Nonsuicidal self-injury and emotion regulation : clinical correlates and novel treatments

Background: Nonsuicidal self-injury (NSSI) and NSSI disorder are common, particularly among adolescents and young adults, and have been associated with several adverse outcomes, including general psychopathology and suicide. It has been recommended to study self-injury separately from suicidal behaviors to better understand its etiology and maintaining factors. One factor that may be important to understanding NSSI is emotion regulation. The Difficulties in Emotion Regulation Scale (DERS) is a useful measure of the construct; however, for a measure to have broad research and clinical utility it must be brief. Despite the clinical relevance of NSSI, treatments that specifically target the behavior are scarce. One exception is emotion regulation group therapy (ERGT) that was developed to directly target NSSI and its proposed underlying mechanism of difficulties in emotion regulation. Although ERGT has shown promise in reducing adult NSSI and related difficulties it has never been evaluated under “real-world” conditions delivered by community clinicians, nor has it been tested in adolescents. Despite the clinical relevance, many individuals with NSSI never get access to empirically supported treatments. There is evidence, that online interventions could increase the availability of effective treatments but online therapy has never been evaluated for NSSI.

Aims: The aim of the present thesis was to study clinical and psychosocial correlates and outcomes associated with NSSI, to develop a brief measure of emotion regulation, and to develop and evaluate novel treatments that can be easily and widely implemented for individuals who engage in NSSI.

Methods: In Study I, we conducted a case-control study (N = 25,161) and a longitudinal cohort study (N = 5,370) using data from a regional clinical care register and Swedish national registers. We compared clinical and psychosocial correlates and subsequent adverse outcomes in three groups of adolescent patients who presented to child and adolescent mental health services with self-injury only, self-injury with suicidal ideation and behaviors, and patients without any indication of self-injury or suicidal ideation and behavior. In Study II, we developed a 16-item version of the DERS (DERS-16) and investigated its reliability and validity in a clinical sample (N = 96) and two community samples (Ns = 102 and 482). In Study III, we studied ERGT in a multi-site uncontrolled trial (N = 95). In Study IV, we adapted ERGT for adolescents to a novel emotion regulation individual therapy (ERITA) protocol that we evaluated in 17 adolescents with NSSI disorder and their parents, using an uncontrolled trial design. Finally, in Study V, we developed an online version of ERITA and included 25 adolescents with NSSI disorder and their parents in an uncontrolled pilot trial. In all intervention studies, measures were administered pre-treatment, post-treatment and at 6-month follow-up. Mediation analyses were conducted in Studies IV and V.

Results: In Study I, results demonstrated that adolescent patients with self-injury with and without suicidal ideation and behavior were more burdened in terms of clinical care utilization, global functioning, mental disorders, and psychosocial problems than the clinical controls, and were at greater risk for several important adverse outcomes in emerging adulthood. Although the self-injury group was more burdened and at greater risk compared to controls, they were not as burdened as the self-injury with suicidal ideation and behavior group. Results from Study II showed that the shortened DERS-16 demonstrated excellent internal consistency, good test-retest reliability, and good convergent and discriminant validity. In all treatment studies (Studies III-V), treatment compliance and measures of credibility were acceptable, and participation in treatment was associated with significant reductions in NSSI and related difficulties. Moreover, change in difficulties in emotion regulation mediated week-to-week changes in NSSI frequency in Studies IV and V.

Conclusions: Self-injury with and without suicidal ideation and behaviors should inform risk assessment and be prioritized within child and adolescent mental health services. The DERS-16 is a valid and brief self-report measure of difficulties in emotion regulation. It is feasible to implement ERGT within a community-based health care system. ERITA may be a promising treatment for NSSI among adolescents, both in a traditional face-to-face format, and in an online format. Due to treatment length and format, ERGT and ERITA carry the potential to increase access to psychological treatments for adults and youth with NSSI. Also, in line with the theoretical model underlying the ERITA interventions, improvement in difficulties in emotion regulation mediates reduction in NSSI during treatment, thus providing further preliminary support for the underlying role of emotion regulation difficulties in the maintenance of self-destructive behaviors.

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. Adolescent Self-Harm With and Without Suicidal Ideation and Behaviors: Crosssectional and Longitudinal Analyses of a Swedish Regional Register. [Submitted]

II. Bjureberg, J., Ljótsson, B., Tull, M. T., Hedman, E., Sahlin, H., Lundh, L.-G., Bjärehed, J., DiLillo, D., Messman-Moore, T., Hellner Gumper, C., Gratz, K. L. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. Journal of Psychopathology and Behavioral Assessment. 2016; 38: 284-96.
https://doi.org/10.1007/s10862-015-9514-x

III. Sahlin, H., Bjureberg, J., Gratz, K. L., Tull, M. T., Hedman, E., Bjärehed, J., Jokinen, J., Lundh, L.-G., Ljótsson, B., Hellner, C. Emotion regulation group therapy for deliberate self-harm: a multi-site evaluation in routine care using an uncontrolled open trial design. BMJ Open. 2017; 7: e016220.
https://doi.org/10.1136/bmjopen-2017-016220

IV. Bjureberg, J., Sahlin, H., Hellner, C., Hedman-Lagerlöf, E., Gratz, K. L., Bjärehed, J., Jokinen, J., Tull, M. T., Ljótsson, B. Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study. BMC Psychiatry. 2017; 17: 411.
https://doi.org/10.1186/s12888-017-1527-4

V. Bjureberg, J., Sahlin, H., Hedman-Lagerlöf, E., Gratz, K. L., Tull, M. T., Jokinen, J., Hellner, C., Ljótsson, B. Extending Research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with Nonsuicidal Self-Injury Disorder: Open Pilot Trial and Mediation Analysis of a Novel Online Version. [Submitted]