Hanna Sahlin

Association Between Deliberate Self-harm and Violent Criminality

Importance Individuals who self-harm may have an increased risk of aggression toward others, but this association has been insufficiently investigated. More conclusive evidence may affect assessment, treatment interventions, and clinical guidelines. Objective To investigate the association between nonfatal self-harm and violent crime. Design, Setting, and Participants This population-based longitudinal cohort study, conducted from January 1, 1997, through December 31, 2013, studied all Swedish citizens born between 1982 and 1998 who were 15 years and older (N = 1 850 252). Individuals who emigrated from Sweden before the age of 15 years (n = 104 051) or immigrated to Sweden after the age of 13 years (ie, <2 years before the beginning of the follow-up; n = 22 009) were excluded. Data analysis was performed from April 21, 2016, to June 4, 2016. Exposures Receipt of self-harm–associated clinical care. Main Outcomes and Measures Conviction of a violent crime according to the Swedish penal code. Results The study cohort consisted of 1 850 525 individuals (950 382 males and 900 143 females), and the mean (SD) follow-up time was 8.1 (4.7) years (range, 0-17.0 years; minimum age, 15 years; maximum age, 32 years). During a mean follow-up period of 8.1 years, 55 185 individuals (3.0%) received clinical care for self-harm. The crude hazard ratio was 4.9 (95% CI, 4.8-5.0) for violent crime conviction in exposed individuals compared with the unexposed group. Women who self-harm were at particularly high risk for expressing violent behaviors. After adjustment for relevant psychiatric comorbidities and socioeconomic status, an almost doubled hazard of violent offense remained (hazard ratio, 1.8; 95% CI, 1.8-1.9). Conclusions and Relevance Self-harm is associated with an increased risk of conviction for a violent offense in both sexes. The risk of violence, as well as the risk of suicide and self-harm, should be assessed among offending and self-harming individuals.

Non-suicidal self-injury and interpersonal violence in suicide attempters

The current study compared characteristics of suicidal behavior and interpersonal violence in suicide attempters with and without a history of non-suicidal self-injury (NSSI). A total of 100 suicide attempters were assessed with Karolinska Interpersonal Violence Scale (KIVS) and Karolinska Suicide History Interview concerning interpersonal violence and NSSI. There was a high degree of comorbid NSSI in suicide attempters (44%). Suicide attempters with NSSI-history reported more interpersonal violence as adults and more severe suicidal behavior compared to suicide attempters without NSSI. Comorbid NSSI was related to severity of suicidal behavior in a gender specific manner. Comorbid NSSI in suicide attempters may increase suicide and violence risk.

Emotion regulation group therapy for deliberate self-harm: A multi-site evaluation in routine care using an uncontrolled open trial design

Objective Emotion regulation group therapy (ERGT) has shown promising results in several efficacy trials. However, it has not been evaluated outside a research setting. In order to increase the availability of empirically supported treatments for individuals with borderline personality disorder and deliberate self-harm, an evaluation of ERGT in routine clinical care was conducted with therapists of different professional backgrounds who had received brief intensive training in ERGT prior to trial onset. Design Multi-site evaluation, using an uncontrolled open trial design with assessments at pretreatment, post-treatment and 6-month follow-up. Setting 14 adult outpatient psychiatric clinics across Sweden. Participants Ninety-five women (mean age=25.1 years) with borderline personality disorder (both threshold and subthreshold) and repeated self-harm were enrolled in the study. Ninety-three per cent of participants completed the post-treatment assessment and 88% completed the follow-up assessment. Primary and secondary outcome measures Primary outcome was self-harm frequency as measured with the Deliberate Self-Harm Inventory. Secondary outcomes included self-harm versatility, emotion dysregulation, other self-destructive behaviours, depression, anxiety, stress symptoms and interpersonal and vocational difficulties. Intervention ERGT is an adjunctive, 14-week, acceptance-based behavioural group treatment that directly targets both self-harm and its proposed underlying mechanism of emotion dysregulation. Results At post-treatment, intent-to-treat analyses revealed a significant improvement associated with a moderate effect size on the primary outcome of self-harm frequency (51%, reduction; Cohen’s d=0.52, p<0.001) as well as significant improvements in the secondary outcomes of self-harm versatility, emotion dysregulation, other self-destructive behaviours and general psychiatric symptomatology. These results were either maintained or further improved on at 6-month follow-up. Conclusions ERGT appears to be a feasible, transportable and useful treatment for deliberate self-harm and other self-destructive behaviours, emotion dysregulation and psychiatric symptoms when delivered by clinicians in the community. Trial registration number NCT01986257; results.

Adolescent self-harm with and without suicidality: cross-sectional and longitudinal analyses of a Swedish regional register

Background Self‐harm is common and there is a need for studies that investigate the relevance of this behavior in clinical samples to inform risk assessment and treatment. The objectives in the current studies were to compare clinical and psychosocial correlates and subsequent adverse outcomes in youth who present to child and adolescent mental health services (CAMHS) with self‐harm only (SH), self‐harm with suicidality (SH+SU), with those without any indication of SH or SH+SU. Methods We conducted a case–control study and a longitudinal cohort study using data from a regional clinical care register, and Swedish national registers. The case–control study included all patients (5–17 years) between 2011 and 2015 (N = 25,161). SH and SH+SU cases were compared with controls (patients without SH) regarding a range of correlates. The longitudinal study included former CAMHS patients (N = 6,120) who were followed for a median time of 2.8 years after termination of CAMHS contact regarding outcomes such as clinical care consumption, social welfare recipiency, and crime conviction. Results In the case–control study, both the SH and SH+SU groups received more clinical care, had lower global functioning, and higher odds of having mental disorders compared to controls. In most comparisons, the SH+SU group had more problems than the SH group. In the longitudinal study, the same pattern emerged for most outcomes; for example, the adjusted hazard ratio for recurrent care due to self‐harm was 23.1 (95% confidence interval [CI], 17.0–31.4) in the SH+SU group compared to 3.9 (95% CI, 2.3–6.7) in the SH group. Conclusions Adolescent patients presenting with self‐harm have higher risks for adverse outcomes than patients without self‐harm. Suicidality in addition to self‐harm is associated with more severe outcomes, importantly recurrent episodes of care for self‐harm.

Experiences of change in Emotion Regulation Group Therapy. A mixed-methods study of six patients

Emotion Regulation Group Therapy (ERGT) is a treatment for non-suicidal self-injury (NSSI) that has recently been implemented in Sweden and evaluated in an open trial with 95 patients in 14 adult outpatient psychiatric clinics (Sahlin et al., 2017). The purpose of the present study was to explore in more detail six of these patients’ experiences of change in ERGT by means of a person-oriented mixed-methods design. Reliable change and clinical significance were calculated for each individual on measures of self-harm, depression, anxiety, stress, and emotion regulation. Semi-structured interviews were carried out, transcribed and analysed using thematic analysis. Both the quantitative and qualitative data on change suggested that the most consistent changes occurred on emotion regulation. The treatment sessions that were most appreciated were those that focused on emotion awareness and emotion regulation. The participants also expressed appreciation of what ERGT afforded in terms of belonging and sharing with others, and the sense of equality in the relationship to the therapist. Critical comments were expressed concerning some parts of the treatment, as for example not having access to an individual therapist. Among the limitations of the study are the small convenience sample, which does not allow for any generalizing conclusions, and that the interviews took place a considerable time (2-3 years) after the participation in ERGT.

Predictors of improvement in an open-trial multisite evaluation of emotion regulation group therapy

ABSTRACT Emotion regulation group therapy (ERGT) is a novel treatment specifically targeting deliberate non-suicidal self-harm (DSH) in individuals with borderline personality disorder (BPD). Identifying robust predictors of positive response to ERGT could aid clinicians in treatment selection; however, to date, only one such study has been conducted. Thus, we aimed to replicate previously identified predictors of treatment response to ERGT by investigating demographic, clinical, and diagnostic predictors in 95 women with BPD or subclinical BPD who had participated in an open-trial evaluation of ERGT. Outcomes evaluated were frequency of DSH and emotion dysregulation. Assessments were conducted at pretreatment, post-treatment, and 6-month follow-up. Multilevel mixed linear models and multilevel negative binomial generalized estimated equations were used to identify significant interactions between the predictors and outcomes. We found that greater pretreatment DSH frequency was associated with greater improvements in DSH during treatment (b = 0.998, SE = 0.00, p = 0.03) and follow-up (b = 0.997, SE = 0.00, p < 0.01) and that greater BPD severity was associated with greater improvements in DSH during treatment (b = 0.84, SE = 0.06, p = 0.02) and in emotion dysregulation at follow-up (b = −3.05, SE = 1.47, p = 0.04). Co-occurring disorders were associated with poorer treatment response during follow-up. Results were generally consistent with a previous study of the predictors of response to ERGT. The findings provide further support for the utility of this treatment across a range of BPD patients, including patients with severe DSH and BPD.