Deliberate self-harm among adolescents : course, outcome and treatment

Background: Self-harm among adolescents is prevalent, and is a risk factor for suicide, which is one of the leading causes of death among youth worldwide. There is a need to better understand the role and impact of self-harm within clinical samples, and the subsequent risks associated with self-harm with and without suicidal intent. Dialectical behavior therapy (DBT) has the strongest empirical support for treatment of self-harm among adolescents, and extended knowledge on important treatment components is critical for the development of brief, efficacious interventions that are easily accessible for adolescents.

Aim: The aims were to study clinical and psychosocial correlates as well as long-term outcome among clinical samples with self-harm and explore experiences of care among young adults who have participated in specialist-level interventions targeting self-harm (i.e. DBT).

Methods: The clinical and psychosocial correlations was studied in a case-control study (N = 25,161) comparing three subgroups of patients; 1) self-harm only, 2) self-harm and suicidality, and 3) neither self-harm nor suicidality (controls). Linear regression and logistic regression were used to calculate associations. Outcomes were studied in three different longitudinal cohort studies: 1) outcomes after self-harm with and without suicidal ideation/behavior (N = 6,120), 2) outcomes for boys or girls with self-harm (N = 110,072), and 3) outcomes after nonsuicidal self-injury (NSSI) or suicide attempt (SA) using NSSI and SA as time-varying covariates (N = 2,219). By using Cox regression, Hazard Ratios with 95% Confidence Intervals were estimated for each outcome. Salient treatment components were studied with a qualitative analysis of 19 semi-structured interviews with former DBT patients.

Results: Self-harm within clinical populations was associated with higher clinical and psychosocial burden and higher risk of adverse outcomes, e.g. alcohol/substance misuse, violent and nonviolent criminality, as compared with patients with no self-harm. Patients with both self-harm and suicidality are the most vulnerable group. The young self-harming patient valued a therapist who showed explicit concern and trust in the patient’s competence to change destructive behaviors, but also meeting and learning from peers.

Conclusion: Help-seeking boys and girls with self-harm need appropriate care and assessment, including prevention and treatment of alcohol and substance use. Self-harm might serve as a risk marker for emotion dysregulation and impulsivity within both sexes. Suicidality in addition to self-harm need to be regularly assessed and signals highly increased risks for future adverse outcomes. Interventions that lower the risks are necessary. Young patients with self-harm, can be strongly motivated, and work hard, to improve their well- being and pursue a life worth living. Teaching and learning from peers might be of particular value and importance among adolescents.

List of scientific papers

I. Bjureberg, J., Ohlis, A., Ljótsson, B., D’Onofrio, B. M., Hedman-Lagerlöf, E., Jokinen, J., Sahlin, H., Lichtenstein, P., Cederlöf, M., Hellner, C. (2019). Adolescent self-harm with and without suicidal ideation and behaviors: Cross-sectional and longitudinal analyses of a Swedish regional register. Journal of Child Psychology and Psychiatry. 60(3), 295-30.
https://doi.org/10.1111/jcpp.12967

II. Ohlis, A., Bjureberg, J., Lichtenstein, P., D’Onofrio, B. M., Fruzzetti, A. E., Cederlöf, M., Hellner, C. (2020). Comparison of suicide risk and other outcomes among boys and girls who self-harm. European Child & Adolescent Psychiatry. 2020 Dec; 29(12):1741-1746.
https://doi.org/10.1007/s00787-020-01490-y

III. Bjureberg, J., Kuja-Halkola, R., Ohlis, A., Lichtenstein, P., D’Onofrio, B. M., Hellner, C., Cederlöf, M. Adverse clinical outcomes in adolescents with clinician-rated nonsuicidal self-injury and suicide attempt: Longitudinal cohort study. [Manuscript]

IV. Ohlis, A., Bjureberg, J., Simonsson, O., Kerj, E., Hallek, C., Fruzzetti, A. E., Cederlöf, M., Hellner, C. Helpful approached from the DBT-A patient’s perspective: A qualitative analysis of former patients’ experiences. [Manuscript]