Depression, self-harm and suicide - Universiteit Utrecht

Lecture 12 Depression, self-harm and suicide 

Moods and emotions 

• Relatively sudden changes in both positively- and negatively valanced affect 

• The intensity and/or frequency of negative emotion peaks in early adolescence 

• Young adolescents also experience less positive emotions 

• Emotions become more complex with a comprehension of mixed emotions 

• Dramatic changes of mood 

• The incidence of dysphoric or depressed moods radically increases, especially for girls 

• Social aspects of emotion expression and regulation become more developed 

• Increased in the ability to mask emotions 

• The use of emotion to manage relationships 

• Yet, emotional expression during early adolescence 

• The social referencing aspects of emotion become highly attuned 

• in early adolescence, there is a sharp increase in the awareness of other's perceptions of the self, and therefore shame 

• More daily fluctuations in self-esteem 

• Adolescents are more “moody” or variable in their emotions across the course of a day or week 

Changes in negative and positive mood in mid-adolescence 

• Significant drop in positive mood, no change in negative mood 

• Mood variability across adolescence using daily internet diaries 

• Three times a year at age 13-18 

• 4 different moods: happiness, sadness, angry, anxiety 

• Steady decrease across mid- to late adolescence in variability  

• Anxiety: does not show the same pattern, slight decrease but not an entire decrease 

• Moodiness decreases across adolescent period 

Depression in all its forms 

• Depression: an enduring period of sadness 

• Depressed mood: an enduring period of sadness, without any other related symptoms 

• Depressive syndrome: sadness plus other symptoms such as crying, feelings of worthlessness, and feeling guilty, lonely or worried 

• Major depressive disorder: depressed mood or loss of interest or pleasure in almost all activities plus 4 of other symptoms (for at least 2 weeks) 

• Clinical valuation on slide 

Gender differences in CDI depression in mid-adolescence 

• Girls show higher levels of depression than boys 

• Depression over the lifespan 

• 5-9: boys are more depressed than girls, but as soon as adolescence hit, then girls show higher rates of depressive disorders than boys. Across the lifespan, women show higher levels of depression than men. 

• But: men also show a significant increase in depression across the lifespan as well. 

Self-harm 

• NSSI: non-suicidal self-injury 

What is self harm? 

• A variety of behaviors in which an individual intentionally inflicts harm to his or her body for purposes not socially recognized or sanctioned and without suicidal intent 

• Includes: see slide 

Prevalence 

• 4% of adults report a history 

• 14% of adolescents 

• High school populations in the US and Canada consistently show a 13-24% prevalence rate 

• 17% of young adults 

Developmental course 

• Two developmental pathways: early onset and long-lasting, adolescence-limited 

• Early onset self-injury is common around the age of 7 

• Most often, however, self-injury behaviors begin in middle adolescence between the ages of 12 and 15 

• Can last for weeks, months, or years 

• 30-40% of college respondents report initiating self-injury while 17 years old or older and stopped within 5 years 

Frequency and other facts 

• Lifetime frequency varies dramatically – one to 100s of incidents 

• The number of forms used by an individual varies from 1 to over 10 

• 1 in 5 self-injurious university students indicated that they had hurt themselves more than intended at least once 

• 1 in 10 indicated that they had hurt themselves so badly that they should have been seen by a medical professional 

Who self-injures? 

• Gender 

• Females are significantly more likely to self-injure than males 

• Other study: males are equally likely to self-injure as females, particularly among non-clinical samples 

• Ethnicity 

• more common among Caucasians 

• Others showing similarly high rates in minority samples 

Is self-harm contagious? 

• No hard and fast conclusions can be drawn – no good study of this effect 

• Anecdotal reports from adults working with youth in school settings report a fad quality to the behavior. There could be groups that intend to injure together. 

• Survey results of secondary school nurses, counselors and social workers suggest that there are groups of youth injuring together or separately as part of a group membership 

• Media – increasing prevalence of self-injury in movies, books, and news reports may play a role in the spread of self-injury 

Why do people self-injure? 

• Emotional triggers: overwhelming sadness, anxiety, or emotional numbness 

• A way to manage intolerable feeling or experience some sense of feeling 

• Used as means of coping with anxiety or other negative feelings and to relieve stress or pressure 

• To feel in control of their bodies and minds 

• To express feelings 

• To reenact a trauma in attempt to resolve it or to protect others from their emotional pain 

Two different pathways: 

• Dealing with stress 

• Hyperstress: overwhelmed, not able to cope > trigger (images of self-harm etc.) > self-injury > feeling relieved, being in control, being calm 

• Dealing with dissociation from the world 

• Feeling numb, lost, alone, disconnected and/or unreal > self-injury > feeling real, alive and/or able to function again 

Nock & Prinstein Model (2004) 

• Reasons for self-injury > two by two table: look at function of self-injury, why do we keep repeating it? (positive reinforcement (positive stimuli) or negative reinforcement (removal of a negative stimulus)) 

• Functions 

• Automatic: a function towards the self: we want to feel something > positive reinforcement and serving the self. Doing it to stop bad feelings > negative reinforcement + feeling relieved 

• Social: to get attention, express something to people. Positive reinforcement (to get attention) or negative reinforcement (to avoid punishment from others) 

Self-harm cycle 

• Self-harm is causing the harm to the self. As a result of the pain > release (feeling of relief, wanting to do it again) > shame (to the self for self-harming) > hurt (emotional turmoil) > trigger for self-harm 

Psychiatric heterogeneity 

• 12% of adolescent self-injurers do not fit criteria for any mental disorder 

• Skin cutters report more anxiety 

• Endorsers of automatic functions (e.g., to stop bad feelings, feel relaxed) - more likely: suicide attempt, feel hopeless, PTSD symptoms 

• Users of a range of methods and experience less pain – more likely to have a suicide attempt 

Is self-injury a suicidal act? 

• Self-injury is often undertaken as a means of avoiding suicide 

• Individuals who report self harm are also more likely to have considered or attempted suicide 

• Nevertheless, the majority of individuals with self-harm history do not report considering suicide 

• Non-suicidal self-injury may best be understood as a symptom of distress that, if unsuccessfully mitigated, may lead to suicide behavior 

What distinguishes NSSI that attempt suicide from those who do not? 

• Study of Brausch 

• Self harm behavior questionnaire 

• Results 

• Significant differences on anhedonia, negative self-evaluation and negative self-esteem. 

• Anhedonia: inability to feel pleasure in normally pleasurable activities 

• Self-injury only: better of in lower levels of anhedonia, lower sense of negative self-evaluation and higher self-esteem 

• Graph: parent support, peer support and disordered eating 

• Sign. Difference: parent support. Individuals who self-harmed only had higher levels of parent support 

• Conclusion:  

• Cumulative risk: anhedonia, low levels of parent support, negative self-evaluation etc. 

• Peers not as important as parents at times of distress > family interventions are important 

Study BMJ 

• Aims... 

• Results 

• Higher self harm rates in girls 37,4 compared with boys 12,3 per 10000 

• Higher incidence rates in low SES (deprived) 27,1 compared to higher SES (nondeprived) 19,6 

• Girls in 13-16 age group showed 68% increase across time from 45,6 in 2011 to 76,9 in 2014 

• What’s happening? Referred to mental health services? 

• No referral for 55,8% 

• 12,4% referred for self harm episode (direct) 

• 14,1% referred within a one year afterwards 

• Those in deprived areas are less likely to be referred 

• More than a fifth were prescribed antidepressants, with more girls prescribed them than boys 

• Boys were more likely to be prescribed hypnotics or anxiolytics than girls 

• Risks to mortality 

• A total of 43 deaths occurred among young people in the self harm cohort and 176 in the comparison cohort (this group is 20x bigger) 

• 65% (self harm cohort) compared with 26,6% (comparison cohort) were classified as unnatural deaths 

• Those who self harmed were an estimated nine times more likely to die unnaturally during the follow-up period than their unaffected peers 

• In the self harm cohort the risk for mortality was increased for: 

• All causes of mortality and for each cause of death category 

• Suicide 

• Fatal acute alcohol or drug poisoning 

• Accidents 

• Boys in the self harm cohort had a higher increase in risk of all cause mortality compared to all other groups 

• Conclusion 

• Need to investigate reason for increase among 13-16 year-old girls 

• Primary care important target for identification and early intervention 

• More work on prevention needed 

• Intervention 

• Focus on: 

• Enhancing awareness of the environmental stressors that trigger self-injury 

• Helping individuals identify, practice and use more productive and positive means of coping with their emotional states 

Overall conclusion: NSSI represents a continuum of self-harm behaviors, where suicide is the final endpoint