Rebecca C. Brown

Non-suicidal Self-Injury in Adolescence

Purpose of ReviewNon-suicidal self-injury (NSSI) is a common mental health threat among adolescents. This review aims to present the current literature on epidemiology, etiology, and therapeutic approaches with a focus on the period of adolescence.Recent FindingsNSSI is widespread among adolescents both in community as well as in clinical settings with lifetime prevalence rates between 17 and 60% in recent studies. It is influenced by multiple factors including social contagion, interpersonal stressors, neurobiological background, as well as emotional dysregulation and adverse experiences in childhood.SummaryThere is still a lack of studies regarding the psychotherapeutic as well as the psychopharmacological treatment of NSSI in adolescence. Furthermore, sufficient evidence for prevention programs is missing.

Differential Neural Processing of Social Exclusion and Inclusion in Adolescents with Non-Suicidal Self-Injury and Young Adults with Borderline Personality Disorder

Introduction Non-suicidal self-injury (NSSI) is a symptom of borderline personality disorder (BPD). However, NSSI often occurs independently of BPD. Altered neural processing of social exclusion has been shown in adolescents with NSSI and adults with BPD with additional alterations during social inclusion in BPD patients. Aims of this study were to investigate differences in neural processing of social inclusion and exclusion situations between adolescents with NSSI and young adults with BPD and NSSI. Methods Using fMRI, neural processing of positive and negative social situations (paradigm: “Cyberball”) was explored. Participants were 14 adolescents with NSSI, but without BPD (Mage = 15.4; SD = 1.9), 15 adults with BPD and NSSI (Mage = 23.3; SD = 4.1), as well as 15 healthy adolescents (Mage = 14.5; SD = 1.7), and 16 healthy adults (Mage = 23.2; SD = 4.4). Results Behavioral results showed enhanced feelings of social exclusion in both patient groups as compared to healthy controls but only the NSSI group showed enhanced activation during social exclusion versus inclusion compared to the other groups. While both NSSI and BPD groups showed enhanced activation in the ventral anterior cingulate cortex during social exclusion as compared to their age-matched controls, enhanced activation during social inclusion as compared to a passive watching condition was mainly observed in the BPD group in the dorsolateral and dorsomedial prefrontal cortex, and the anterior insula. Discussion While neural processing of social exclusion was pronounced in adolescents with NSSI, BPD patients also showed increased activity in a per se positive social situation. These results might point toward a higher responsiveness to social exclusion in adolescents with NSSI, which might then develop into a generalized increased sensitivity to all kinds of social situations in adults with BPD.

Knowledge transfer: a worldwide challenge in child mental health: a recommendation to the readership of CAPMH concerning the revised version of the IACAPAP Textbook of Child and Adolescent Mental Health

BackgroundTransfer of knowledge is an important issue throughout all scientific disciplines, especially in the medical and psycho-social field. The issue of worldwide knowledge transfer in child mental health is one of the aims and goals of the journal Child and Adolescent Psychiatry and Mental Health (CAPMH). The demand for mental health training is high worldwide, and especially in low- to lower-middle income countries, where inadequate access to knowledge resources in the field of child and adolescent mental health (CAMH) is prevalent. At the same time, many of these countries are showing an increased risk for mental health issues in children and adolescents. The International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) Textbook of Child and Adolescent Mental Health counters this problem. It is an open-access e-textbook aiming to provide an overview of current and established treatment and practical approaches for child and adolescent psychiatrists, psychotherapists and allied (mental health) professionals worldwide. First published in 2012, the updated and revised version was launched in 2015. The aim of this commentary is to review and disseminate the usefulness and practicability of content and further material included in the new version of the textbook.ReviewOverall, the textbook contains ten sections divided into 59 chapters, with a total of 1435 pages. The original version of the textbook was written in English. The revised version contains translations of 49 chapters into different languages (to date French, Spanish, Hebrew, Arabic, Portuguese, Russian, Norwegian and/or Japanese), with additional material for knowledge dissemination and self-directed learning (e.g. videos and quizzes) for several chapters. The textbook and the add-on materials for dissemination are of high quality and convey a great introduction to important topics concerning mental health. Apart from knowledge transfer, there is a pragmatic focus on clinical practice and on regional and cultural differences.ConclusionThe textbook is a new and unique opportunity for professionals all over the world to improve their knowledge, skills and expertise in CAMH. High-quality, up-to-date and freely accessible materials in the field of CAMH are combined with the opportunity to share insights with colleagues.

Increasing Knowledge, Skills and Confidence concerning Students’ Suicidality through a Gatekeeper Workshop for School Staff

Introduction: Around one-third of adolescents in Germany report a lifetime history of suicide ideation. School staff (e.g., teachers or school social workers) can serve as gatekeepers to identify adolescents at risk and transfer them to appropriate mental health professionals. The aim of this study was to evaluate a gatekeeper training for school staff. Methods: A total of N = 603 school social workers, school psychologists, and teachers participated in one of 33 1.5-day workshops. Knowledge, attitudes, confidence in skills, and perceived knowledge were assessed at pre and post workshops and at 6-month follow-up (FU). Behavioral changes were assessed via self-report at FU. Results: Knowledge, perceived knowledge, and confidence in own skills concerning suicidality increased significantly from pre- to post-assessment and was still significantly increased at 6-month FU. Attitudes toward suicidal adolescents were neutral to positive before the workshop and remained un-changed at FU. Overall, participants were very satisfied with the workshop. Although participants stated to be motivated to make behavioral changes at 6-month FU, they reported obstacles such as lack of resources and support from school administration. Discussion: This 1.5-day gatekeeper workshop was effective in enhancing knowledge and confidence in school staff regarding suicidality. Future workshops would benefit from ongoing supervision and inclusion of school administration in order to facilitate long-term changes on a behavioral level.

Somatosensory Stimulus Intensity Encoding in Borderline Personality Disorder

Borderline Personality Disorder (BPD) is clinically characterized by emotional instability, interpersonal disturbances and dysfunctional behavior such as non-suicidal self-injury (NSSI). During NSSI, patients with BPD typically report analgesic or hypoalgesic phenomena, and pain perception and pain processing in BPD have been repeatedly investigated. Most of the studies so far focused on affective-motivational and cognitive-evaluative neural components of pain within categorial study designs. By contrast, rather basic somatosensory aspects such as neural intensity-encoding of somatosensory stimuli were not examined in further details. Thus, we investigated patients with BPD and healthy controls (HC) by functional magnetic resonance imaging (fMRI) during an unpleasant sensory stimulation task with parametrically increasing stimulus intensities. 15 females diagnosed with BPD and 15 HCs were investigated with fMRI during four individually adjusted levels of electrical stimulus intensities. Ratings of stimulus intensity were assessed by button presses during fMRI. fMRI-data were analyzed by analyses of variances (ANOVA) at a statistical threshold of p < 0.05 FWE-corrected on cluster level. Subjective ratings of stimulus intensities were alike between BPD and HC, and intensity levels identified with equal accuracy. Significant intensity-encoding neural activations were observed within the primary and secondary somtasensory cortex, the posterior insula, the posterior midcingulate cortex (pMCC) and the supplementary motor area (SMA) in both, HC and BPD. Notably, there were no significant between-groups differences in intensity-encoding neural activations, even at lowered significance thresholds. Present results suggest a similar neural somatosensory stimulus intensity encoding in BPD as previously observed on a behavioral level. The alterations in neural affective-motivational or cognitive-evaluative components reported so far may be restricted to pain rather than unpleasant stimulus processing and were absent in our study.

Association of child maltreatment subtypes and long-term physical health in a German representative sample

ABSTRACT Background: Child maltreatment is a major public problem, associated with enormous consequences on the individual and socioeconomic level. Studies show a clear impact of child maltreatment on long-term physical health. However, there is a lack of analyses comprising a wide variety of subtypes of maltreatment and addressing cumulative effects of different maltreatment subtypes experienced during childhood on physical health. Objective: The objective of this analysis was to assess the association of different subtypes and the intensity of child maltreatment with long-term physical health outcomes. Methods: In a cross-sectional observational approach, a representative sample of the German population (N=2510) was assessed regarding socioeconomic information, their current health status, and their experiences of child maltreatment using the Childhood Trauma Questionnaire (CTQ). Chi2-Tests were performed to compare differences of physical health conditions in adulthood in association with child maltreatment and binary regression analyses to assess the relationship of physical health and number of different subtypes of maltreatment experienced during childhood. Results: Odds increased significantly for obesity (1.8), diabetes (1.26), cancer (1.28), hypertension (1.16), chronic obstructive pulmonary disease (1.51), history of myocardial infarction (1.29) and stroke (1.31) with increasing number of experienced subtypes of child maltreatment. Growing intensity of each subtype of maltreatment was associated with higher rates of all assessed physical health conditions, which could point towards a dose-dependency of the relationship between maltreatment and long-term physical health. Conclusions: Child maltreatment is associated with increased odds for the leading morbidity and mortality causes in Germany. Interventions encompassing secondary and primary preventive strategies are critical to target this major public health problem and its devastating consequences.

Nonsuicidal Self-Injury in Adolescents

BACKGROUND 25-35% of adolescents in random samples drawn from German schools have been found to have manifested at least one episode of nonsuicidal self-injury (NSSI). The prevalence in samples from child and adolescent psychiatric clinics is approximately 50%. NSSI can arise as a symptom in the setting of various types of mental illness. METHODS This review is based on a selective literature search carried out in the PubMed, PsycINFO, and Cochrane Library databases, with special consideration of regional study samples. RESULTS NSSI is usually resorted to as a dysfunctional coping strategy for emotional regulation. The main risk factors for NSSI include bullying, accompanying mental illnesses, and a history of abuse and neglect in childhood. Neurobiological studies have shown abnormal stress processing in persons with NSSI and an elevated pain threshold in persons with repetitive NSSI. Psychotherapeutic interventions of various kinds lessen the frequency of NSSI; to date, no particular type of psychotherapy has been found to be clearly superior to the others. Randomized controlled trials have revealed small to moderate effects from dialectic-behavioral therapy and mentalization-based therapy in adolescent patients. No psychoactive drug has yet been found to possess specific efficacy against NSSI in adolescents. CONCLUSION The first ever German-language clinical guidelines for the treatment of NSSI have now been issued. Psychotherapy is the treatment of first choice. More research is needed so that subgroups with different disease courses can be more clearly defined.

Non-suicidal self-injury in adolescents.

BACKGROUND 25-35% of adolescents in random samples drawn from German schools have been found to have manifested at least one episode of nonsuicidal self-injury (NSSI). The prevalence in samples from child and adolescent psychiatric clinics is approximately 50%. NSSI can arise as a symptom in the setting of various types of mental illness. METHODS This review is based on a selective literature search carried out in the PubMed, PsycINFO, and Cochrane Library databases, with special consideration of regional study samples. RESULTS NSSI is usually resorted to as a dysfunctional coping strategy for emotional regulation. The main risk factors for NSSI include bullying, accompanying mental illnesses, and a history of abuse and neglect in childhood. Neurobiological studies have shown abnormal stress processing in persons with NSSI and an elevated pain threshold in persons with repetitive NSSI. Psychotherapeutic interventions of various kinds lessen the frequency of NSSI; to date, no particular type of psychotherapy has been found to be clearly superior to the others. Randomized controlled trials have revealed small to moderate effects from dialectic-behavioral therapy and mentalization-based therapy in adolescent patients. No psychoactive drug has yet been found to possess specific efficacy against NSSI in adolescents. CONCLUSION The first ever German-language clinical guidelines for the treatment of NSSI have now been issued. Psychotherapy is the treatment of first choice. More research is needed so that subgroups with different disease courses can be more clearly defined.