Borderline personality disorder and adolescent suicide attempt: the mediating role of emotional dysregulation.

BACKGROUND: Emotional dysregulation seems to be a core feature of Borderline Personality Disorders (BPD). In addition, recent research in the adolescent population has shown that suicidal behaviours have been associated with maladaptive strategies of emotion regulation. METHODS: This study examined the relative contributions of emotional dysregulation to suicide attempt history in a clinical sample of borderline adolescents. Data were analyzed from 85 participants of the Collaborative European Research Network on Borderline Personality Disorder. Participants completed measures of BPD traits and symptoms, suicide behaviours, emotional dysregulation, attachment styles and lifetime depressive disorders. RESULTS: In an SEM model, lifetime depressive disorders and insecure attachment styles have a significant direct effect on lifetime suicide attempt, but only lifetime depressive disorders have an indirect effect through emotion dysregulation. The results suggest that emotional dysregulation has a mediating role in suicide attempts among BPD adolescents. CONCLUSIONS: These findings call for the development of interventions targeting the role of emotion dysregulation in effectively predicting and preventing suicidality in borderline adolescents.

Validation of the French version of the McLean screening instrument for borderline personality disorder (MSI-BPD) in an adolescent sample.

BACKGROUND: The study examines the psychometric properties of the French version of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) created by M. Zanarini to screen borderline personality disorder in clinical and non-clinical populations. METHOD: In this multicentric longitudinal study from the European Network on Borderline Personality Disorder, a sample of 84 adolescent patients from five psychiatric centres and 85 matched controls without psychiatric comorbidity completed the MSI-BPD, French version, and were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV), in order to assess the presence or absence of borderline personality disorder. RESULTS: The MSI-BPD showed excellent internal consistency (α = 0.87 [0.84;0.90]). Compared to the semi-structured reference interview (SIDP-IV), the MSI-BPD showed substantial congruent validity (AUC = 0.93, CI 95%: 0.90-0.97). The optimal cut-off point in the present study was 5 or more, as it had relatively high sensitivity (0.87) and specificity (0.85). In our sample, the cut-off point (7 or more) proposed by the original developers of the MSI-BPD showed high specificity (0.95) but low sensitivity (0.63). CONCLUSIONS: The French version of the MSI-BPD is now available, and its psychometric properties are satisfactory. The French version of the MSI-PBD can be used as a screening tool for borderline personality disorder, for clinical purposes or in research studies.

Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide attempters.

BACKGROUND: Borderline personality disorder (BPD) and history of prior suicide attempt (SA) have been shown to be high predictors for subsequent suicide. However, no previous study has examined how both factors interact to modify clinical and suicide severity among adolescents. METHODS: This study presents a comprehensive assessment of 302 adolescents (265 girls, mean age = 14.7 years) hospitalized after a SA. To test clinical interactions between BPD and history of prior SA, the sample was divided into single attempters without BPD (non-BPD-SA, N = 80), single attempters with BPD (BPD-SA, N = 127) and multiple attempters with BPD (BPD-MA, N = 95). RESULTS: Univariate analyses revealed a severity gradient among the 3 groups with an additive effect of BPD on the clinical and suicide severity already conferred by a history of SA. This gradient encompassed categorical (anxiety and conduct disorders and non-suicidal-self-injury [NSSI]) and dimensional comorbidities (substance use and depression severity) and suicide characteristics (age at first SA). According to regression analyses, the BPD-MA group that was associated with the most severe clinical presentation also showed specific features: the first SA at a younger age and a higher prevalence of non-suicidal self-injury (NSSI) and anxiety disorders. The BPD-MA group was not associated with higher impulsivity or frequency of negative life events. CONCLUSIONS: Based on these findings and to improve youth suicide prevention, future studies should systematically consider BPD and the efficacy of reinforcing early interventions for anxiety disorders and NSSI.

Repeating a suicide attempt during adolescence: risk and protective factors 12 months after hospitalization.

Suicide attempts (SAs) are a public health concern in adolescence. A brief hospitalization is recommended, but access to inpatient wards is often not available. In addition, numerous risk factors for SA recurrence have been identified, but few studies have explored protective factors. Here, we aimed to assess the role of both risk and protective factors on SA relapse in a context of free access to inpatient services. We performed a prospective follow-up study of 320 adolescents who were hospitalized for an SA between January 2011 and December 2014 in France. Assessments at baseline included socio-demographics, clinical characteristics, temperament, reasons for living, spirituality, and coping. Patients were re-evaluated at 6 months and 12 months for depression severity and SA relapse. A total of 135 and 91 patients (78 girls, 12 boys, aged 13-17) were followed up at 6 and 12 months, respectively. At the 12-month follow-up, 28 (30%) subjects had repeated an SA. Adolescents who either had a history of SA or were receiving psychotropic treatment at baseline were at higher risk of recurrence. Several variables had a protective effect: (1) productive coping skills, namely, working hard and achieving, physical recreation, and seeking relaxing diversions; (2) a particular temperament trait, namely, cooperativeness; and (3) having experienced more life events. We also found a significant interaction: the higher the depression score during follow-up, the lower the protective effect of productive coping. Our findings confirm that a history of SA and seeking psychiatric care with medication are risk factors for SA relapse. However, productive coping strategies and cooperativeness are protective factors, and the improvement of such strategies as well as treatment of persisting depression should be a goal of psychotherapy treatment offered to suicidal adolescents.

Gender Differences Related to Spirituality, Coping Skills and Risk Factors of Suicide Attempt: A Cross-Sectional Study of French Adolescent Inpatients.

Background: Suicide attempts in adolescence represent a major public health concern, since these behaviors are associated with psychosocial burden and an increased risk of suicide. This cross-sectional study aimed to explore possible gender differences related to protective and risk factors in adolescents who have attempted suicide. Methods: Participants were French adolescents hospitalized for attempt suicide in five French pediatric departments. The participants were evaluated on 12 instruments measuring individual risk and protective factors. Results: Our sample included 320 adolescents aged 13-17 years (M = 14.43, SD = 1.29), of whom 82% were female and 35% were repeat attempters. Boys had greater difficulties at school and used more lethal means such as strangulation. We failed to find any differences between the two groups as regards the main Axis I psychiatric diagnoses. Boys tend to use more non-productive coping skills such as tension reduction or wishful thinking and girls use more reference to other strategies such as seeking social support. Although spirituality scores were low overall sample, they were significantly higher among girls. Conclusions: In the end, we find little difference between the two groups in terms of risk factors. However, we have shown gender differences in spirituality and some coping strategies. These results should be taken into consideration when designing suicide prevention programs.

Treatment compliance and risk and protective factors for suicide ideation to completed suicide in adolescents: a systematic review.

OBJECTIVE: To review the literature regarding adolescent suicide risk and explore the associations between treatment compliance (expressed as a concept including measured adherence to treatment and/or mental health service utilization) and risk and protective factors for suicidal behavior (SB), as well as the association between treatment compliance and reattempts. METHODS: PubMed, LILACS, and Google Scholar were searched using the following terms: (adolescent*) AND (suicide*) AND (risk factor OR protective factors) AND (treatment compliance OR treatment attrition OR treatment adherence OR treatment drop out OR treatment retention OR mental health utilization). We retrieved studies that focused on the relation of treatment compliance to risk and protective factors for SB and that had only adolescent samples. RESULTS: Of 4,841 articles, 30 original articles were selected for review. Most studies indicated high mental health service (MHS) utilization and poor treatment adherence by SB patients. Social minority status and conduct disorder were associated with less treatment adherence, while female sex, parental perceived need for treatment, and major depression were associated with greater treatment adherence. Inpatient and intensive emergency care after SA and family interventions improved MHS utilization and treatment compliance. However, we found no substantial protective effect of treatment compliance against reattempts. CONCLUSION: Effective treatment planning for compliance requires considering psychopathology, treatment planning, and social, familial, and individual factors.

Suicide Attempts Among French and Brazilian Adolescents Admitted to an Emergency Room. A Comparative Study of Risk and Protective Factors.

BACKGROUND: Suicide is the second most common cause of preventable mortality among Brazilian and French adolescents. The aim of the current study was to compare the main risk and protective factors associated with a suicide attempt (SA) and to highlight differences based on geographical characteristics. METHOD: We compared a Brazilian sample (N = 45) of adolescents admitted to the emergency room of a public hospital in São Paulo for SA to a French sample (N = 320) of adolescents hospitalized for SA across 5 paediatric departments. Then, we ran several multivariate models to examine how each selected variable was related to geographic origin and to the other selected variables linked to geographic origin. RESULTS: The two samples presented no significant differences regarding gender, age or schooling. Both samples had high rates of depressive disorders, anxiety disorders, substance use, disruptive disorders, borderline psychopathology, and lifetime SAs. However, the Brazilian sample presented significantly higher levels of psychopathology and had more insecure attachment relationships (fearful and detached), whereas the French sample had a more secure attachment style. Brazilian adolescents had more recourse to spiritual beliefs and spiritual support, whereas the French adolescents had higher scores on the Reasons for Living Inventory and used more help-seeking strategies from their social network, mainly close friends. Multivariate models showed that two productive coping strategies (seeking spiritual support and social action) and the dependence score were significantly associated with membership in the Brazilian cohort, whereas a secure attachment style and depression severity (evaluated by the Beck Depression Inventory) were significantly associated with membership in the French cohort. CONCLUSION: Despite presenting similar psychopathologies, Brazilian adolescents presented a more insecure attachment style and used the religious kind of coping more commonly than their French counterparts. We hypothesize that religion may compensate for the social vulnerabilities present in a middle-income country such as Brazil. More transcultural studies may help to elucidate this phenomenon.

A case-control association study of 12 candidate genes and attempted suicide in French adolescents.

Background Suicide is the second leading cause of death for 10-19-year-olds. Evidence has shown that attempted suicide is a complex interplay of genes and environmental factors. In the adult population, possible associations between genetic polymorphisms and suicidal behaviors have been investigated for several genes, most often with inconsistent findings and poor replicability of significant associations. This study aimed to identify gene variants conferring risk for adolescent suicide attempt. Methods We selected the genes and variants after an analysis of the literature and a selection of the most significant associations identified. We performed analysis on 22 single nucleotide polymorphisms (SNPs) in 12 genes (COMT, CRHR1, FKBP5, SLC6A4, HTR1B, HTR2A, TPH1, TPH2, BDNF, NTRK2, NOS1 and IL28RA) for association with suicide attempt, hopelessness and impulsivity in an independent sample, composed of 98 adolescent suicide attempters who required hospitalization based on emergency assessments, and 150 healthy volunteers. Quality controls, deviations from the Hardy-Weinberg disequilibrium and statistical tests of association (case/control) were calculated using PLINK. Asymptotic p-values were corrected with the Benjamini-Hochberg method. The level of significance was set to 0.05. Results We identified four polymorphisms of interest, rs10868235 (NTRK2), rs1659400 (NTRK2), rs2682826 (NOS1) and rs7305115 (TPH2), with significant associations for suicide attempts or for the quantitative hopelessness or impulsivity phenotypes. However, none of the associations withstand statistical correction tests. Conclusion Our results do not support the role of the 22 SNPs selected in suicide attempt or hopelessness and impulsivity in adolescent population. However, the relatively small sample size and the probable effect of gene-gene interaction or gene-environment interaction on suicidal behavior could not be ruled out.

[Asperger's syndrome symptoms in children, adolescents and young adults] / Quand évoquer le syndrome d'Asperger chez l'enfant, l'adolescent et le jeune adulte ?

Asperger's syndrome symptoms in children, adolescents and young adults. Asperger syndrome (AS) is a neurodevelopemental disorder which is classified into autism- spectrums disorders (ASDs). AS is characterized by significant difficulties in social interaction and nonverbal communication, stereotyped and restricted patterns of behaviour, activities and interests. There is no clinically significant delay in cognitive development nor general delay in language. However, there are specific abnormalities such as literal interpretations, miscomprehension of nuance, unusually pedantic and formal speech. Clinical aspects are very heterogeneous and vary depending on age and psychiatric comorbidities. Among the associated disorders, Attention Deficit Hyperactivity Disorder, mood and anxiety disorders are commonly found. To identify these conditions and offer appropriate treatment, elevated vigilance is needed in clinical practice.

Quand évoquer le syndrome d'asperger chez l'enfant, l'adolescent et le jeune adulte ? Le syndrome d'Asperger est un trouble neuro-développemental faisant partie de la grande famille des troubles du spectre de l'autisme. Les personnes ayant un syndrome d'Asperger ont des difficultés dans le domaine des interactions sociales, de la communication verbale et non verbale et peuvent avoir une bizarrerie comportementale avec des stéréotypies et des intérêts restreints. Ils n'ont pas de retard du langage et le développement cognitif n'est pas marqué par un retard global mais par des atteintes spécifiques dans certains domaines comme les fonctions exécutives. Les aspects cliniques sont très hétérogènes, ils varient en fonction de l'âge et des comorbidités psychiatriques. Parmi les troubles associés on retrouve fréquemment le trouble de déficit de l'attention avec ou sans hyperactivité. Une prise en charge précoce, multidisciplinaire et intégrative permet une meilleure qualité de vie et une diminution des complications psychiatriques telles que les troubles anxieux, la dépression et les conduites suicidaires.

Genetic Association Studies of Suicidal Behavior: A Review of the Past 10 Years, Progress, Limitations, and Future Directions.

Suicidal behaviors (SBs), which range from suicidal ideation to suicide attempts and completed suicide, represent a fatal dimension of mental ill-health. The involvement of genetic risk factors in SB is supported by family, twin, and adoption studies. The aim of this paper is to review recent genetic association studies in SBs including (i) case-control studies, (ii) family-based association studies, and (iii) genome-wide association studies (GWAS). Various studies on genetic associations have tended to suggest that a number of genes [e.g., tryptophan hydroxylase, serotonin receptors and transporters, or brain-derived neurotrophic factors (BDNFs)] are linked to SBs, but these findings are not consistently supported by the results obtained. Although the candidate-gene approach is useful, it is hampered by the present state of knowledge concerning the pathophysiology of diseases. Interpretations of GWAS results are mostly hindered by a lack of annotation describing the functions of most variation throughout the genome. Association studies have addressed a wide range of single-nucleotide polymorphisms in numerous genes. We have included 104 such studies, of which 10 are family-based association studies and 11 are GWAS. Numerous meta-analyses of case-control studies have shown significant associations of SB with variants in the serotonin transporter gene (5-HTT or SLC6A4) and the tryptophan hydroxylase 1 gene (TPH1), but others report contradictory results. The gene encoding BDNF and its receptor (NTRK2) are also promising candidates. Only two of the GWAS showed any significant associations. Several pathways are mentioned in an attempt to understand the lack of reproducibility and the disappointing results. Consequently, we review and discuss here the following aspects: (i) sample characteristics and confounding factors; (ii) statistical limits; (iii) gene-gene interactions; (iv) gene, environment, and by time interactions; and (v) technological and theoretical limits.

Treatment compliance and risk and protective factors for suicide ideation to completed suicide in adolescents: a systematic review

Objective: To review the literature regarding adolescent suicide risk and explore the associations between treatment compliance (expressed as a concept including measured adherence to treatment and/or mental health service utilization) and risk and protective factors for suicidal behavior (SB), as well as the association between treatment compliance and reattempts. Methods: PubMed, LILACS, and Google Scholar were searched using the following terms: (adolescent*) AND (suicide*) AND (risk factor OR protective factors) AND (treatment compliance OR treatment attrition OR treatment adherence OR treatment drop out OR treatment retention OR mental health utilization). We retrieved studies that focused on the relation of treatment compliance to risk and protective factors for SB and that had only adolescent samples. Results: Of 4,841 articles, 30 original articles were selected for review. Most studies indicated high mental health service (MHS) utilization and poor treatment adherence by SB patients. Social minority status and conduct disorder were associated with less treatment adherence, while female sex, parental perceived need for treatment, and major depression were associated with greater treatment adherence. Inpatient and intensive emergency care after SA and family interventions improved MHS utilization and treatment compliance. However, we found no substantial protective effect of treatment compliance against reattempts. Conclusion: Effective treatment planning for compliance requires considering psychopathology, treatment planning, and social, familial, and individual factors.

Risk and Protective Factors for Suicidality at 6-Month Follow-up in Adolescent Inpatients Who Attempted Suicide: An Exploratory Model.

OBJECTIVE: To assess risk and protective factors for suicidality at 6-month follow-up in adolescent inpatients after a suicide attempt. METHODS: One hundred seven adolescents from 5 inpatient units who had a suicide attempt were seen at 6-month follow-up. Baseline measures included sociodemographics, mood and suicidality, dependence, borderline symptomatology, temperament and character inventory (TCI), reasons for living, spirituality, and coping scores. RESULTS: At 6-month follow-up, 41 (38%) subjects relapsed from suicidal behaviours. Among them, 15 (14%) had repeated a suicide attempt. Higher depression and hopelessness scores, the occurrence of a new suicide attempt, or a new hospitalization belonged to the same factorial dimension (suicidality). Derived from the best-fit structural equation modelling for suicidality as an outcome measure at 6-month follow-up, risk factors among the baseline variables included: major depressive disorder, high depression scores, and high scores for TCI self-transcendence. Only one protective factor emerged: coping-hard work and achievement. CONCLUSION: In this very high-risk population, some established risk factors (for example, a history of suicide attempts) may not predict suicidality. Our results suggest that adolescents who retain high scores for depression or hopelessness, who remain depressed, or who express a low value for life or an abnormally high connection with the universe are at higher risk for suicidality and should be targeted for more intense intervention. Improving adolescent motivation in school and in work may be protective. Given the sample size, the model should be regarded as exploratory.

Coping skills among adolescent suicide attempters: results of a multisite study.

OBJECTIVES: A multisite study was undertaken to advance our understanding of how coping skills, depression, and suicidal ideation are related among adolescents who attempt suicide. Two hypotheses were postulated: productive coping and nonproductive coping would be associated, respectively, with lower and higher depression scores when age, sex, and stressful life events (SLEs) were controlled; and productive coping and nonproductive coping would be associated, respectively, with the presence and absence of suicidal ideation when age, sex, and SLEs were controlled. METHODS: Participants were 167 adolescents (13 to 17 years of age) hospitalized for attempting suicide in 5 pediatric departments across France. Four instruments were administered: the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version, the Adolescent Coping Scale, the Life Events Questionnaire, and the Columbia-Suicide Severity Rating Scale. Descriptive analyses and univariate and multiple regression models were completed. RESULTS: Both hypotheses were confirmed. Focus on the positive emerged as a significant variable in both models; depression emerged as a significant variable in the suicidal ideation model. The only sex difference observed was that girls made greater use of wishful thinking and seek social support. CONCLUSIONS: These findings suggest that coping skills are important mechanisms through which depression and suicidal ideation are maintained after attempting suicide. In intervening with adolescents who have attempted suicide, it may be useful to emphasize cognitive work geared to looking on the bright side, positive thinking, and fighting depression.

Coping strategies associated with suicidal behaviour in adolescent inpatients with borderline personality disorder.

OBJECTIVES: To compare the coping strategies of adolescents with borderline personality disorder (BPD) to the coping strategies of adolescents without BPD, and to explore the association of coping with suicidal ideation and attempts among adolescents with BPD. METHOD: Adolescent inpatients (n = 167) aged 13 to 17 years were admitted after suicide attempts and evaluated within 10 days, using the abbreviated version of the Diagnostic Interview for Borderlines-Revised, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version supported by a team consensus best estimate method for the primary diagnosis, the Adolescent Coping Scale, and the Columbia-Suicide Severity Rating Scale. RESULTS: Firstly, compared with adolescents without BPD, adolescents with BPD relied more on nonproductive coping strategies, mostly avoidant strategies, and less on productive coping strategies. Secondly, coping appeared as a factor associated with suicidal ideation in adolescents with BPD. While while controlling for age, sex, and depression, multivariate analyses showed a significant positive association between the coping strategy to focusing on solving the problem and suicidal ideation. CONCLUSION: The use of avoidant strategies by adolescents with BPD could be viewed as attempts to increase emotional regulation. Problem-solving strategies in the immediate aftermath of a suicide attempt may prevent adolescents with BPD from overcoming a crisis and may increase suicidal ideation.