Online Emotion Regulation Therapy May Reduce Frequency of Self-Injury

Adolescents who engage in non-suicidal self-injury (deliberate harm to one’s body without suicidal intent) are known to be at risk of a variety of problems, including suicidal behaviors. A study published yesterday in JAMA Network Open suggests that adolescents diagnosed with non-suicidal self-injury (NSSI) who participate in an online emotion regulation therapy may be less likely to engage in such self-harm behaviors compared with those receiving usual care.

“There are very few empirically supported treatments for NSSI in adolescence. Dialectical behavior therapy is promising; however, it is a long and resource-demanding treatment that is not widely available,” wrote Johan Bjureberg, Ph.D., of the Karolinska Institutet in Stockholm and colleagues. “Briefer and more accessible treatments for NSSI are needed.”

To test whether a brief treatment delivered online might be able to help youth, Bjureberg and colleagues recruited adolescents aged 13 to 17 diagnosed with non-suicidal self-injury disorder (listed as a condition for further study in DSM-5) who did not have any immediate suicide risk. In total, 166 adolescents were randomly assigned to receive either 12 weeks of online emotion regulation therapy alongside usual care or usual care alone.

Usual care included weekly symptom assessments and supportive therapy sessions every two weeks. The online therapy included 11 educational modules for the adolescents and six modules for their parents. Emotion dysregulation is believed to in part drive NSSI behavior, and the modules aim to teach participants more adaptive ways of responding to their emotions. The participants also had online access to a therapist who encouraged engagement and answered questions.

NSSI frequency was both self-reported by the adolescents weekly and assessed by clinicians before and after treatment.

At the start of the study, the participants reported about 2.5 NSSI episodes per week. From pretreatment to one month post-treatment, the adolescents receiving the online therapy reported a 68% reduction in the number of NSSI episodes per week, whereas those in usual care alone reported no change. Similarly, at the one-month follow-up, the clinicians observed an 82% reduction in NSSI frequency for the online therapy group compared with a 47% reduction for those in usual care. The adolescents receiving the online therapy also reported greater improvements in their emotion regulation and overall functioning as well as fewer self-destructive behaviors compared with usual care at one-month and three-month follow-ups.

There was no difference in depression, anxiety, and stress symptoms between the two groups after the treatment, the researchers wrote. They noted that these findings are consistent with the online therapy’s emphasis on encouraging participants to accept internal experiences and control their behaviors while emotionally distressed, rather than trying to control the emotions themselves. “[T]argeting emotion regulation may not be sufficient for the treatment of anxiety and depression among adolescents,” they wrote.

To read more on this topic, see the Psychiatric News article “People Who Self-Injure Describe Behaviors as Addictive.”

(Image: iStock/KatarzynaBialasiewicz)

---

Psychiatric News Invites Applications for
Medical Editor-in-Chief

APA members who have administrative experience, are passionate about disseminating news in the field of psychiatry, and are knowledgeable about print and digital communications are invited to apply. Watch a short video in which the current editor-in-chief discusses this influential and key position. The deadline for applications, which should include a vision statement and a curriculum vitae, is July 19, 2023.

LEARN MORE

Adding Fluoxetine to CBT May Not Further Reduce Depressive Symptoms in Youth With MDD

A combination therapy of fluoxetine and cognitive-behavioral therapy (CBT) is not superior to CBT alone for treating teens and young adults with major depression, according to a study published in Lancet Psychiatry.

“[W]e did not find evidence that adding fluoxetine to CBT was beneficial for reducing depressive symptoms,” wrote Christopher Davey, M.B.B.S., Ph.D., of Orygen, the National Centre of Excellence in Youth Mental Health in Australia, and colleagues. “Our results show that adding fluoxetine to CBT might be more effective for treating anxiety symptoms than for depressive symptoms.”

Davey and colleagues conducted a 12-week randomized trial involving 153 participants aged 15 to 25 with moderate-to-severe major depression (score of 20 or higher on the Montgomery-Åsberg Depression Rating Scale, or MADRS). All participants received weekly 50-minute CBT sessions as well as daily fluoxetine (up to 40 mg/day) or placebo pills. The researchers evaluated the participants’ depressive and anxiety symptoms, social functioning, quality of life, and suicidal thoughts every four weeks.

After 12 weeks, there was no statistical difference between the two study groups in terms of depression symptoms; MADRS scores decreased by 15.1 points among patients receiving CBT plus fluoxetine and 13.7 points among patients receiving CBT plus placebo. However, participants in the fluoxetine group showed statistically significant improvements in anxiety symptoms, as measured by the Generalized Anxiety Disorder 7-item scale (GAD-7); GAD-7 scores decreased by 5.3 points in the fluoxetine group compared with 3.2 points in the placebo group.

During the study, there were five suicide attempts in the CBT plus placebo group and one in the CBT plus fluoxetine group; all but one of these attempts were by participants 18 and older. In contrast, there were almost twice as many instances of nonsuicidal injury among participants taking fluoxetine compared with placebo, with most incidents occurring in participants under 18.

“The results of this study will probably discourage the combined use of CBT and medication as a first-line approach to treating youths with moderate-to-severe depression,” wrote Benedetto Vitiello, M.D., of the University of Turin, Italy, in an accompanying editorial. “Instead, a stepped-treatment approach, with initial monotherapy followed by the addition of another modality in case of insufficient response or to prevent relapse, seems to be a more reasonable use of resources.”

For more information on a related topic, see the Psychiatric News article “Adding Paroxetine May Not Improve CBT for Social Anxiety.”

(Image: iStock/izusek)

Follow Psychiatric News on Twitter!

Meta-Analysis Finds Childhood Abuse, Neglect Associated With Self-Injurious Behavior

Understanding patients’ history of childhood abuse or neglect may help determine their risk of non-suicidal self-injury, according to a meta-analysis published in the January issue of Lancet Psychiatry.

Non-suicidal self-injury—defined as direct and deliberate destruction of one’s own bodily tissue without suicidal intent—is estimated to affect more than 5% of adults, 17% of adolescents, and 30% of adolescents with a mental disorder. Moreover, non-suicidal self-injury is known to be one of the strongest predictors for future suicide attempts, Richard T. Liu, Ph.D., of Brown University and colleagues wrote. While most patients who engage in repeated self-injurious behavior stop within a few years, about one-fifth of patients develop a chronic pattern of self-injury.

The meta-analysis by Liu and colleagues included 71 studies that evaluated the association between childhood maltreatment (including sexual abuse, physical abuse, physical neglect, emotional abuse, and emotional neglect) and non-suicidal self-injury. The researchers found that overall childhood maltreatment was positively associated with non-suicidal self-injury (odds ratio [OR] = 3.42). The association was strongest for emotional abuse (OR = 3.03) and weakest for emotional neglect (OR = 1.84), although the analysis for emotional neglect included the fewest studies.

The association of maltreatment with non-suicidal self-injury was found to be stronger in community samples than in clinical samples, suggesting that “screening for history of childhood maltreatment might be of most benefit in community settings,” they wrote.

In an accompanying commentary, Lianne Schmaal, Ph.D., and Sarah Bendall, Ph.D., of Orygen and the University of Melbourne wrote that “Disclosure of past childhood maltreatment to a health professional can be a distressing experience. Because non-suicidal self-injury might function to distract from distress in some people, disclosures of distressing maltreatment have the potential to raise the risk of non-suicidal self-injury afterwards.” Therefore, such assessments should be done in accordance with principles of trauma-informed care.

For related information, see the American Journal of Psychiatry article “Association of a History of Child Abuse With Impaired Myelination in the Anterior Cingulate Cortex: Convergent Epigenetic, Transcriptional, and Morphological Evidence.”

(Image: iStock/Sasiistock)

---

Have You Voted in APA’s 2018 Election Yet?

If not, take a moment to do so now: Voting closes on Wednesday, January 31. Learn about this year’s slate of candidates, their priorities, and backgrounds at the APA elections page and watch video interviews of the candidates for president-elect, treasurer, and trustee-at-large. Click here to vote now and be part of the process.

Follow Psychiatric News on Twitter!

Nonsuicidal Self-Injury Often Begins in Younger Children

A new study of 665 young people in the third, sixth, and ninth grades finds patterns of nonsuicidal self-injury that vary by age and gender. Nonsuicidal self-injury (NSSI) is the term for intentional, non-fatal, self-inflicted damage caused by cutting, hitting, burning, or excessive rubbing. Reported rates range between 7 percent and 24 percent of adolescents; however, little was known about rates among younger children.

Now the new study finds that even third graders engage in NSSI, with boys and girls doing so at about the same rate (7 percent to 8 percent). By sixth grade, boys (6 percent) are far more likely than girls (2 percent) to harm themselves. However, by ninth grade, those proportions are sharply reversed, with 19 percent of girls and just 5 percent of boys engaging in NSSI, wrote Andrea Barrocas, M.A., of the University of Denver, and colleagues in the July Pediatrics. The researchers urged both pediatricians and hospital emergency room personnel to fully evaluate cases of NSSI to help prevent negative physical and mental health outcomes.

To read a comprehensive review of how psychotherapy can successfully treat psychiatric disorders in children and adolescents, see the new book from American Psychiatric Publishing, Cognitive-BehaviorTherapy for Children and Adolescents.

(Image: Miroslav Dziadkowiec/Shutterstock.com)