A unified theoretical framework for understanding suicidal and self-harming behavior: Synthesis of diverging definitions and perspectives

Borderline Personality Disorder (BPD) has largely been associated with self-harm and chronic suicidality, despite the fact that these behaviours comprise only one diagnostic criterion. Treatments for self-harm are mostly indicated for individuals with BPD. Emerging literature suggests that youth with histories of depression are at risk of both self-harm and completed suicide. For individuals with repeated self-harm, co-occurring suicidal ideation and behavior is not uncommon. In the field of self-harm research, two major positions and corresponding definitional terms have evolved. “Deliberate self-harm” is a broad definition that includes direct suicidal and non-suicidal forms of the behavior. “Non-suicidal self-injury” (NSSI) encompasses only behaviours resulting in direct tissue damage in the absence of suicidal intent. Neither position systematically evaluates indirect self-harm. The discrepancy between definitions and deficiency of either alone produces an inability to compare results in clinical research, and limits the applicability of evidence-based treatments. We propose that these behaviors are best understood as possible dimensions on a broad self-harm spectrum, within a theory derived from the literature on suicide, self-harm, NSSI, and BPD. Methods: Research and theory review. Results: A number of recent empirical studies have concluded that self-harm and suicide should not be considered separately, lending support to a broader definition of self-harm than that encompassed by NSSI alone. Extending the definitional scope of self-harm enables a more thorough understanding of indirect self-harming behaviors, proposed to have the same function as NSSI. These studies as well as Emerging Models from DSM-5 inform the proposed theory. Conclusion: The proposed unified theoretical framework provides a formulation of both NSSI and suicidal behavior as two dimensions on a broad spectrum of self-harming behaviors. The empirical and theoretical basis for the theory is presented alongside the clinical and research utility of integrating a literature that remains divergent

REKOMMENDATIONER FÖR INSATSER VID SJÄLVSKADEBETEENDE : Nationellt kvalitetsdokument för psykiatrin

Rekommendationer för insatser vid självskadebeteende är framarbetade inom ramen för Nationella självskadeprojektet som på uppdrag av regeringen och Sveriges kommuner och landsting (SKL) utvecklat och samordnat kunskap kring självskade- beteende generellt och psykiatrins insatser specifikt. Dokumentet är antaget av projektets styrgrupp, representanter från brukar-, anhörig- och intresseorganisationer samt SKL:s nationella nätverk för ledning och styrning.Rekommendationer för insatser vid självskadebeteende sammanfattar aktuell kunskap om effektiva insatser inom specialistpsykiatrin och baseras på aktuell forskning. I de fall då tillräcklig forskning saknas och konsensus funnits i program- gruppen, baseras rekommendationerna på klinisk erfarenhet och erfarenheter från personer med egen erfarenhet av självskadebeteende. Dokumentet uppdateras regelbundet och kompletteras med nyare rön samt redigeras med tanke på att öka användbarheten.Behovet av att arbeta utifrån en gemensam kunskapsbas är stort. Dokumentet ska bidra till en likvärdig vård över landet. Rekommendationerna utgör stommenför den vård som psykiatrin bör erbjuda personer med självskadebeteende.De implementeras lokalt och kompletteras med regionala planer/riktlinjer som specificerar hur rekommendationerna ska uppfyllas i den kliniska vardagen.Detta dokument har genomgående fokus på individen med självskade- beteende och tydliggör behov av rätt bemötande, riktad behandling, samordning och kontinuitet. Stommen utgörs av sju rekommendationer som till stor del utgår från NICE Quality Standards for Self harm (NICE, 2013) som sedan har kompletterats och anpassats till svenska förhållanden. Dokumentet syftar till:• Att vara ett beslutsstöd för ledningen inom den specialiserade psykiatrinvid utvecklingsinsatser för bättre vård.• Att verka för en likvärdighet i landet vad gäller vårdutbud och kvalitet.• Att stödja medarbetare inom psykiatrin i det dagliga arbetet.• Att stödja individer som söker vård genom att ge kunskap om vad somkan efterfrågas

Brukarstyrd inläggning : MANUAL FÖR UTBILDNING OCH IMPLEMENTERING

Personer med självskadebeteende och komplex psykisk ohälsa kan förväntas vara suicidnära. De kommer att vara suicidnära under hela den Brukarstyrda inläggningen (BI). På tre dagar kan vi inte ändra på det. Det kan ta år tills stress inte längre triggar suicidalitet. Det vi kan hjälpa till med under BI är stressen.Denna manual (med tillhörande utbildning som tillhandahålls som uppdragsutbildning för hälso- och sjukvårdspersonal via Lunds universitet) är vårt bidrag till att sprida kunskap och stötta psykiatriska verksamheter som är intresserade av att erbjuda Brukarstyrd inläggning

The rationale for a novel non-suicidal self-injury prevention program for youth

Non-suicidal self-injury (NSSI) is self-inflicted physical harm that is associated with suicidality, although it is not an expression of suicidal intent. NSSI behaviours range from minor skin scratching to injury requiring medical attention, and in extreme cases, death. NSSI is understood as an effort to modulate emotion in times of crisis and distress. Causal models have been developed for self-harming individuals with mental health concerns. Ongoing research continues to examine the efficacy of various interventions targeted to specific self-harming populations with co-occurring mental health concerns. Prevalence estimates of NSSI in school-attending youth in Sweden reported that more than 40% had engaged in NSSI, but that a smaller subgroup of approximately 5% engaged in repetitive self-harm. Although engaging in NSSI on a single occasion is not associated with poor mental health and increased risk of suicide, repetitive NSSI does share a relationship with these outcomes. Timely interventions for self-harming youth have a role in decreasing morbidity and mortality associated with repetitive NSSI. However, the role of prevention for youth is unique and possibly transformative with respect to reducing uptake of NSSI in the first place. This theoretical review examines mental health prevention initiatives for youth, and presents a new adolescent NSSI prevention program

Brief Admission Skåne (BAS), an intervention for indivi- duals with symptoms of borderline personality disorder, recurrent self-harm, at high risk for suicide. : Brief admission Skåne: Evaluation of fidelity to the method and individual-therapist experiences

Objectives: To measure treatment fidelity and to evaluate patient and clinician experiences with Brief Admission Skåne (BAS) over the pilot phase and first five months of the intervention phase of a randomized controlled trial (RCT) testing BAS. The purpose of the RCT is to determine whether BAS can reduce the frequency of acute psychiatric admissions for individuals with borderline personality disorder, pervasive self-harm and suicidality. Secondary aims of the RCT are to reduce self-harm (including suicide attempts), increase emotion regulation, and increase life quality. BAS is modelled upon a promising method of Brief Admission implemented in the Netherlands. Methods: Inter-rater reliability between two of the treatment developers rating fidelity are presented alongside preliminary qualitative and quantitative data relating to how patients and their care providers experienced BAS. ResultsA total of N=24, individuals were included in the pilot phase of the study. Patient-clinician concordance regarding positive experiences was uniformly high. The majority of participants (83.3%) endorsed the highest possible rating for overall satisfaction with their experience of BAS. This was concordant with clinician’s evaluation of the care providing experience, with 50.0% reporting they were mostly satisfied and 50.0% reporting that they were completely satisfied. Patient-clinician reports are detailed through qualitative findings. Inter-rater reliability between for fidelity will be reported based upon the intervention phase of the study. Conclusion: The Dutch approach to brief admission has been exported to South Sweden and is currently being systematically evaluated through RCT. To determine adherence to the Dutch approach, fidelity and implementation are carefully considered, with data presented from the first phases of the trial