this study aims to explore the prevalence of DSH and to assess the association with sociodemographic characteristics and clinical conditions, with particular attention to post-traumatic stress disorder (PTSD) symptoms, resilience capabilities, and feelings of hopelessness. Methods: A sample of migrants underwent a baseline evaluation at an outpatient department of the National Institute for Health, Migration and Poverty (INMP). Migrants with a history of torture, rape, or other severe forms of psychological, physical, or sexual violence were invited to undergo screening at the Institute's Mental Health Unit. Trauma-exposed migrants completed a series of self-report questionnaires that assessed the presence of PTSD, depression, anxiety, suicidal ideation, resilience, and feelings of hopelessness, in addition to DSH. Univariate and multivariate log-binomial regression models were used to test the association of age and clinical characteristic of migrants with DSH. Prevalence ratio (PR) with 95% confidence intervals (95% CI) and p-values were estimated. Results: A total of 169 migrants (76.9% males), aged between 18 and 68 years, M = 28.93; SD = 8.77), were selected. Of the sample, 26.6% were frequently engaging in some form of DSH, and 30.2% were diagnosed with at least one trauma-related disorder. DSH behaviors were most common in single and unemployed migrants as well as in subjects with post-traumatic stress symptoms, feelings of anxiety, hopelessness, low capability of resilience, and suicidal ideation. Taking into account age and hopelessness, we found that PTSD and low resilience capabilities were associated with a higher risk of DSH [PR adj: 2.21; 95% CI: (1.30-3.75) and PR adj: 2.32; 95% CI: (1.16-4.62), respectively]. Conclusion: Given the association between trauma exposure and DSH among migrants, exploring the presence of DSH behavior within the immigrant community is crucial for the implementation of measures to develop intervention in a clinical setting.

Adverse Childhood Experiences and Suicidality and Self-Harm in Persons in Secure Forensic Care.

Prior research suggests a greater degree of suicidality and self-harm behavior in those involved with criminal justice and forensic mental health systems. Such individuals also evidence increased exposure to early childhood adversity, which is often associated with suicide risk. Other significant predictors of suicidality have been noted within forensic populations, however, including indicators of specific psychopathology and situational and demographic factors. These populations present with overlapping risk factors that remain underexamined. In the current study, 182 persons residing in secure forensic psychiatric care following incidents of illegal and aggressive behavior were evaluated. Adverse childhood experiences and other empirically derived potential predictors of suicide attempts and self-harm were examined via binomial logistic regression. Findings indicate frequent experiences of early adversity across participants, and that a combination of race, individual adverse childhood experiences, number of biological children, and diagnoses of either posttraumatic stress disorder or borderline personality disorder were significant predictors of suicide attempts, self-harm behavior, and first hospitalization resulting from a suicide attempt. Clinical and research implications are discussed.

Lamotrigine Reduces Stress Symptoms of Chronic Anxiety in the Times of the Covid-19 Natural Catastrophe-A Case Report.

The SARS-CoV-2 pandemic has been a worldwide chronic, stress-inducing natural catastrophe associated with increased emotional challenging. Patients with Post-traumatic stress disorder (PTSD), self-injury behavior, and obesity are predisposed to aggravation of their symptoms at this time, requiring new therapeutic approaches to balance their disrupted neuro-hormonal stress axis. Here we present our observations of an off-label treatment with lamotrigine in an adolescent girl with PTSD, self-injury behavior, and obesity. Lamotrigine was an efficacious pharmaceutical intervention that helped the patient deal with chronic stress and associated anxiety. The results are discussed based on our previous basic research outcomes in animals and humans that focused on the glutamate-cortisol circuits within the limbic brain.

Family Structure and History of Childhood Trauma: Associations With Risk-Taking Behavior Among Adolescents in Swaziland.

Introduction: Risk-taking and self-harm behavior among adolescent are a global challenge. This study explored family structure and history of childhood trauma and their association with risk-taking and self-harm behaviors among adolescents in Swaziland. Methods: Using a cross-sectional design, a sample of 470 male and female adolescents were sampled through simple random sampling from selected high schools in Swaziland. They completed a questionnaire assessing family structure, history of childhood trauma, and risk-taking and self-harm behaviors. Analysis of variance and t-test were used to analyze the results. Results: The findings revealed that family structure significantly influence risk-taking and self-harm behavior among adolescents [F(2, 247) = 5.481; P < 0.004] those from child-headed and single-parent households reported higher risk-taking and self-harm behaviors. The results also revealed adolescents history of childhood trauma to be more risk-takers than those without history of childhood trauma t(468) = 3.409, p < 0.001. Discussion: Study results suggest that family structure and history of childhood trauma have significant association with adolescents' risk-taking and self-harm behaviors.

Clinical Characteristics of Pesticide Self-Harm as Associated with Suicide Attempt Repetition Status.

PURPOSE: Previous suicide behavior predicts future suicide risk. Studies of suicide repetition are important for suicide prevention. This study examined the clinical characteristics and psychiatric comorbidities of pesticide self-harm as associated with suicide attempt repetition status. PATIENTS AND METHODS: This retrospective, observational study included patients admitted to a medical center in northern Taiwan between 2000 and 2015 following suicide attempts by pesticide. Diagnoses were made by a consultation-liaison psychiatry team based on the DSM IV-TR criteria. Independent samples t-test was used to analyze the quantitative variables and Pearson's Chi-squared test with a Bonferroni adjustment for categorical variables. Univariate binary logistic regression analysis was conducted to determine the predictors for repeated suicide attempt and multivariate binary logistic regression analysis to identify significant associated factors. RESULTS: Among 151 patients, organophosphate pesticides were the most used (80.8%). The average age was 52.9±17.2 years. Most patients were married males from rural areas, with depressive disorder most often diagnosed (40.4%). Nearly one-third of them were suicide repeaters (n=43, 28.5%); these patients were less likely to be married (53.5%, p=0.001), had previously used psychiatric services (72.1%, p<0.001) and chose complex suicide (46.5%, p=0.014) more often compared to nonrepeaters. No significant differences were found between repeaters and nonrepeaters regarding psychiatric comorbidities. Multivariate logistic regression analysis revealed that marital status (odds ratio: 2.916, 95% confidence interval: 1.234-6.891, p=0.015) and previous psychiatric services usage (odds ratio: 6.897, 95% confidence interval: 3.012-15.625, p<0.001) were significant risk factors associated with suicide repetition. CONCLUSION: Pesticide suicide repeaters were characterized by less likely to be married and more likely to use psychiatric services before suicide attempts. These features help ensuring that the needs of people who have made a suicide attempt are addressed, and it reduces the likelihood of repetition.

[New Technologies in the Diagnostics and Treatment of Brain Deseases: from Neurosciences to the Multidisciplinary Clinical Practice and Maintaining of Mental Health].

Over the past years, the prevalence of brain diseases and, consequently, their social significance and economic burden for society has been steadily increasing throughout the world. Brain diseases are a heterogeneous group of diseases that unite a number of disorders that are within the competence of both neurology and psychiatry, often concurrent or comorbid with each other. Z. P. Soloviev Research and Clinical Center for Neuropsychiatry is a leading medical organization in Moscow, which performs a full treatment cycle, studies the data and has postgraduate training programs in this field of medicine. It is conducting a number of relevant research programs; some in collaboration with international clinics. This study deals with the following programs: fundamental aspects of depression and stress-reactivity, suicidal and self-damaging behavior, usage of biofeedback and gravity therapy in rehabilitation and training programs for medical workers in successful communication.

Prevalence and Clinical Correlates of Self-Harm Behaviors in Gilles de la Tourette Syndrome.

Introduction: Major symptoms of Gilles de la Tourette syndrome (GTS) are tics, but in 90% of cases, psychiatric comorbidities occur. Self-harm behaviors (SHBs) could result from deliberate action and unintentional injury from tics. Methods: We examined 165 consecutive GTS patients aged 5 to 50 years (75.8% males). The median duration of GTS was 14 years (interquartile range, 9-22 years). The patients were evaluated for GTS and comorbid mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Self-harm behavior was diagnosed during the interview. To determine a direct relationship between SHB and clinical variables, we conducted two analyses, at the time of evaluation and lifetime. We also compared the group of children and adults with SHB. We also tried to distinguish between deliberate (non-tic-related SHB) and accidental (tic-related SHB). Results: Lifetime SHB was reported by 65 patients (39.4%), and in 55 of the cases, it was present at the time of evaluation. The age at the onset of SHB was reported in 55 of the cases (84.6%), and the median was 10 years (interquartile range, 7-13 years). In 30 of the patients (46.2%), SHB was evaluated as mild; in 26 (40%), as moderate; and in only 9 cases (13.9%), as severe. In the multivariable analysis for the predictor of lifetime SHB, attention-deficit/hyperactivity disorder (p = 0.016) and obsessive-compulsive disorder (OCD; p = 0.042) were determined as risk factors, while for current SHB, only tic severity (p < 0.0001) was statistically significant. When comparing predictors of SHB for children and adults, tic severity was determined as predictor for lifetime SHB in children (p < 0.0001), while the anxiety disorder was associated with lifetime SHB in adults (p = 0.05). Similarly, tic severity was a predictor of current SHB in the children group (p = 0.001), but this was not confirmed for adults. The group of patients with tic-related and non-tic-related SHB did not differ. Conclusions: Self-harm behavior appears mostly in children and adolescents and rarely begins in adulthood. Self-harm behavior is associated mainly with tic severity, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder. Clinical correlates of SHB are age related and differ at different points of life. Tic severity is the main factor associated with SHB in children. In the adult group, anxiety disorder and other psychiatric comorbidities may play the most important role.

Nonsuicidal self-injury disorder: Does Criterion B add diagnostic utility?

The current paper evaluates Criterion B for Non-Suicidal Self-Injury Disorder, which states that non-suicidal self-injury (NSSI) must occur for at least one function. The majority of individuals who engage in NSSI report at least one function, so it is unclear if Criterion B provides diagnostic utility in individuals who already meet Criterion A (i.e., NSSI occurring on 5 or more days in the past 12 months). This paper compared individuals meeting Criterion A (threshold group) to those with 1-4 acts of NSSI in the past year (subthreshold group) in two different samples. The first sample included 217 undergraduate students, and the second sample included 1082 individuals from a behavioral health hospital, all with past-year NSSI. The majority of both samples reported at least one function of NSSI (99%). For the undergraduate sample, the number of and level of endorsement of functions were similar across threshold and subthreshold groups. For the behavioral health sample, the threshold group endorsed significantly more functions for NSSI and greater endorsement of affect regulation, self-punishment, and toughness compared to the subthreshold group. While some differences were found between NSSI groups, overall endorsement of functions for NSSI appears to be a universal characteristic regardless of NSSI frequency.

Differences between non-suicidal self injury and suicide attempt in Chinese adolescents.

PURPOSE: Self-harm behaviors are predominant health risks among adolescents. This study aimed to elucidate the lifetime prevalence and differences in social psychological factors between non-suicidal self-injury (NSSI) and suicide attempt (SA) among Chinese adolescents. METHOD: Data were collected from 2131 middle school students with a mean age of 13.92 (SD 1.63) years (49.1% girls). Participants were asked to self-report NSSI and SA over their lifetime. Post hoc tests pairwise comparisons and multinomial logistic regression analyses were conducted to investigate differences and similarities between subjects with NSSI and attempted suicide. RESULTS: The prevalence of lifetime NSSI and SA endorsed by the participants were 23.2% and 3.2%, respectively, and the co-occurrence of these two behaviors (NSSI+SA) was reported to 2.3%. Boys were comparable with girls in the prevalence rate of NSSI, but not in the rate of SA. It revealed that single-child was not the risk factor for self-harm behavior in Mainland China, but lower higher family cohesion and adaptability. Factors that distinguished the NSSI+SA group from the NSSI only group were female gender, lower grade, impulsivity, health risk behaviors and family cohesion. Being female gender, single-parent family, depressive symptoms and impulsivity were factors differentiating attempted suicide from NSSI. CONCLUSIONS: Our findings suggest that Chinese adolescents engaging both in NSSI and SA had severe suicidal attempts and were different from those who engaged in NSSI alone.

Sex and age differences in symptoms in borderline personality symptomatology.

OBJECTIVE: Variations in the symptoms of borderline personality disorder (BPD) as a function of sex and age remain unclear. In this study, we examined sex and age differences with regard to various symptoms encountered in BPD. METHODS: Using a compilation of four samples, all cross-sectional from the same recruitment site and with identical self-report measures for borderline personality symptomatology (BPS), we examined sex- and age-related differences with regard to borderline personality among 1,503 primary care patients. RESULTS: Men and women did not differ significantly in their overall scores or rates of BPS. With regard to sex differences in symptoms among respondents with substantial BPS, engagement in sexually abusive relationships was more common among women than men. Overall scores and rates of BPS were greater among younger respondents compared to older respondents. With regard to age differences among those with substantial BPS, self-cutting and scratching were more common in younger individuals whereas finding life dull and meaningless was more common among older individuals. CONCLUSIONS: There appear to be few overall symptomatic differences among individuals with borderline personality with regard to sex and age.

Evaluation of the Relation between Deliberate Self-Harm Behavior and Childhood Trauma Experiences in Patients Admitted to a Secondary-Care Psychiatric Outpatient Clinic for Adolescents and Young Adults.

INTRODUCTION: The aim of this study was to determine the prevalence and the features of deliberate self-harm (DSH) behavior in patients admitted to the psychiatric outpatient clinic for adolescents and young adults and also to detect the association between the act of DSH and childhood traumas. METHOD: In this study, we included all patients who were admitted to the secondary-care psychiatric outpatient clinic for adolescents and young adults in Bakirkoy Research and Training Hospital Psychiatry, Neurology and Neurosurgery throughout a month. A sociodemographic data form, the Childhood Trauma Questionnaire (CTQ-28), Childhood Abuse and Neglect Question List and the Deliberate Self-Harm and Intent Screening Form were applied to three hundred participants. RESULT: The prevalence of DSH was 50.0% among the participants (56.8% for females and 28.8% for males). Childhood abuse was detected in 57.0% of all participants (60.4% of females and 46.6% of males). Among patients with act of DSH, the rate of childhood abuse was 71.3%, while it was 42.7% in the subjects without act of DSH. CONCLUSION: DSH is a common behavior among adolescent psychiatric patients. It is more common in females than in males. The prevalence of experience of childhood abuse and neglect is remarkably high and is associated with self-harm behavior.