Suicide and NonSuicidal Self-Injury in
Adolescents
Saundra Stock, MD
Suicide
 CDC - 17% of adolescents
think about suicide each
year
 Thoughts of death part of
MDE
 3rd leading cause of death
in adolescents about 2,000
deaths per year
 25% decline in suicide rate
in 10-19 year range in past
decade
 Suicide attempts often
impulsive in nature
FDA warning
 FDA reviewed 23 studies with 9 different meds > 4,300 pts
 NO SUICIDES in these studies
 Adverse events reporting - SI or potentially
dangerous behavior reported by 4% of pts on
meds vs. 2% on placebo
 17 of 23 studies asked about SI - no new SI or
worsening of SI, actually decreased during
treatment
Meta Analysis of 27 RCTs with SSRIs
 Studies were for MDD, OCD and non-OCD
anxiety
 For MDD
– NNT = 10
– NNH = 112
 More effective and less SEs when treating
OCD or non-OCD anxiety
JAMA 2007
Suicide and SSRIs
 FDA black box warning for risk of suicide for all
ages with ALL antidepressants
 Need to advise families about this risk and give
crisis info
 FDA recommended
– Weekly contact the first 4 weeks
– Every other week through week 12
– As indicated after week 12
Suicide and SSRIs
 FDA changed black box warning from specific
monitoring to more general one
All patients being treated with antidepressants for any
indication should be monitored appropriately and
observed closely for clinical worsening, suicidality, and
unusual changes in behavior, especially during the
initial few months of a course of drug therapy, or at
times of dose changes, either increases or decreases.
Treating Adol Suicide Attempters Study
(TASA)
Youth Most likely to re-attempt suicide
 Higher level of suicidal thoughts
 Higher level self report of depressive sx’s esp
hopelessness and anxiety
 2 or more prior attempts
 Low lethality of index attempt
 H/o maltreatment
 Low family cohesion
 Avg time to re-attempt 6 weeks
MDD trials
 ADAPT, TADS and TORDIA have not
shown great results for CBT in reducing
risk of suicide attempts or NSSI
 Family therapy may be helpful
 Groups CBT and DBT, perhaps some
reduction in risk
General advice for families regarding SI
 No firearms in home
 Limit access to medication including over the
counter meds
 Remove access to parent’s medications
 Remove razors from bathroom or other sharps
 Increase supervision (e.g. keep doors open, limit peer
contact to with adults present)
 Importance of seeking help if suicidal thoughts
develop or worsen
 Crisis numbers (234-1234), emergency room
resources and 911
NSSI and link to suicide
 Suicide is the 3rd leading cause of death in
adolescents
 90% of youth who suicide have a psychiatric
disorder
– The largest group (35%) have MDD
– Previous self harm is present in 40% of youth
who suicide
 Several large studies now with youth and
MDD looking at treatment options and
outcomes: TADS, TORDIA, ADAPT
TORDIA and SI/NSSI
 354 youth with MDD
– 23.9% NSSI baseline
– 9.5% SA
– 14% NSSI + SI
 Over 24 weeks 13% with NSSI made a
suicide attempt vs 3% with prior SA
 11% had NSSI over the 24 weeks (more
common than a SA
 Predictors of SA were NSSI and
hopelessness
Tordia study
JAMA 2008
Switch SSRIs
Pts ages
12-18 failed
2month
SSRI trial
N= 334
Paroxetine
Fluoxetine
Citalopram
47% improved
Switch SSRI +
add CBT
Better
outcome
54.8%
Switch to
venlafaxine
48.2%
improved
Switch to
venlafaxine +
CBT
Better
outcome
54.8%
Non-Suicidal Self Injury (NSSI)
 Intentional destruction of one’s body tissue
without suicidal intent & for purposes
which are not socially sanctioned
 Common methods:
70%-90% of people who self-injure engage in
skin cutting, scraping, or carving
21-44% banging, bruising, and self-hitting
15-35% burning
Klonsky, E. David; Muehlenkamp, Jennifer J.; Lewis, Stephen P.; Walsh, Barent
(2012-06-25).
Nonsuicidal Self-Injury (Advances in Psychotherapy, Evidence Based Practice)
NonSuicidal Self-Injury
“Condition for further study” in DSM 5
A. 5 or more episodes in 1 year
B. 2 or more
• Preceded by negative affect
• Prior to engaging in the act, a period of preoccupation
with the intended behavior that is difficult to resist.
• The urge to engage in self-injury occurs frequently,
although it might not be acted upon
• The activity is engaged in with a purpose; maybe relief
from a negative feeling/cognitive state or interpersonal
difficulty or induction of a positive feeling state. The
patient anticipates these will occur either during or
immediately following the self-injury.
C. Behavior and consequences cause distress
D. Not exclusively during intoxication or psychosis
Epidemiology
 10-15% teens have self-injured at least once
– Most studies find 6-8% of teens and young adults
reporting current, chronic self-injury
– More common in clinical populations
 Self-injury typically begins at ages 12-15 years
 M=F lifetime rates, however females may
engage in NSSI more often
 Females tend to cut; Males hit or bang
 More comon in Hispanic or Native American in
US studies. UK study found more in Asian
decent
Biology – little is known
 Endogenous opioids (mixed evidence)
– Released with physical injury and may explain
positive emotions and limited pain
– Studies with naloxone (opioid antagonist)
negative
 Serotonin: animal models with low
serotonin engage in self injury. Also low
with aggression and suicidal behavior
 ? Dopamine: reduced in Lesch-Nyhan
 No differences on phsiologic measures of
emotional responses compared to controls
Course and Prognosis
 Occurs with a wide range of diagnoses
 Few longitudinal studies of NSSI exist
 Questions to be answered:
– How many people stop NSSI and when?
– Is NSSI a precursor to specific mental disorders?
– How often does it lead to suicidal behavior?
Some information on NSSI and sucide attempts
from several large studies on depression in
adolescents
TORDIA and SI/NSSI
 354 youth with MDD
– 23.9% NSSI baseline
– 9.5% SA
– 14% NSSI + SI
 Over 24 weeks 13% with NSSI made a
suicide attempt vs 3% with prior SA
 11% had NSSI over the 24 weeks
 Predictors of SA were NSSI & hopelessness
ADAPT study
 Original trial N=208 British teens with moderate to
severe depression randomized to SSRI or SSRI +
12 weeks of CBT.
 Outcome at 28 weeks found no difference btwn
treatment groups.
 Subsequent analysis looked at those at risk for
suicide attempt
ADAPT study
 N= 163 teens 11-17 yrs
 Suicide attempt in 28 week f/u period
– 30% made a SA, lower each month
– Risk factors: +SI, depression severity,
hopelessness, NSSI or SA in the month before
baseline and impaired family functioning
 NNSI
– 37% had self injury, lower each month
– Risk factors: NSSI in month prior to study,
depression severity, anxiety, hopelessness,
female and younger age
ADAPT: suicide attempts & self injury
 N= 163 teens 11 to17 years (mean age 14)
 Avg 67 weeks of depression
– CDI score mean 59.9
 One month prior to the study
– 28 (17%) had made SA
– 58 (36%) had engaged in NSSI
 During the 28 weeks of the study
– 50 (30%) youth made a SA
– 60 (37%) youth engaged in NSSI
ADAPT study results
 Suicide
– NSSI a stronger predictor of suicide attempt than
a prior suicide attempt
– 10 fold greater risk of suicide attempt than those
who had no self injury and good family
functioning
 NSSI
– 36% had NSSI the month prior to the study and
37% engaged in NSSI during the study period.
– Most significant predictor of subsequent self
injury was prior self injury
ADAPT self-injury
 Compared with suicidality, self-injury over
the 24 week follow- up period was
associated with a different pattern of
predictors.
– Poor family functioning was not associated
with self-injury (but was associated with suicide
attempts)
– Hopelessness & anxiety disorder at baseline
along with being both younger and female,
were associated with self-injury but not with
suicidality.
ADAPT suicide risk factors
 A higher risk of suicide attempt during follow-up
significantly associated with suicidality,
depression severity, hopelessness, the presence
of a suicide attempt or self- injury in the month
before baseline, and impaired family functioning
 Multiple logistical regression revealed impaired
family functioning and self injury were
significantly associated with suicide attempt
 ROC4 analysis showed self-injury to be the
strongest predictor of suicide attempt
Assessment of NSSI: implications for
intervention
 Age of onset
 Methods used for NSSI & access to those
materials
 Frequency & interval from thoughts to action
 Last self-injury
 Location of injury and medical severity
 Thoughts before, during and after NSSI
 Function of behavior (intra or interpersonal)
Assessment measures
 Self-Injurious thoughts and behavior interview
(SITBI)
 Suicide Attempt Self Injury Interview SASII
(Linehan)
 Suicide Behavior Questionairre (SBQ Linehan)
Both Linehan assessment items online at
http://blogs.uw.edu/brtc/publications-assessmentinstruments/
Concern for teens: all ask specifics about actions
which they may not have thought of yet
Function of NSSI
 Most common are INTRApersonal reasons
1. To regulate emotions
•
•
Release emotions, calm down, stop numb feelings
Reduces high arousal emotions (anger, anxiety,
frustration) more than low arousal (i.e. sadness)
2. Self punishment
 Sometimes INTERpersonal
–
–
Interpersonal influence: “letting others know
how I feel” “getting back at someone” or getting
out of repsonsibilties
Peer bonding: “fitting in”
Interventions for NSSI
 Few studies in adolescents looking at strictly
NSSI
 Therapy that focuses on:
– Emotion regulation
– Problem solving
– Improved self esteem
DBT, CBT or problem based
Research has repeatedly documented that
people who engage in NSSI have more
frequent & intense negative emotions as well
as poorer global emotion regulation skills
Level of intervention
 Ongoing monitirong only might be
appropriate if: only 1-2 episodes of NSSI
 Outpatient TX: consider if > episodes of
NSSI, intrapersonal reasons, multiple
methods used, SI present at times, NSSI
performed alone
 Inpatient TX: high frequency/urgency to
thoughts or NSSI, high medical severity,
ongoing +SI present as well
Improving Emotion Regulation
 Several therapies which accomplish this
 Essential components:
– Emotion psychoeducation
• Label emotions, context they occur and function
served including adpative aspect of + and –
emotions
– Reducing emotional vulnerabilities
• Sleep, eating and exercising
– Improving distress tolerance
• Distraction or relaxation techniques; replacements
if needed
– Increasing positive emotional experiences
Problem Solving
 Typical steps include:
– Identifying the problem
– Identifying the goal
– Generating/brainstorming solutions
– Evaluating solutions and potential outcomes
– Implementing a solution
– Reassessing effectiveness after
implementation
Problem Solving
 Nock 2008 found adolescents with NSSI
generated as many options to problems as
adolescents without NSSI
 Adolescents with NSSI selected negative
options more often
 Adolescents with NSSI rated their selfefficacy lower
 Therefore, may need more focus on later
steps in problem solving for youth with NSSI
Nock: Journal of Consulting and Clinical Psychology 2008, Vol. 76, No. 1, 28–38
Interpersonal skills: a means to increase
self esteem/self efficacy
 Less effective at communication skills and
seeking help from others
 People experience increased social support
following self-injury (including suicide
attempts)
 One study with preadolescents found
improved father-child relationship in the
18months following NSSI
 Family therapy: high levels of parental
expressed emotions and criticism for adol with
NSSI (N=36)
New directions:
Motivational interviewing
 Suggested as a means to help reduce NSSI
 5 core elements for therapy
– Expressing empathy
– Avoiding argumentation (not insisting on as a
target based on person’s interest in change)
– Rolling with resistance
– Supporting self-effcicacy
– Developing discrepancy (help pt ID that there is a
gap from where they are & want to be)
References
 Bridge JA, Goldstein TR, Brent DA: Adolescent suicide and suicidal
behavior. J Child Psychol Psychiatry 2006; 47:372–394
 Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM: Psychological autopsy
studies of suicide: a systematic review. Psychol Med 2003; 33:395–405
 Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, Mackway-Jones K,
Appleby L: Suicide after deliberate self-harm: a 4-year cohort study. Am J
Psychiatry 2005; 162:297–303
 Glenn CR Emotional Reactivity in Nonsuicidal Self-injury: Divergence
Between Self-Report and Startle Measures Int J Psychophysiol 2011
May 80(2): 166-170I
 Brent DA et al. Predictors of spontaneous and systematically assessed
suicidal adverse events in the Treatment of SSRI-Resistant Depression
in Adolescents (TORDIA) study. Am J Psychiatry 2009; 166:418–426
 Goodyer I et al Selective serotonin reuptake inhibitors (SSRIs) and
routine specialist care with and without cognitive behaviour therapy in
adolescents with major depression: randomised controlled trial. BMJ
2007; 335:142
References
 Wilkinson P et al. Clinical and Psychosocial Predictors of Suicide
Attempts and Nonsuicidal Self-Injury in the Adolescent Depression
Antidepressants and Psychotherapy Trial (ADAPT) Am J Psych Feb
2012
 Nonsuicidal Self-Injury (Advances in Psychotherapy, Evidence Based
Practice) Klonsky, E. David; Muehlenkamp, Jennifer J.; Lewis,
Stephen P.; Walsh, Barent (2012-06-25).
 Nock MK, Mendes WB. Physiological Arousal, Distress Tolerance,
and Social Problem–Solving Deficits Among Adolescent SelfInjurersJournal of Consulting and Clinical Psychology 2008, Vol. 76,
No. 1, 28–38
 Wedig MM and Nock MK Parental Expressed Emotion and
Adolescent Self-Injury J. Am. Acad. Child Adolesc. Psychiatry,
2007;46(9):1171Y1178.