EDITORIAL
Adolescent Self-Harm: New Horizons? Alan Apter,
N
onfatal suicidal behavior is common in adolescents, especially in adolescent girls.1 This behavior is often recurrent, and all forms of deliberate self-harm are probably the most common reason for emergency room admissions and psychiatric hospitalization in this age group. These young people pose major challenges for clinicians and constitute a major public health issue. Moreover, all forms of nonfatal suicidal behavior may predict completed suicide.2 In general, it appears that contemporary psychiatric treatment services do not prevent recurrence of suicidal behavior3; therefore, there have been many efforts to develop evidencebased therapy protocols for adolescent suicidal behavior. Some have been based on straightforward cognitive-behavioral therapy manuals and others on the flexible integration of various evidence-based interventions, such as the sophisticated Treatment of Adolescent Suicide Attempters (TASA) study. In addition, some success has been achieved with family therapy techniques, such as Attachment-Based Family Therapy. A recent promising line of investigation has been attempts to adapt Interpersonal Therapy for Adolescents for suicidal youth with learning disabilities. A comprehensive and critical review of all these efforts that was recently published in the Journal rather bleakly stated that “despite more than 2 decades of research and several large clinical trials, there are still no empirically validated treatments that prevent the repetition of adolescent suicidal behavior.”4 Perhaps unexpectedly, the most promising advances in the therapy of suicidal persons in general and young people in particular have come from the area of borderline personality disorder (BPD). This disorder is notoriously difficult to treat and is strongly associated with all forms of suicidal behavior, nonsuicidal selfinjury, and different health risk behaviors. Individuals with BPD have severe difficulties with emotional regulation and are characterized by affective instability. They show pronounced
1048
www.jaacap.org
MD
sensitivity to environmental stress, which is a BPD characteristic shown to increase vulnerability for suicidal and self-harm behavior in individuals diagnosed with BPD. Indeed, individuals with BPD are typically highly emotionally reactive, their reactions tend to be extreme, and the time taken to return to their baseline affective state is often considerably longer than for individuals without the condition. Such traits are strongly predictive of adult personality disorders and are associated with increased long-term impairment, morbidity, and mortality. An important question to answer is whether therapeutic interventions in adolescence could prevent the development of adult personality disorders linked to self-harming behavior. Although diagnosing a personality disorder in adolescence was rather frowned upon, the work of Miller et al.5 and of Westen et al.6 has brought about considerable change in diagnostic practice in this area, and now the diagnosis is made fairly commonly in young people. The first report of successful treatment of suicidal adolescents with BPD came from a rather different ideological context: that of mentalization-based therapy (MBT), a psychodynamic-based approach developed by Fonagy and colleagues, which some of this innovative work also was published in the Journal by Rossouw and Fonagy.7 This study compared MBT with treatment as usual. MBT is a year-long, manual-based treatment with weekly individual and monthly family sessions. The focus of MBT is on increasing the adolescent’s and family’s capacity to understand action in terms of thoughts and feelings, which in turn is hypothesized to augment self-control and regulation of affect. The impact of MBT on self-harm was mediated by a decrease in avoidant attachment and an increase in self-reported ability to mentalize. This issue of the Journal presents the first fully fledged attempt to conduct a randomized controlled trial of dialectical behavior therapy (DBT) for adolescents with BPD (Mehlum et al.8).
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 10 OCTOBER 2014
EDITORIAL
DBT is a comprehensive, multimodal outpatient treatment that has been adapted for use with selfharming adolescents (DBT-A) by Miller et al.5 In DBT-A treatment length has been shortened from 12 to 3 to 5 months, includes parents in weekly skills training groups, and adds a new skills module to address common skill deficits in teens with emotion dysregulation and their families. The design of the trial was highly sophisticated. The randomized controlled trial reported 19 weeks of therapy, including weekly individual sessions (60 minutes), weekly multifamily skills training, family therapy sessions, and telephone coaching with individual therapists outside therapy sessions as needed. The control therapy (enhanced usual care) was 19 weeks of standard care (“enhanced for the purpose of the study by requiring that [enhanced usual care] therapists agreed to provide on average no less than one weekly treatment session per patient throughout the trial,” p. 1085). The therapy was conducted in a community mental health setting. Overall the results of the trial were favorable, and DBT-A was more effective in decreasing self-harm than the control therapy. This is certainly good news given the challenges that these difficult patients pose for therapists. DBT-A is much shorter than MBT, which is a definite advantage.
Some lingering doubts remain. For obvious reasons, most subjects were girls, and because boys commit suicide more commonly than girls, we still need to find a solution to this gender paradox. DBT-A included components that were missing in enhanced usual care, such as attention to families, which Brent et al.4 focused on as a critical element in preventing recurrent suicidal behavior, and more therapy may just be better than less therapy. Nonetheless, it does appear that DBT-A is effective, feasible, relatively short, and can be delivered with a high level of fidelity, making it a welcome addition to our therapeutic armamentarium. Gaps remain in our knowledge, and further research in this highly important field of clinical adolescent psychiatry is imperative. &
Accepted August 8, 2014. Dr. Apter is with Schneider’s Children’s Medical Center of Israel and Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel. Disclosure: Dr. Apter reports no biomedical financial interests or potential conflicts of interest. Correspondence to Alan Apter, MD, Schneider Hospital, Psychiatry, 14 Kaplan Street, Petah Tikva, 49202 Israel; e-mail: eapter@clalit. org.il 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2014.07.011
REFERENCES 1. Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self-harm in adolescents: self-report survey in schools in England. BMJ. 2002; 325:1207-1211. 2. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res. 2007;11: 129-147. 3. Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70: 300-310. 4. Brent DA, McMakin DL, Kennard BD, Goldstein TR, Mayes TL, Douaihy AB. Protecting adolescents from self-harm: a critical
5.
6.
7.
8.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 10 OCTOBER 2014
review of intervention studies. J Am Acad Child Adolesc Psychiatry. 2013;52:1260-1271. Miller AL, Muehlenkamp JJ, Jacobson CM. Fact or fiction: diagnosing borderline personality disorder in adolescents. Clin Psychol Rev. 2008;28:969-981. Westen D, DeFife JA, Malone JC, DiLallo J. An empirically derived classification of adolescent personality disorders. J Am Acad Child Adolesc Psychiatry. 2014;53:528-549. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51:1304-1313 e3. Mehlum L, Tørmoen A, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53:1082-1091.
www.jaacap.org
1049
Adolescent Self-Harm: New Horizons? Alan Apter,
N
onfatal suicidal behavior is common in adolescents, especially in adolescent girls.1 This behavior is often recurrent, and all forms of deliberate self-harm are probably the most common reason for emergency room admissions and psychiatric hospitalization in this age group. These young people pose major challenges for clinicians and constitute a major public health issue. Moreover, all forms of nonfatal suicidal behavior may predict completed suicide.2 In general, it appears that contemporary psychiatric treatment services do not prevent recurrence of suicidal behavior3; therefore, there have been many efforts to develop evidencebased therapy protocols for adolescent suicidal behavior. Some have been based on straightforward cognitive-behavioral therapy manuals and others on the flexible integration of various evidence-based interventions, such as the sophisticated Treatment of Adolescent Suicide Attempters (TASA) study. In addition, some success has been achieved with family therapy techniques, such as Attachment-Based Family Therapy. A recent promising line of investigation has been attempts to adapt Interpersonal Therapy for Adolescents for suicidal youth with learning disabilities. A comprehensive and critical review of all these efforts that was recently published in the Journal rather bleakly stated that “despite more than 2 decades of research and several large clinical trials, there are still no empirically validated treatments that prevent the repetition of adolescent suicidal behavior.”4 Perhaps unexpectedly, the most promising advances in the therapy of suicidal persons in general and young people in particular have come from the area of borderline personality disorder (BPD). This disorder is notoriously difficult to treat and is strongly associated with all forms of suicidal behavior, nonsuicidal selfinjury, and different health risk behaviors. Individuals with BPD have severe difficulties with emotional regulation and are characterized by affective instability. They show pronounced
1048
www.jaacap.org
MD
sensitivity to environmental stress, which is a BPD characteristic shown to increase vulnerability for suicidal and self-harm behavior in individuals diagnosed with BPD. Indeed, individuals with BPD are typically highly emotionally reactive, their reactions tend to be extreme, and the time taken to return to their baseline affective state is often considerably longer than for individuals without the condition. Such traits are strongly predictive of adult personality disorders and are associated with increased long-term impairment, morbidity, and mortality. An important question to answer is whether therapeutic interventions in adolescence could prevent the development of adult personality disorders linked to self-harming behavior. Although diagnosing a personality disorder in adolescence was rather frowned upon, the work of Miller et al.5 and of Westen et al.6 has brought about considerable change in diagnostic practice in this area, and now the diagnosis is made fairly commonly in young people. The first report of successful treatment of suicidal adolescents with BPD came from a rather different ideological context: that of mentalization-based therapy (MBT), a psychodynamic-based approach developed by Fonagy and colleagues, which some of this innovative work also was published in the Journal by Rossouw and Fonagy.7 This study compared MBT with treatment as usual. MBT is a year-long, manual-based treatment with weekly individual and monthly family sessions. The focus of MBT is on increasing the adolescent’s and family’s capacity to understand action in terms of thoughts and feelings, which in turn is hypothesized to augment self-control and regulation of affect. The impact of MBT on self-harm was mediated by a decrease in avoidant attachment and an increase in self-reported ability to mentalize. This issue of the Journal presents the first fully fledged attempt to conduct a randomized controlled trial of dialectical behavior therapy (DBT) for adolescents with BPD (Mehlum et al.8).
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 10 OCTOBER 2014
EDITORIAL
DBT is a comprehensive, multimodal outpatient treatment that has been adapted for use with selfharming adolescents (DBT-A) by Miller et al.5 In DBT-A treatment length has been shortened from 12 to 3 to 5 months, includes parents in weekly skills training groups, and adds a new skills module to address common skill deficits in teens with emotion dysregulation and their families. The design of the trial was highly sophisticated. The randomized controlled trial reported 19 weeks of therapy, including weekly individual sessions (60 minutes), weekly multifamily skills training, family therapy sessions, and telephone coaching with individual therapists outside therapy sessions as needed. The control therapy (enhanced usual care) was 19 weeks of standard care (“enhanced for the purpose of the study by requiring that [enhanced usual care] therapists agreed to provide on average no less than one weekly treatment session per patient throughout the trial,” p. 1085). The therapy was conducted in a community mental health setting. Overall the results of the trial were favorable, and DBT-A was more effective in decreasing self-harm than the control therapy. This is certainly good news given the challenges that these difficult patients pose for therapists. DBT-A is much shorter than MBT, which is a definite advantage.
Some lingering doubts remain. For obvious reasons, most subjects were girls, and because boys commit suicide more commonly than girls, we still need to find a solution to this gender paradox. DBT-A included components that were missing in enhanced usual care, such as attention to families, which Brent et al.4 focused on as a critical element in preventing recurrent suicidal behavior, and more therapy may just be better than less therapy. Nonetheless, it does appear that DBT-A is effective, feasible, relatively short, and can be delivered with a high level of fidelity, making it a welcome addition to our therapeutic armamentarium. Gaps remain in our knowledge, and further research in this highly important field of clinical adolescent psychiatry is imperative. &
Accepted August 8, 2014. Dr. Apter is with Schneider’s Children’s Medical Center of Israel and Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel. Disclosure: Dr. Apter reports no biomedical financial interests or potential conflicts of interest. Correspondence to Alan Apter, MD, Schneider Hospital, Psychiatry, 14 Kaplan Street, Petah Tikva, 49202 Israel; e-mail: eapter@clalit. org.il 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2014.07.011
REFERENCES 1. Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self-harm in adolescents: self-report survey in schools in England. BMJ. 2002; 325:1207-1211. 2. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res. 2007;11: 129-147. 3. Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70: 300-310. 4. Brent DA, McMakin DL, Kennard BD, Goldstein TR, Mayes TL, Douaihy AB. Protecting adolescents from self-harm: a critical
5.
6.
7.
8.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 10 OCTOBER 2014
review of intervention studies. J Am Acad Child Adolesc Psychiatry. 2013;52:1260-1271. Miller AL, Muehlenkamp JJ, Jacobson CM. Fact or fiction: diagnosing borderline personality disorder in adolescents. Clin Psychol Rev. 2008;28:969-981. Westen D, DeFife JA, Malone JC, DiLallo J. An empirically derived classification of adolescent personality disorders. J Am Acad Child Adolesc Psychiatry. 2014;53:528-549. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51:1304-1313 e3. Mehlum L, Tørmoen A, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53:1082-1091.
www.jaacap.org
1049
